Jocko Podcast 56 w/ Peter Attia - Overcoming Stress, Sleep Deprivation, and The Darkness

2017-01-04T08:47:45Z

Join the Conversation on Twitter: @jockowillink @peterattiaMD @echocharles 0:00:00 - Opening - "The Corner" 0:08:55 - Peter Attia Intro 0:11:03 - Beginnings Of Peter Attia. From Mechanical Engineering & Math to Medicine. 0:20:02 - Johns Hopkins Hospital and turmoil. 0:27:24 - Addiction to Pain-killers 0:39:53 - Sleep Deprivation 0:52:03 - Desensitized to the horrors of the Hospital VS Emotional attachments to patients. 1:09:01 - Surprising Negatives and Positives about Human Nature. 1:16:36 - Peter Attia Self Reflection and Lessons learned. 1:30:21 - Frustration and Fighting the system. Then leaving. 1:41:45 - Switching to Consulting 1:56:09 - Health, Nutrition and Lifestyle 2:20:34 - Final Thoughts 2:26:20 - Interesting Support stuff. Onnit Supplements, Jocko Store, Amazon Click-Through , Psychological Warfare on iTunes. 2:37:09 - Jocko White Tea, Extreme Ownership Muster 002 2:42:57 - Final Gratitude and Closing

AI summary of episode

So that was like it that was a super difficult time and you know in part you sort of feel like you're letting your mentors down because a lot of people had invested a lot in me right Hopkins had taken me right year I was like one of the six chosen ones they only take six categoricals a year so now you're going to leave that program. They got bonuses like all these things happened that were a function of some of my brother was like you know he was like breaking every record at his law firm right like nobody could work as hard. Like you know, because you always feel that like, you know how likely you know you're gaining some weight or I mean a lot of times you know why you're gaining weight. I mean it was like being a kid in a candy store again because I got to go spend a whole summer in school again learning finance like learning all of these things that you know for some people might seem kind of drive but when you're like just dying to. Because, and Brian's one of these guys who's just, you know, he's just, he's like a Renaissance man, you know, like not only is a great surgeon, he's like a gifted artist. And I am pretty glad that I didn't have my first kid till I was 35, which on the one hand you sort of think, well, God, I'm so old, you know, like I'm not going to be, I'm not going to be like the 50-year-old grandfather, right? And I remember saying to like, you know the controller at this bank, I'm like, hey man, like it's going to be really hard to build you a model of losses when you don't have any historical losses. And I didn't want to leave California because, you know, four years in California, for the first time was, you know, when you know, you guys know what it's like. Like she was kind of like, you know, like all good leaders. I don't remember the exact stats but you're going to spend like you know 50 60% of your entire health care dollars and like the last year or two of your life I mean something as an I right Because like if you're in the military and you and I were working together, I would be like, hey Peter, you got to get, you got to get, you got to act like, what is it, what is it, whatever. So just through empirical testing in myself over the past year and a half, I've realized that an average blood glucose and this thing tells me every time I hit click, like it gives me my last 14 days, I just realized like for my average to be below 85 and my standard deviation to be below 10 is like super dialed in. And because I feel that way with all of my friends, like if Tim introduces me to somebody, like Tim's introduced me to like a dozen people, it doesn't amazing relationships have come out of that, right? And, you know, she's an example of someone who came in basically dead, but in situations like that, like, you know, I'm sure you can relate to this. But, you know, he knows that I'm not going to send him somebody that's not you know, going to be really interesting and going to benefit his listeners, not just, you know, whatever agenda that person might have. And you know, this would be like, if you asked the most junior guy, you know, to do something like, he, he'd be kicking his own ass to say yes. Like boom, I feel like when that happens, I feel like in lock on, there's almost no amount of sleep deprivation that will stop me from functioning and getting something done that's important on task, on time. And she's, you know, I mean, like, I gotta, I gotta sure hope I never have to know what she went through, because I can't, can't really imagine, right? They've gotten better now, you know, and some of those guys that committed horrible crimes, it, you know, kind of inspired the seal teams to step up that screening process as much as possible to make sure that we're not let guys through that are, that are deranged some way that are going to do something horrible like that. You know, if something's so strange, like not, you know, so I was like God damn it man. I don't know how to like, it's, you know, it's not like a war zone or anything. And there were you know a couple of attendings I'd become really close to who really believed in me and really said like you're going to you're going to do something really special and then to say actually I'm going to leave. Like I can pull an all nighter once a week, that's, you know, not that that's a good thing to do, but it was like kind of a confidence thing. But, you know, trauma patient, like you just wouldn't think to go to someone's funeral that you'd never known because like, I'd never known that boy, right? They could have figured out like, okay, the reason this person, like, acts like a lazy sack of shit is actually because of this. And and that's just one of many stories like that that happened through residency where I was like it's almost like we want to live in the 1950s here. You can almost guarantee that, you know, if she's living in where she's living, to get hit by a stray bullet, like, you know, she wasn't living in, you know, Roland Park. so I you know got a bunch of books on case interviews and I'd be sitting in the trauma bay waiting for bodies to come in I'd be like reading my cases you know case interview things before so that that's that was sort of the transition. I mean, but, but no, it's, yeah, you, you, you sort of like, you know, opiate's make you itch like crazy. Nobody could build as many hours like nobody could like crush it like he could and he was being rewarded for it now he ended up hating it he left he's now a public defender or he's prosecutor rather. So I started to, you know, even though it didn't seem like exercise, it wouldn't seem like exercise today at the time. oh my god like you know I remember the first time we learned what was called the efficient front here which is basically this differential equation that describes you know an investment philosophy. So the first observation is that when you look at a significant illness, like a completely disruptive insult, you know, cancer, you have pancreatic cancer, which means you're going to die, and you're going to die soon. And it was like, you know, Jockel is always like, yeah, 430. And so, you know, really it was just very easy for me to sort of take Kirk on his word that like, if Jocco's great guy, then that's all I need to know. I mean I could go after easier problems to solve where you can like you know get grants and you know just play the game and that's frankly what most people do in this space. And one sense the simplest organ in the body like it's really simple to understand what it's doing you know unlike the brain or the liver where it's just like.

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Episode transcript

[00:00:00] This is Jockel Podcast number 56 with echo Charles and me, Jockel Willink. Good evening, echo.
[00:00:14] Silent screams and broken dreams. AddX, junkies, pushers and feens.
[00:00:23] Crowded spaces and sad faces never look back as the police chase us.
[00:00:31] Consumed slowly by chaos, a victim of the streets.
[00:00:36] Hungry for knowledge, but afraid to eat.
[00:00:40] Life of destruction, it seems no one cares, a man child alone with burdens to bear.
[00:00:49] Trapped in a life of crime and hate, it seems the ghetto will be my fate.
[00:00:56] If I had just one wish, it would surely be that God would send angels to set me free.
[00:01:06] Free from the madness of a city running wild.
[00:01:11] Free from the life of a ghetto child.
[00:01:18] And that is a poem written by a young, deandre macula, a criminal drug dealer who, when he wrote that poem, was doing time.
[00:01:39] After being one of the main subjects in a book called The Corner, which is written by David Simon and Edward Burns,
[00:01:47] which documents the violent drug trade in Baltimore, Maryland.
[00:01:53] And that sort of morphed into an HBO series that was called The Corner as well, which paved the way for another series,
[00:02:03] which is called The Wire, which is just an outstanding mini series that came out on HBO.
[00:02:11] But The Wire is fictional, even though it's based on kind of the same situation in Baltimore, but The Corner's real.
[00:02:20] The book The Corner's real, and it gives a very clear, any very grim view at the life of drugs and crime in the inner city, namely in Baltimore.
[00:02:34] And I'm going to go back to the book now.
[00:02:40] We can't stop it.
[00:02:43] Not with all the lawyers, guns, and money in this world.
[00:02:47] Not with guilt or morality or righteous indignation.
[00:02:50] Not with crime summits or task forces or committees.
[00:02:55] Not with policy decisions made in places that can't be seen from the lost corner of Fayette and Monroe.
[00:03:02] No lasting victory in the war on drugs can be bought by doubling the number of beat cops or tripling the number of prison beds.
[00:03:10] No peace can come from Kingpin, statutes, and civil, civil forfeiture laws and warrantless searches.
[00:03:17] And whatever the hell else is about to be tossed into next year's crime bill.
[00:03:22] Down on Fayette Street, they know.
[00:03:25] Today, as on every other day, the shop will be opened by mid-morning, and the touts will be on the corners, chirping out product names as if the stuff is street legal.
[00:03:35] The runners will bring a little more of the package down, and the fiends will queue up to be served.
[00:03:41] A line of gaunt, passive, supplicant, stretching down the alley and around the block.
[00:03:48] The corner is rooted in human desire, crude and certain and immediate.
[00:03:56] And the hard truth is that all the law enforcement in the world can't mess with desire.
[00:04:03] Down at Fayette and Monroe, and every corner like it and Baltimore, the dealers and fiends have won because they are Legion.
[00:04:11] They've won because the state of Maryland and the federal government have imprisoned thousands and arrested tens of thousands, and put maybe a hundred thousand on parole and probation roles, and still it isn't close to enough.
[00:04:24] By raw demographics, the men and women of the corners can claim victory.
[00:04:29] In Baltimore alone, a city of fewer than 700,000 souls, with some of the highest recorded rates of intravenous drug use in the nation, they are 50, perhaps 60,000 strong.
[00:04:44] Three of them available for every prison bed in the entire state of Maryland.
[00:04:49] The slingers are manning more than 100 open air corners serving up the product as fast as they can get it off the southbound metro liner.
[00:04:58] And the fiends are chasing down that blast 24-7.
[00:05:04] In neighborhoods with where no other wealth exists, they've constructed an economic engine so powerful that they'll readily sacrifice everything to it.
[00:05:16] And make no mistake, that engine is humming, no slacking profit margins, no recessions, no bad quarterly reports, no layoffs, no naturalized unemployment rate.
[00:05:27] Get it straight, they're not just out here to sling and shoot drugs.
[00:05:33] In drug markets, in cities across the nation, lives without any obvious justification are given definition through a simple self-sustaining capitalism.
[00:05:44] The corner has a place for them every last soul, doubts, runners, lookouts, mules, stick up boys, stash dealers, and forces, fiends, burn artists, police snitches, all necessary in the world of the corner.
[00:06:03] Each is to be used, abused, and ultimately devoured with unfailing precision.
[00:06:13] It's about the fiends, thousands of them who want that good dope, they need it.
[00:06:20] The way other souls need to breathe air.
[00:06:24] It's about the slingers, the young crews working the packages, all of them willing to trade a morality that they've never seen or felt for a fleeting moment.
[00:06:32] They're working the package with the hidden knowledge that they will fall, that with rear exception, the money won't last, and the ride will be over in six months, or four, or three.
[00:06:48] Violence.
[00:06:57] Violence is no longer the prerogative of the professional, but a function of impulse and emotion.
[00:07:04] The contract killers and the well-planned assassinations of earlier eras are mere myth on these corners.
[00:07:12] Now, the moment a truth generally comes down to some man-child with hurt feelings waving a 38 around spraying bullets up and down the block.
[00:07:22] The accidental shooting of bystandards is now commonplace.
[00:07:32] Even 15-year-old hoppers have loaded 38's hidden in the alley.
[00:07:38] The job is a little better than a death wish.
[00:07:49] In the end, the corner best serves the hard core, the junkyard dogs with neither the time nor the inclination for pity.
[00:08:04] The corner proves itself every day.
[00:08:09] It destroys whatever it touches.
[00:08:17] And eventually, the corner destroyed DeAndre, McCullough.
[00:08:23] Even though he received the second chance in his life, and he actually got to play a small role in that series that came out on HBO, the wire.
[00:08:33] He got some other jobs in the entertainment industry as well, but the corner called them back.
[00:08:41] And that guy, DeAndre, who wrote that poem, he ended up dead over heroin overdose in 2012 at the age of 35.
[00:08:53] Now, there's a reason I'm bringing all this up, and that is because we have a guest tonight.
[00:09:00] A guest that is actually more responsible for this podcast than anyone, and we'll get to that later.
[00:09:09] But his name is Peter Atia.
[00:09:11] And he grew up a boxer, been a long distance, and during South Leigh,
[00:09:18] got his degree in medical engineering and applied mathematics, and then got his doctorate as an MD from Stanford.
[00:09:28] And it is residency in surgery.
[00:09:32] And the reason that I started off this whole talk about the corner is because he did that residency at a place called John Hopkins Hospital,
[00:09:48] which is about three miles from the actual corner of Fayette, Monroe Street.
[00:09:54] The war zone that's pictured in the book, the place where DeAndre, McCullo lived, and where violence was, and in many ways still is just a part of life.
[00:10:06] And Peter was at Ground Zero in the war zone.
[00:10:11] And saw more darkness and suffering probably than any person should have to, and learned a lot from it.
[00:10:20] And we're going to get to that in a bit. But first of all, Peter Atia, welcome to the show.
[00:10:28] Thank you for having me, sir.
[00:10:30] Glad to have you on finally.
[00:10:34] And you grew up. We'll get right into it.
[00:10:40] You grew up, tell us a little bit about just growing up. You grew up in Canada.
[00:10:43] You know, you've covered, if for those of you that hadn't listened to the Tim Ferriss interview with you, listen to him, what does that three of them?
[00:10:51] Yeah, I think there's three of them. You can listen to those and get more details on Peter, his whole background.
[00:10:59] But for those that are just listening right now, you grew up in Canada, gives a little, little statement about that.
[00:11:05] I grew up in Toronto. You know, immigrant parents, so grew up, you know, sort of in the wonderful lower middle class, not the best suburb of Toronto.
[00:11:17] It's Toronto, like New York has five boroughs. Four of them are nice. One of them is not. I grew up in the one that's not so nice.
[00:11:25] And meaning it's just a dump. I don't know how to like, it's, you know, it's not like a war zone or anything.
[00:11:32] And I have lived now in the United States for about half my life. So I high school in college was in Canada and then everything from Med School beyond has been here.
[00:11:41] And I am now a dual citizen of the town.
[00:11:44] How did that transition work? Because you didn't, you obviously applied mathematics degree.
[00:11:50] And then you worked in the civilian world a little while with that degree, right?
[00:11:55] So my plan was always to do a PhD in aerospace engineering. And so that's why I did the mechanical engineering and applied math.
[00:12:05] I did the two things for undergrad got it. And then was sort of just in the almost about ready to go and start that PhD in aerospace.
[00:12:14] And then I had just a complete change of heart and decided I wanted to go into medicine.
[00:12:19] So that, so what I had to do for a year then was you got to take this thing called the M cat, which of course I didn't have any of the courses to take it.
[00:12:28] So I had to sort of teach myself the chemistry and biology that summer took the M cat.
[00:12:33] But then I still have a lot of times that's what I do in the summer time. I'll teach myself you.
[00:12:37] Yeah, chemistry and biology.
[00:12:39] Yeah, I didn't do that well.
[00:12:41] And then I had to do what's called a post back year where you go back in the process of applying to medical school without actually having the courses to get in.
[00:12:51] So if you get in it's conditional.
[00:12:53] And so that year because I'd already graduated, I just taught calculus.
[00:12:58] So I was like a, you know, adjunct lecture at the university and taught calculus, which I always enjoyed.
[00:13:05] I mean, because I taught it for a couple years before.
[00:13:07] And so that's why you're waiting to get into medical applying and then and getting my courses like I forget what I had to take biology and psychology biochemistry.
[00:13:16] I'd to take a few prerequisites to get it because in engineering and math I'd never taken a single course.
[00:13:21] In fact, the day before I took the M cat, this, this is only going to be funny for geeks who get biology.
[00:13:27] So I'll, okay, I'll find a moment.
[00:13:29] But that won't be made.
[00:13:30] Yeah, I'm studying for the M cat this summer that I'm supposed to take the test and the whole time I'm studying.
[00:13:36] I'm like, you know, I can't believe how sloppy these textbooks are.
[00:13:39] They keep confusing myosis and my toesus.
[00:13:42] Like why can't they just spell it the same way both times?
[00:13:45] Like they, I didn't realize that it was two separate things, right?
[00:13:48] Myocies is when a cell separates.
[00:13:51] Separate spirits and they.
[00:13:52] But doesn't replicate its DNA.
[00:13:53] My toesies is when it creates an equal copy.
[00:13:55] And I literally not until the day before the M cat realized that those were two separate things.
[00:14:00] And that's how how how clueless I was going into this test.
[00:14:05] Yeah, and it was a lucky reason I knew that was because I was helping one of my daughter study for their biology something.
[00:14:10] Yeah, anybody who took any biology course should know that.
[00:14:13] But I hadn't taken any.
[00:14:15] So it's like you get in medical.
[00:14:17] Yeah.
[00:14:17] You go there.
[00:14:18] What's that?
[00:14:19] Four years?
[00:14:19] Another four years of school.
[00:14:20] Uh-huh.
[00:14:21] And then you get done with that.
[00:14:22] And now it's time to do your residency.
[00:14:23] So, you know, do you get to pick where you're going to go?
[00:14:26] Not sort of.
[00:14:28] So it's a funny system called the match system.
[00:14:31] So when you're in your.
[00:14:35] Yes, you're beginning your fourth year of medical school.
[00:14:37] By that point, you have to figure out what you want to do.
[00:14:40] Do you want to be a surgeon?
[00:14:42] Do you want to be an internist?
[00:14:44] Do you want to be a pediatrician or radiologist?
[00:14:46] Whatever you want to do.
[00:14:47] Because all of those have different programs.
[00:14:49] And then you have to apply to those programs.
[00:14:52] So let's say you wanted to do orthopedic surgery.
[00:14:55] You would send out your application to all the orthopedic programs in the country.
[00:15:00] Hopefully you'd get interviews to a good number of them.
[00:15:03] You'd go do the interviews.
[00:15:05] And then you would submit to a match system, a rank order, of the places you'd want to go.
[00:15:12] And you don't put something on there that you don't want to take.
[00:15:15] So if you.
[00:15:16] If you.
[00:15:17] You know, if you applied to 30 programs, you got interviewed at 15 and you liked 10.
[00:15:21] You rank those 10 in order.
[00:15:23] Similarly, the programs after they interview everybody do the same exercise.
[00:15:28] And they do the rank.
[00:15:30] And then a computer matches you one to one.
[00:15:32] That's actually pretty square to a.
[00:15:34] Yeah, so you.
[00:15:36] The only way you're going to guarantee you know where you're going is rank one program and hope you get it.
[00:15:42] So in my case, I think I ranked five programs.
[00:15:49] And I ranked Johns Hopkins first for surgery.
[00:15:54] And I'm not because I wanted to live in Baltimore though, in many ways, I think it was a blessing to do so.
[00:16:00] But you know, because.
[00:16:02] At the time, I don't know that this is true today, but at the time it was probably the best general surgery training program in the country.
[00:16:08] And that was a combination of two things.
[00:16:10] One is you had these kind of legendary surgeons there that had pioneered.
[00:16:15] Some of the most complicated.
[00:16:17] What are called hepatobiliary surgeries, surgeons, you know, surgery of the pancreas and the liver and stuff like that.
[00:16:23] But at the same time as you alluded to, it was in a war zone.
[00:16:26] And so the other aspect of training to be a good surgeon is having great exposure to penetrating trauma.
[00:16:32] So trauma, you always want to divide into blunt and penetrating.
[00:16:36] Blunt trauma is not often operative.
[00:16:38] So people that get hit by cars and things like that.
[00:16:41] You know, ends up being more orthopedic.
[00:16:43] But if you're a general surgeon and you need to be able to cut open the chest and the abdomen and things like that.
[00:16:48] It's penetrating trauma.
[00:16:49] It's it's you want knife and gunfight.
[00:16:51] Not that you want it. But that's that's the training ground to be in.
[00:16:54] So and and sort of Baltimore would have been, you know, probably in the top five.
[00:16:58] What year was this?
[00:16:59] 2001.
[00:17:02] 2001. Yeah.
[00:17:03] 2000.
[00:17:04] Okay.
[00:17:05] And when you were what was it?
[00:17:09] What was the thing that slipped or this is going backwards a little bit?
[00:17:12] What was the thing that transitioned in your mind?
[00:17:13] Were you all the sudden one?
[00:17:14] Do medicine?
[00:17:15] Well, yeah, it's funny.
[00:17:18] I don't know if I've ever talked about this publicly.
[00:17:21] So when I was in engineering school, I in my second year I started doing some volunteer work.
[00:17:29] And I this the reason why is too complicated, but I started volunteering with.
[00:17:36] Some kids that were in a in a shelter that had been abused.
[00:17:39] So it was a home for sexually abused kids.
[00:17:42] And that got me interested in sort of volunteering in a hospital.
[00:17:45] So I was volunteering at a hospital that had you know, it was a pediatric cancer ward.
[00:17:53] So you would just sort of, you know, you'd go up there and you'd kind of hang out with kids and just play with them and stuff like that.
[00:17:58] And so between that experience and then I was still doing this volunteer work with these kids who had been sexually abused.
[00:18:04] A lot of those kids were suicidal.
[00:18:06] So I also found myself in the hospital a lot with these kids after they attempted to kill themselves.
[00:18:11] And I think somewhere in my senior year of engineering, I kind of had this, you know, I don't know what the word is.
[00:18:19] I don't think it's an existential crisis as much as maybe a nervous breakdown.
[00:18:23] But just a bunch of things were kind of going on probably some undiagnosed psychiatric issues on my part.
[00:18:28] But I realized like, I love engineering and math intellectually, but there's no emotional connection outside of the joy of solving a problem,
[00:18:39] which by the way is probably plenty enough.
[00:18:42] But I wondered if there was something else that I'd be more interested in that could scratch two inches, right?
[00:18:47] It could scratch sort of the intellectual inch, but also maybe an emotional inch.
[00:18:52] And so I spent the majority of my senior year thinking about, was there something else I ought to do?
[00:19:00] But I'd been successful in my undergrad, so it was sort of a given that, you know, if you're going to graduate at the top of your class,
[00:19:06] you're going to go off and do the best PhD program.
[00:19:09] So at the very end, when I sort of declined to do that and I turned down a bunch of scholarships,
[00:19:14] it seemed a little odd that I would go and do medicine.
[00:19:18] But that's really the reason it was kind of this epiphany I had one day actually,
[00:19:23] while I was in the hospital when I was sort of had this.
[00:19:26] Actually it's really funny, we just moved as we were talking about earlier.
[00:19:29] And one of the things moving is great for is cleaning up stuff.
[00:19:33] And I actually found my essay that I wrote when I applied to medical school back in, you know, whatever, 95 or 96.
[00:19:41] And it was really interesting to go back and read the story because it's exactly kind of how I remembered it, right,
[00:19:46] which was like this moment I had this sort of insight that this is what I wanted to do.
[00:19:49] So, so that's kind of the series of events that led me to have that seemingly or thog and all change in direction.
[00:20:00] Okay, so now you go through that, you end up, you get your accepted do you residency at John Hopkins, you show up there.
[00:20:08] What's that like?
[00:20:10] Well, I remember when I interviewed at Hopkins for medical school as well,
[00:20:15] and I was lucky enough to get in there for medical school.
[00:20:19] And at the time, I think Hopkins was technically the best medical school in the country.
[00:20:22] I think it was Harvard and Hopkins where the best two and Stanford was, you know, maybe third, fourth, fifth.
[00:20:29] But I remember when I interviewed there for medical school at the end of the interview,
[00:20:35] like I had to spend the night there.
[00:20:37] And so they put us up in the dorms for the med students, which is great idea you get to meet your upper classmates.
[00:20:42] And I remember I said that Friday night, I said, hey, I'm going to go walk down to the harbor.
[00:20:46] It's like a mile and a half down the road and they're like, oh no, no, you can't do that.
[00:20:51] I said, what do you mean?
[00:20:52] They said, you can't walk outside of the hospital. And then they pointed out that on every corner, there was like a booth with an armed guard.
[00:21:00] There's a guard in full armor with an automatic weapon.
[00:21:04] And so I remember the time thinking, yeah, I probably don't want to go here for med school.
[00:21:09] So, and of course, Stanford sort of for a guy who'd never been to California and who'd lived in miserable cold weather as whole life.
[00:21:15] I was like, it could have been a hundred-thranked medical school.
[00:21:19] I was still going there.
[00:21:21] So, I have some actual stats that I pulled up.
[00:21:24] So, war zone in 1993, there was 48 murders for every hundred thousand people.
[00:21:30] There's what's seven hundred thousand in the city.
[00:21:32] The next highest was in 2015, 55.
[00:21:36] And in 1993, again, there was 353 homeless sides, homicides.
[00:21:42] Yeah, almost one a day.
[00:21:44] And so, you know, I have to put this in there.
[00:21:47] Because we're sitting here calling it a war zone. So, when I was in Ramadi in 2006, the one one AD,
[00:21:55] which is the Ready First Brigade, you know, five thousand, six hundred soldiers,
[00:21:59] while we were there with them for six months, they lost 61 guys.
[00:22:04] So, what I'm saying is, now, that doesn't count the enemy casualties.
[00:22:10] Yeah.
[00:22:11] But it counts the friendly casualties that are showing up at our med center.
[00:22:14] Right?
[00:22:15] There, you know, you're talking three or four hundred, well, you just said one a day.
[00:22:19] Yeah, about one a day.
[00:22:21] Okay. So, so you knew how bad it was when you got, well, you know, I sort of knew it was dangerous.
[00:22:30] But I think when I decided that, you know, for this, that season of my life,
[00:22:35] you got to sacrifice everything, and you got to go to the place where you're going to get the best training.
[00:22:40] And I didn't want to leave California because, you know, four years in California,
[00:22:44] for the first time was, you know, when you know, you guys know what it's like.
[00:22:47] Yeah.
[00:22:48] I mean, it was like, I don't ever want to leave this place.
[00:22:50] But I also knew I just couldn't get that level of training on the west coast.
[00:22:54] And it was, you know, you basically had to go to a place like Hopkins,
[00:22:57] Bergman, Wobbans, in Boston, maybe Wash U, in St. Louis,
[00:23:01] was going to offer a very similar environment.
[00:23:04] So then, you know, so then I ended up ranking it first.
[00:23:08] They ranked me first.
[00:23:09] So away, we go, we get lucky.
[00:23:11] We get a very good match made in heaven. And that's like kind of February of your senior year.
[00:23:15] And then reality sits in, which is you've got sort of four months until you have to show up.
[00:23:20] And that was kind of like the, oh, shit moment, right?
[00:23:25] Like that I really just signed up for this.
[00:23:28] And a good friend of mine who was two years ahead of me in medical school.
[00:23:33] His name is Brian Donham. He's now a pediatric head and neck,
[00:23:38] and at Chopin Philadelphia. He was at Hopkins, which was at the time the best earnosen throat program in the country.
[00:23:44] And he actually recommended I read this book, the corner.
[00:23:47] Because, and Brian's one of these guys who's just, you know, he's just, he's like a Renaissance man,
[00:23:53] you know, like not only is a great surgeon, he's like a gifted artist.
[00:23:56] He has side job as medical illustration.
[00:23:58] Like you can't believe what this guy can do.
[00:24:02] But he's introspective, right? And he was, he said, look, you know,
[00:24:05] you're, you're going to sign up to be in this war zone.
[00:24:08] And you're going to be taking care of people that it's going to be very easy to despise.
[00:24:14] So he said, you need to read this book to gain a sense of their perspective.
[00:24:21] Because very, like I said, you know, so at the time, I can't remember the stats.
[00:24:26] I feel like at the time that I was there, we averaged about 16 penetrating traumas a day.
[00:24:32] Now to put that in perspective, in general, surgery, your on call every second to every fourth night.
[00:24:39] So average about every third. I mean, every third night, 120 times a year.
[00:24:43] You will spend the night in the hospital, not sleeping, waiting to take care of any trauma patient.
[00:24:49] So if every third day and night, you know, 16 of these people are getting shot and stabbed,
[00:24:54] you're going to have a lot of time in the ER in the trauma bay, dealing with that.
[00:24:58] And it's really easy to get jaded really quickly.
[00:25:01] It's fun for the first month. And then all of a sudden, every time somebody gets shot,
[00:25:05] it's preventing you from sleeping.
[00:25:06] Which when we're sitting here all well rested, sounds like a very callous thing to say,
[00:25:11] but all of a sudden, you're sort of like, damn it, man.
[00:25:15] I can't eat because the trauma page or just went off again.
[00:25:18] To this day, I still eat shockingly fast, and it drives my wife nuts.
[00:25:24] But she doesn't understand. I said, I think it's just, I'm a victim of you never know
[00:25:29] when you're going to have to stop what you're doing, and that might be your last meal.
[00:25:33] Even I shave quickly because the worst thing that could happen is you got shaving cream all over
[00:25:37] and the trauma page goes off and you've got to run down half shaved.
[00:25:39] You got one side of your beard down on the other side.
[00:25:41] That's a stupid thing like that.
[00:25:43] So that was Brian's recommendation.
[00:25:46] So I got the book immediately, devoured it, found it to be the most depressing thing I had ever had.
[00:25:52] It is heavy.
[00:25:53] It's heavy.
[00:25:54] They've made more depressing by the fact that they pulled no punches.
[00:25:59] No names are changed.
[00:26:00] So every person you read about, you are reading about it and a completely unsensored, unfiltered way.
[00:26:06] And I mean, you read it.
[00:26:09] You're not going to have to be happy about this book.
[00:26:11] You just finish it and you think, yes, you have more empathy than you understand
[00:26:15] where these folks are going to be coming from.
[00:26:18] It's not like you finished that book and go, ah, here's the solution.
[00:26:22] We need a six point plan that's going to do X1.
[00:26:25] It's like I don't actually.
[00:26:26] That's kind of why I read that one excerpt.
[00:26:29] We can't win, which is an awful thought.
[00:26:33] And that's what that's the impression the book gives you.
[00:26:35] It's we can't win.
[00:26:36] And I don't that the way you phrase it of being like,
[00:26:39] it doesn't matter how many police and whatever you do,
[00:26:42] you're going against human desire.
[00:26:44] Well, the stat that you reiterated, and I remember it very well
[00:26:48] from when I read this book the first time was,
[00:26:50] you couldn't take every junkie and put them away.
[00:26:54] If you took every federal and state prison bed in Maryland,
[00:26:58] you'd have three people for it.
[00:27:01] If you just looked at the users, never mind the guns,
[00:27:05] the money, and everything that comes with it.
[00:27:07] So yeah, that's not a solution.
[00:27:09] Now, there's a second reason that I don't think Brian knew,
[00:27:13] because I don't think anybody knew that that book really hit home,
[00:27:16] which it sounds tangential to this story,
[00:27:21] but it becomes highly related.
[00:27:24] At the beginning of end of my third year of medical school,
[00:27:29] I'm going to the gym one day, ride my bike,
[00:27:32] as I always do.
[00:27:33] I get off my bike, go to lock it up,
[00:27:36] and I was like, my back really hurts.
[00:27:39] Really hurt.
[00:27:40] Not like, oh, it's a little stiff.
[00:27:42] Something feels horrible.
[00:27:44] So I started walking down the steps to the gym,
[00:27:48] and I was like, not gonna happen today.
[00:27:51] I couldn't do anything, I couldn't time my shoot.
[00:27:54] So I just went back, got on my bike,
[00:27:57] rode back to my apartment, told my roommate,
[00:28:00] I was like, hey man, I'm gonna go lay down upstairs.
[00:28:03] The next morning I woke up, I couldn't get out of bed,
[00:28:06] and to make a very long story short,
[00:28:09] over the next two weeks, I completely deteriorated.
[00:28:12] You know, I was at the point where I could get in and go to the hospital,
[00:28:16] but I had to have the nurses,
[00:28:18] this is back in the Wild West days,
[00:28:20] where you could just sort of get anything you needed at the pharmacy.
[00:28:22] You know, I'd get nurses or residents to inject
[00:28:24] or all into me, which is a really strong end said,
[00:28:27] I could only sleep if I laid in an L shape over the nurse's station.
[00:28:33] And it just wasn't getting any better.
[00:28:36] And then one day, it pain changed immediately.
[00:28:40] I realized in retrospect what happened, a herniated disc had fragmented broken off,
[00:28:44] so the pain in my back dissipated,
[00:28:46] but now I had this, what turned out to be a 4 centimeter fragment,
[00:28:49] sitting on my S1 nerve root.
[00:28:51] So now it felt like my left foot was being skinned from the bottom.
[00:28:56] But that was constant, so that was an unrelenting pain,
[00:28:59] and it could only be sort of brought under control,
[00:29:03] if I could put my foot into a bag of ice,
[00:29:05] because then I could make my foot go numb,
[00:29:07] and then I could take some pain medicine.
[00:29:09] So this one, on for another week, and then the Dean of the Medical School,
[00:29:12] saw me limp in through the hospital,
[00:29:13] he said, what's wrong?
[00:29:14] And I told him, and he dragged me down to the ER,
[00:29:16] we got an MRI that showed all of this.
[00:29:18] And I was in surgery the next morning.
[00:29:20] This was a Sunday night, Monday morning,
[00:29:22] I'm in the OR.
[00:29:23] It turned into a disaster.
[00:29:25] The guy who operated on me, I prayed on the wrong side.
[00:29:28] So I woke up.
[00:29:29] The left issue was still present,
[00:29:31] but now I had what's called a foot drop on the right side.
[00:29:34] So foot drop is when the nerve that holds your foot up,
[00:29:38] which we take for granted when we walk.
[00:29:40] But if you don't have the ability to what's called dorsiflex,
[00:29:44] your foot would drop, you can't walk,
[00:29:46] you'll end up dragging your toe when you keep tripping.
[00:29:49] This story, I mean, we could spend three hours on the story,
[00:29:52] because it's so idiotic.
[00:29:54] The punch line is I eventually needed many trips back
[00:29:58] to the operating room.
[00:29:59] This guy refused to believe there's anything wrong with me.
[00:30:01] It took another amazing doctor and neurologist
[00:30:04] to actually intervene on my behalf.
[00:30:07] And three months later, I'm unable to walk.
[00:30:12] I'm unable to do anything.
[00:30:13] My mom actually had to fly down from Toronto to look after me.
[00:30:17] And I'm sort of, you go through the checklist, right?
[00:30:22] So there's, I don't know if you've ever heard of Elizabeth Kubler Ross.
[00:30:27] I don't think she's alive anymore, but she wrote a very famous book
[00:30:32] on the stages of dying.
[00:30:35] And it goes through anger and denial and finally acceptance at the end, right?
[00:30:40] And so you know bargaining, it's something that would make sense if you,
[00:30:44] and I'm sure you've heard of that.
[00:30:46] And you've probably watched it on really small scales.
[00:30:49] In combat, you might see these things over the course of compressed.
[00:30:53] Yeah, with a cancer patient, you might see this stretched out over a year.
[00:30:56] And so I was kind of going through this on my own, right?
[00:30:59] We're initially, it was like, oh my god,
[00:31:01] what if I don't finish this rotation I'm doing right now?
[00:31:04] I'm going to be a surgical sub-internship to, well,
[00:31:07] what if I don't graduate on time?
[00:31:09] To, what if I can't be a surgeon?
[00:31:11] And then it was, what if I don't walk ever again?
[00:31:15] So somewhere along the way, I don't remember exactly when,
[00:31:20] probably like a month and a half into this.
[00:31:23] I finally caved in and started taking pain medicine.
[00:31:27] I thought that's where this story was going.
[00:31:29] I was like, at some point, he's going to get on the open.
[00:31:32] Yep. And I had been so reluctant to do so initially.
[00:31:37] Been so stoic, you know, just taking my NSAIDs and even using
[00:31:42] Benadryl, which is a horrible pain medication, of course,
[00:31:45] but it sedates you through some of the pain.
[00:31:48] And so I, you know, started taking per cassette.
[00:31:52] And per cassette is, it's typically 10 milligrams of oxycodone.
[00:31:57] So oxycodone is the fast acting version.
[00:32:01] It's stronger than say a vik so a vikodin is Tylenol and hydrocodone.
[00:32:05] Immediate acting, but hydrocodone is not as strong as oxycodone.
[00:32:08] So per cassette is stronger than vikodin.
[00:32:10] They both have Tylenol. It's just the opiate is stronger.
[00:32:13] And so, you know, if you take a per cassette,
[00:32:17] which would have 500 milligrams of Tylenol and 10 milligrams of oxycodone,
[00:32:21] you know, I probably was taking, you know,
[00:32:24] you start taking two, three, four, five, six of those a day.
[00:32:27] You develop a tolerance.
[00:32:29] And eventually, there's a long-aracting version called oxycontin,
[00:32:36] which is just a time-released version of oxycodone.
[00:32:39] So then you would take that twice a day.
[00:32:41] So at my peak, I was probably taking 80 milligrams of oxycontin a day,
[00:32:47] plus another 120 milligrams of oxycodone.
[00:32:50] I just got rid of the Tylenol altogether.
[00:32:52] You can just get straight oxycodone.
[00:32:54] And so I'm about 200 milligrams a day of oxycodone.
[00:32:58] Equivalent. And again, if I took that today,
[00:33:02] I would just die of you just not breathing.
[00:33:04] But at the time, you know, you build up this tolerance.
[00:33:06] But it also, there was this point where I realized
[00:33:10] that I wasn't just taking it for the physical pain.
[00:33:14] Right? And I think this is the single most important insight I had
[00:33:17] that when coupled with reading that book, six months later,
[00:33:20] was the, I think the single most important realization I ever had
[00:33:24] with respect to this problem,
[00:33:26] which was, at some point it was, I was just so depressed
[00:33:30] that I couldn't walk. And I was so worried that, you know,
[00:33:33] I'd never be able to do anything again,
[00:33:35] that at least the drug gave me a high that took me away from that.
[00:33:39] And so then it got to the point where I was just taking that drug
[00:33:42] all the time, and I just stopped engaging,
[00:33:45] like, wasn't engaged with anyone anything.
[00:33:48] And then I sort of had this realization that that was happening.
[00:33:52] And I was like, I want to stop.
[00:33:56] So at the time I was dating this girl,
[00:33:59] she was an anesthesiology resident. She was a few years older than me.
[00:34:02] Just the coolest, coolest person.
[00:34:05] And I said to her, she was kind of the only one that knew what was going on.
[00:34:08] Because at the time, even the doctors who were prescribing this,
[00:34:11] like, this just wasn't on people's radar as a problem back then.
[00:34:14] I think today people would be like,
[00:34:16] homeboy's got 200 milligrams of oxycon today.
[00:34:19] That's probably not good, but at the time it was just like,
[00:34:21] it was like, tick tax, right?
[00:34:23] So that would legitimately kill it.
[00:34:25] If I took 200 milligrams with that, that would really jack someone up.
[00:34:29] I would think, I think if I took 200 today, I would stop breathing.
[00:34:32] Yeah, because that's how opiates kill you.
[00:34:34] They repress, they inhibit respiratory drive.
[00:34:37] Whenever someone overdoses on heroin, they just stop breathing.
[00:34:41] So yeah, I think 200 would, I don't know.
[00:34:44] We'd have to, I'd have to look at the farmed one.
[00:34:46] We don't have to actually, you have to stay here one before that.
[00:34:49] So the girl you're eating.
[00:34:51] She said, you can't just stop, right?
[00:34:54] The withdrawal is so painful that you have to taper off.
[00:35:00] You have to probably go on methadone,
[00:35:02] and then you'd have to start some pretty potent anti-depressants.
[00:35:06] They, like, M-A-O-I's or T-C-A,
[00:35:09] so you have to go on a drug like nor trip to lean,
[00:35:11] which is an end of itself kind of a crazy thing.
[00:35:14] And I was like, yeah, but I think I'm just going to stop cold turkey.
[00:35:18] Now, unlike alcohol, so if you took an alcoholic,
[00:35:21] you know, you took someone who's drinking 20 alcohol,
[00:35:24] you know, alcohol beverages a day,
[00:35:26] and they've been doing that forever.
[00:35:28] And you stop them, they will die.
[00:35:31] They will get something called delirium trements,
[00:35:33] and they will die a horrible cardiac death.
[00:35:35] They will break into a rhythm,
[00:35:36] and they will die.
[00:35:37] So when we had alcoholics in the hospital,
[00:35:39] let's say we had to operate on somebody who happened to be an alcoholic,
[00:35:42] we would actually just put them on an ethanol IV.
[00:35:45] We weren't even trying to detox them.
[00:35:47] We just wanted to make sure they didn't die,
[00:35:49] and go into these delirium trements.
[00:35:51] But heroin and opiate is not like that.
[00:35:53] It is not physiologically lethal to stop cold turkey.
[00:35:58] It's just unbearable.
[00:36:00] And so I was like, I'm going to do it.
[00:36:03] So against her better judgment,
[00:36:07] I just stopped one day.
[00:36:09] And she could not have been more right.
[00:36:13] It was the darkest.
[00:36:15] I mean, I got laughed about it now.
[00:36:17] It was the darkest month of my life.
[00:36:19] It was a month?
[00:36:20] Oh, at least.
[00:36:22] I mean, it was, I would just sit on a park bench
[00:36:25] for the whole afternoon,
[00:36:27] like complete flat affect.
[00:36:30] But it's all mental.
[00:36:32] It's not a physical thing.
[00:36:33] No, there's physical stuff going on.
[00:36:35] I mean, but, but no, it's,
[00:36:37] yeah, you, you, you sort of like, you know,
[00:36:39] opiate's make you itch like crazy.
[00:36:41] You get constipated.
[00:36:42] So there's like a reversal of a whole bunch of physical stuff.
[00:36:44] But the biggest thing is the craving and the depression.
[00:36:49] And so the depression of coming off this thing was brutal.
[00:36:55] In many ways, and I don't tell that story to say,
[00:36:58] well, look at how special I am that I detox.
[00:37:01] That's not a point at all.
[00:37:02] I had two things going for me that virtually no junkie has going for them, right?
[00:37:06] The first is, I didn't have a network of people around me
[00:37:09] that we're doing the same thing.
[00:37:11] So I was sort of the only guy doing it.
[00:37:12] So for me to go and be around my friends was to be around people who weren't doing this.
[00:37:16] We always used to joke that if you really want to kick a heroin head,
[00:37:20] but you have to get a whole bunch of new friends.
[00:37:22] Like you, you don't get to decide you're not doing heroin,
[00:37:24] and then go back and hang with your friends that are doing heroin.
[00:37:26] You need to watch trainspotting to learn that.
[00:37:28] The second thing, and perhaps the more important thing,
[00:37:30] is I finally did connect with a doctor who was able to put me on the right path.
[00:37:34] So I, I had ended up going back to the operating room.
[00:37:37] Probably a half a dozen times over the course of the year
[00:37:40] to have, all these problems corrected.
[00:37:43] And then I found something else to fixate on, which was physical therapy.
[00:37:46] So I started to, you know, even though it didn't seem like exercise,
[00:37:49] it wouldn't seem like exercise today at the time.
[00:37:51] It was the first activity I was able to do.
[00:37:53] And so, you know, within six months, I could like walk
[00:37:57] like a reasonable distance again.
[00:37:59] And so I would be spending three hours a day at physical therapy
[00:38:02] just doing like the most trivial exercises.
[00:38:04] But basically the root cause of my depression was getting better.
[00:38:08] So that's really the only reason I think I was able to kind of detox off this stuff.
[00:38:12] Whereas I think for many people,
[00:38:14] hey, it's not clear what the root cause is or be.
[00:38:16] It's not getting better if it is clear.
[00:38:18] And so that's why I think it's really, it's a brutal addiction.
[00:38:22] And it seems like also you had a future.
[00:38:25] Right, you had a life, you were in medical school.
[00:38:27] You're going to, you know, you're, yes, I think there's a lot of these people
[00:38:30] that are drug addicts.
[00:38:31] What do they, they have no life that they're looking forward to.
[00:38:34] They're just looking forward to it.
[00:38:35] Absolutely.
[00:38:36] And so in February of that senior year when I had to submit my rank list,
[00:38:41] I think we match in March and Misspoke earlier,
[00:38:44] I was still not functional perfectly.
[00:38:47] Like there was no way in February of 2001 that I could have with
[00:38:51] the statistical residency.
[00:38:53] But I had to make a decision at that point,
[00:38:55] which was will I be ready on July 1st.
[00:38:58] And if I won't be, I should not submit my rank.
[00:39:01] I should defer a year, sit out of your medical school, whatever.
[00:39:05] And I remember that was the hardest decision I'd to make.
[00:39:07] And I just gamble.
[00:39:08] I was like, you know what, I'm going to be ready.
[00:39:10] And I'm going to make it happen no matter what.
[00:39:12] And so I submitted, matched, and then in addition to now reading the
[00:39:16] corner to prepare for Baltimore and reflecting on my own sort of
[00:39:21] struggle with addiction, which was completely fresh in my mind.
[00:39:24] I'm also like rehabbing like it's my day job.
[00:39:27] And going through like, and I,
[00:39:30] most people take the last quarter and med school off,
[00:39:32] but I didn't have the ability to do that now because
[00:39:34] I had to go straight through till graduation day because I'd missed so much
[00:39:38] time during my injury.
[00:39:40] So when I showed up in Baltimore a couple of days before July 1st,
[00:39:45] I mean, it still wasn't crystal clear to me that I could go,
[00:39:49] you know, two days without sleeping, standing in an OR for eight
[00:39:53] hours at a time, all those sorts of things.
[00:39:56] Now, that's one of the things, the sleep deprivation,
[00:39:59] because people always, obviously, I take a lot of slack because I don't sleep
[00:40:03] a lot and the sleep deprivation.
[00:40:07] So what did that, but what's that like when you're going through residency?
[00:40:10] And you're just saying, I mean, there's days where you're going 24,
[00:40:12] 48 hours, no sleep, and how did that affect you?
[00:40:17] What did you think of that?
[00:40:18] What do you think looking back at it?
[00:40:20] What's your opinion of it now?
[00:40:23] Well, you know, when I decided that I was going to go in the surgery,
[00:40:27] I mean, I always, I'm pretty insecure in general.
[00:40:30] Most people don't necessarily appreciate that on the outside, but always thinking,
[00:40:35] I don't know if I've got what it takes, your how do I figure it out.
[00:40:38] And so my whole MO in life is test the system hard.
[00:40:43] So when I was in medical school, still deciding this, I figured, well,
[00:40:47] every Thursday night, I'm going to pull an all nighter in my room,
[00:40:51] standing up, not allowing myself to eat, sleep, drink, pee, do anything,
[00:40:57] and I'm going to stand up my desk for eight hours and practice suturing.
[00:41:01] You know, sort of try to mimic what it would be like to be an operating room all night,
[00:41:05] not being able to go pee, not being able to drink, not being able to do this thing.
[00:41:08] And so I had a little bit of confidence, you know, I figured, okay, I can do this.
[00:41:12] Like I can pull an all nighter once a week, that's, you know,
[00:41:15] not that that's a good thing to do, but it was like kind of a confidence thing.
[00:41:18] Right.
[00:41:19] So then you show up, but there's no preparing you for what you're in store for.
[00:41:22] Now, I got to point out, this is not the way it is anymore.
[00:41:25] So in 2000, I want to say like four.
[00:41:30] It's like labor laws came in.
[00:41:33] Exactly.
[00:41:34] A whole bunch of laws came in that we could spend hours talking about how it turns out the laws haven't.
[00:41:40] They haven't fixed the underlying reproblem, but nevertheless,
[00:41:43] a whole bunch of work requirement hours stuff got fixed, right?
[00:41:46] So you couldn't work more than 80 hours in a week or 88,
[00:41:49] depending on if your program had an exemption,
[00:41:52] and you couldn't work more than 24 hours consecutively and stuff like that.
[00:41:56] But by the time those laws really kicked in, I was already gone.
[00:42:01] And so I don't really know what it's like today,
[00:42:06] but I would imagine it's less demanding from a sleep deprivation standpoint.
[00:42:12] But at the time, there were no such rules,
[00:42:15] and you were at the sort of every second, every third,
[00:42:19] every third, every fourth night call, but then your post called day, you would still work.
[00:42:23] So our mutual friend Kirk Parsley, which of course is how we met,
[00:42:27] this is one of his favorite stories about me.
[00:42:30] He loves this story, because it's so crazy.
[00:42:35] So this is July of 2001.
[00:42:39] So I am one month into being a doc, right?
[00:42:43] And I'm on an every third night call rotation at this hospital called Bayview,
[00:42:48] which is about five miles from what we call the mothership,
[00:42:52] which is Hopkins.
[00:42:54] And it's out in like East Baltimore.
[00:42:56] It's in a real crappy part town, not that there's a real, I mean,
[00:42:59] I hate saying this, but I don't,
[00:43:00] there aren't that many good parts of town, at least back then,
[00:43:03] and Baltimore.
[00:43:05] And so I'm, so I show up on a Monday at five o'clock in the morning.
[00:43:11] So I slept in my own bed Sunday night.
[00:43:13] So Monday morning, I show up at five to round.
[00:43:15] We do our whole thing.
[00:43:17] And that night I'm supposed to go home.
[00:43:21] So that's my off call.
[00:43:22] As you call your swing day, you show up at five.
[00:43:25] You'll be home by seven p.m. that night, if all goes well.
[00:43:28] So you worked your, you know, 14 hours,
[00:43:30] and then you sleep in your own bed,
[00:43:31] and then you get to come back the next day,
[00:43:32] and then you're going to be on call.
[00:43:34] So we're rounding that afternoon.
[00:43:37] So, and the, one of the senior residents says,
[00:43:41] hey, so and so didn't show up for their shift in the ER.
[00:43:44] The ER always staffs one surgical resident full time.
[00:43:48] And this guy just didn't show up.
[00:43:50] And she's like, and it's a seven p.m.
[00:43:52] to seven a.m.
[00:43:54] Shift.
[00:43:55] Can you cover it?
[00:43:56] And you know, this would be like,
[00:43:58] if you asked the most junior guy, you know,
[00:44:01] to do something like, he, he'd be kicking his own ass to say yes.
[00:44:05] Like, he couldn't wait to do that, right?
[00:44:07] So I was like, hell, yes, I will do that.
[00:44:10] So then I go down to the ER,
[00:44:12] and I work all night, seven to seven.
[00:44:14] And then the next morning is now my on call day.
[00:44:17] So now I'm seven a.m.
[00:44:20] cranking away until that night,
[00:44:22] and then I'm up all night on call.
[00:44:25] So, and then it's now Wednesday,
[00:44:28] and it's my post call day,
[00:44:30] and I'm there till five or six p.m.
[00:44:33] So I've basically been up from about four a.m. Monday,
[00:44:37] and it's now five or six p.m. Wednesday.
[00:44:40] And I get in my car to drive home,
[00:44:44] and I have to make it,
[00:44:45] I have to go down this miserable street called Eastern Avenue
[00:44:49] to hit the 83 to drive up to my place.
[00:44:53] And I'm driving along Eastern Avenue,
[00:44:56] which is like red light after red light after red light,
[00:44:59] or stop sign or whatever,
[00:45:01] and every time I met a stop light,
[00:45:03] I fall asleep, my foot pops off the clutch,
[00:45:05] and I stall.
[00:45:06] Like, I am so tired,
[00:45:09] I can't even handle the gradual easing off the clutch
[00:45:14] and the gas just to move up and up.
[00:45:16] I can't do it.
[00:45:17] So finally, in one moment of lucid clarity,
[00:45:20] I'm like, you can't get on the freeway,
[00:45:22] you're gonna die.
[00:45:24] So it's like, what's the solution?
[00:45:26] I was like, you gotta get over and take a nap.
[00:45:28] So I pull over my car on the side of Eastern Avenue,
[00:45:31] right in front of this park called Patterson Park,
[00:45:34] which at the time,
[00:45:36] I don't think I fully understood that that was an open air drug traffic market.
[00:45:41] So I got up, but here's the best part, sorry.
[00:45:43] The logical thing to do would have been just been stayed in the car
[00:45:46] and taken a nap.
[00:45:47] But I was like, I haven't seen the sunlight in like days
[00:45:50] and it's the sun is still out.
[00:45:51] Like, I'm gonna go nap in the park.
[00:45:54] So I get out of the park,
[00:45:55] I'm in green scrubs that are covered in blood stains
[00:45:59] because I was too dumb to not change.
[00:46:01] I go laid out in the park,
[00:46:03] I take my page off and I clip it
[00:46:05] to my neck and I set the alarm to go off in one hour.
[00:46:09] There's like seven p.m.
[00:46:11] It'll wake me up and I'll feel perfectly rest
[00:46:13] and I'll be able to drive home.
[00:46:15] So I laid out in middle of Patterson Park.
[00:46:18] And the next thing I know I wake up,
[00:46:19] it's like one in the morning, two in the morning.
[00:46:22] There's needles everywhere.
[00:46:26] There's, I have like a bites on my arm
[00:46:28] that look like they're from rats
[00:46:30] because they're nothing I've ever seen before.
[00:46:32] Like these bites all over me.
[00:46:34] And I'm just thinking myself like,
[00:46:36] how did I not get killed here?
[00:46:38] Like the only thing that prevented me from dying
[00:46:41] was how ridiculous the site was.
[00:46:43] You know, if something's so strange,
[00:46:45] like not, you know,
[00:46:46] so I was like God damn it man.
[00:46:48] So I get back in my car and drove home.
[00:46:50] And when I tell Parsley that story,
[00:46:52] he loves it because he's like,
[00:46:53] that's the classic example of how
[00:46:55] complete deprivation of sleep
[00:46:57] and pairs your judgment.
[00:46:59] So, you know,
[00:47:01] there were a couple stories in residency
[00:47:02] where I had to do like those three night
[00:47:04] back to back to back to back.
[00:47:05] Another time it happened,
[00:47:06] I remember was in an O5.
[00:47:07] Do you feel like though, okay,
[00:47:09] driving a car is kind of boring, right?
[00:47:11] Stop lights.
[00:47:12] But when you're really tired,
[00:47:13] but then all of a sudden something happens.
[00:47:15] Like boom, I feel like when that happens,
[00:47:17] I feel like in lock on,
[00:47:18] there's almost no amount of sleep deprivation
[00:47:21] that will stop me from functioning
[00:47:22] and getting something done that's important
[00:47:23] on task, on time.
[00:47:25] Absolutely.
[00:47:26] Is that true?
[00:47:27] I think so, yeah.
[00:47:28] No, I think in adrenaline rush
[00:47:29] in the moment.
[00:47:30] I've been able to provide any amount of
[00:47:32] clarity and focus that's necessary.
[00:47:34] The problem is very few things are life or death that way.
[00:47:36] Now in your world,
[00:47:37] there were plenty of things.
[00:47:38] But in my world, not.
[00:47:39] And this is the extra,
[00:47:40] I was going to tell was,
[00:47:42] in probably my third year,
[00:47:45] I think it was my third year.
[00:47:48] I was the same sort of deal.
[00:47:50] I ended up covering for somebody
[00:47:52] and then covering for two people
[00:47:53] and two consecutive nights
[00:47:54] and then it was my turn.
[00:47:55] So, that was like three straight nights
[00:47:57] of not sleeping.
[00:47:58] And it's the middle of the night,
[00:47:59] and this guy comes in the ER
[00:48:01] who's got a really diseased gall bladder
[00:48:04] and in retrospect,
[00:48:05] it should have never come out that night.
[00:48:07] But a lot of times,
[00:48:08] the dirty little secret is surgeons
[00:48:10] want to operate at night
[00:48:11] because they can get better OAR time
[00:48:13] electively as opposed to waiting the next day
[00:48:15] if it's not emergent.
[00:48:16] So, sure enough,
[00:48:17] we're in the middle of the operating room
[00:48:18] doing a laparoscopic gall bladder removal
[00:48:21] at two in the morning
[00:48:22] when we don't really need to be there
[00:48:23] at two in the morning.
[00:48:24] We could have slept
[00:48:25] at the next day.
[00:48:28] And sure enough,
[00:48:29] so in a lapar,
[00:48:30] removing a gall bladder is a two surgeon procedure.
[00:48:32] So, there's the main surgeon,
[00:48:34] which because we're teaching hospital,
[00:48:35] I'm the main surgeon.
[00:48:36] I'm actually doing the operation
[00:48:37] and then there's the attending
[00:48:38] who's holding the camera
[00:48:39] and retracting for me.
[00:48:41] So, I'm doing this.
[00:48:43] And yeah,
[00:48:44] that's a stimulating activity,
[00:48:45] but of course,
[00:48:46] I've done a hundred of them,
[00:48:47] so it's not that stimulating.
[00:48:48] Well, I can't stay awake.
[00:48:50] And I finally somehow managed
[00:48:53] to fall asleep on this patient.
[00:48:55] Like, I faced plant into the patient.
[00:48:58] Luckily, it was laparoscopic,
[00:49:00] so I didn't contaminate the surgical.
[00:49:02] But so,
[00:49:03] even something is stimulating is surgery.
[00:49:06] Because if the guy's aorta was bleeding,
[00:49:09] I'm just like,
[00:49:10] I would've said,
[00:49:11] yeah, exactly.
[00:49:12] But now,
[00:49:13] I was like,
[00:49:14] yeah,
[00:49:14] when I was gallbladder's no big thing,
[00:49:15] yeah,
[00:49:16] yeah,
[00:49:16] it wasn't stimulating enough
[00:49:17] to overcome three days of sleep debt.
[00:49:19] Did you figure out any tricks
[00:49:21] or any, you know,
[00:49:23] for instance,
[00:49:24] when I was going through cell training,
[00:49:26] and even my whole career,
[00:49:27] and even to this day,
[00:49:28] I take little power now,
[00:49:30] so if I'm feeling that tired,
[00:49:31] I elevate my feet,
[00:49:32] and I sleep for like six to eight minutes,
[00:49:35] and it totally returged me.
[00:49:37] Did you take power now?
[00:49:39] No.
[00:49:40] Aside from your power now,
[00:49:41] you have a seat.
[00:49:42] You have a seat.
[00:49:42] I was in seven hours,
[00:49:43] and almost got as you killed.
[00:49:45] I did.
[00:49:46] I once took a power nap in my car.
[00:49:48] Again, same thing.
[00:49:49] It was like eight o'clock at night.
[00:49:51] I got to the pool.
[00:49:52] I had a rule,
[00:49:53] which was after you left the hospital.
[00:49:54] You never went home.
[00:49:55] Because I knew if I went home,
[00:49:56] I wasn't going to leave.
[00:49:57] So I would always go from the hospital
[00:49:59] to the gym,
[00:50:00] or the pool,
[00:50:01] or whatever I was doing.
[00:50:02] And on this particular night,
[00:50:03] I get there.
[00:50:04] It's eight o'clock at night.
[00:50:05] I am so tired.
[00:50:06] I'm nauseous.
[00:50:07] Like the thought.
[00:50:08] So you didn't want to go home
[00:50:09] just because you knew you'd go home.
[00:50:10] I thought it was a sleep.
[00:50:11] I thought it was a sleep.
[00:50:11] You didn't want to go to sleep,
[00:50:12] because you've been awake for three days.
[00:50:13] Why didn't you want to go home?
[00:50:14] Why didn't you want to go home?
[00:50:15] Well, because I was really funny.
[00:50:20] I got a friend of mine who again,
[00:50:22] a couple years ahead of me,
[00:50:23] gave me interesting advice.
[00:50:24] Whether it was right or wrong.
[00:50:25] I don't know.
[00:50:26] He said,
[00:50:27] you're going to be tired,
[00:50:28] no matter what in residency.
[00:50:30] Don't stop doing all the other things in your life.
[00:50:33] Because you'll still be tired.
[00:50:34] Now,
[00:50:35] I don't know that that was the right advice.
[00:50:36] But I took it hard.
[00:50:37] I thought advice.
[00:50:38] And on my view was,
[00:50:39] I'm going to continue to work out.
[00:50:41] Every day,
[00:50:42] I'm not on call.
[00:50:43] I'm going to do all the stuff I want to do.
[00:50:44] So yeah,
[00:50:45] so it would be to the pool.
[00:50:46] And so same thing,
[00:50:47] I got there.
[00:50:48] But on this particular night,
[00:50:49] I was so tired.
[00:50:50] I was so nauseous.
[00:50:52] I couldn't suppress the desired vomit.
[00:50:54] And I was like,
[00:50:55] I'm not going to,
[00:50:55] if I puking the pool,
[00:50:56] they'll kick me out.
[00:50:57] I won't get this one.
[00:50:58] It's just not going to be worth it.
[00:50:59] So I was like,
[00:51:00] just sit here for like 30 minutes
[00:51:03] and take a quick nap.
[00:51:04] So same thing took the page right,
[00:51:05] which normally could wake me up.
[00:51:07] Clip it here.
[00:51:08] And it was freezing,
[00:51:09] because there was like the winter.
[00:51:10] So I left.
[00:51:11] No,
[00:51:12] it wasn't cold.
[00:51:13] But I remember wanting to leave the radio on.
[00:51:15] I like a dumbass.
[00:51:16] So the car is off.
[00:51:17] So alternator is off.
[00:51:19] Radios on.
[00:51:20] What, you know how the story ends?
[00:51:21] I wake up at 2 in the morning.
[00:51:22] Batteries dead.
[00:51:23] I'm in the middle of the parking lot.
[00:51:24] I can't, you know.
[00:51:25] Had to call my girlfriend to get jumper cables to get me out.
[00:51:29] That's a one that girlfriend went on to become my wife.
[00:51:32] So short answer.
[00:51:35] No,
[00:51:36] I didn't have a great strategy.
[00:51:37] I did have a friend who,
[00:51:39] and I never tried this.
[00:51:41] But he told me he would put coffee grounds in his eyelids.
[00:51:44] Apparently it hurts so much that you put in closer eyes.
[00:51:47] Okay.
[00:51:49] You know, that's, I mean,
[00:51:51] I would not that, but I've told people this all the time too.
[00:51:54] You know, do do a little bit of physical exercise.
[00:51:56] If you're super tired,
[00:51:57] that definitely picks you back up.
[00:51:59] There's got to be some reality or some scientific reason for that.
[00:52:03] Happening.
[00:52:04] That's another thing you can do.
[00:52:06] But,
[00:52:07] so you are so okay.
[00:52:08] We know it sucks.
[00:52:09] You're not sleeping and you're dealing with these patients.
[00:52:12] And, and how do you start to
[00:52:15] detach
[00:52:17] from this reality that's around you?
[00:52:20] So you're not getting, you know,
[00:52:22] you, you, you said already you like the kind of the emotional involvement with people.
[00:52:26] But then at the same time,
[00:52:27] you said it didn't take long before you despise these patients that are coming in.
[00:52:31] Because they're interrupting your sleep and bothering you.
[00:52:34] That's got to be a crazy balance to try and strike as a human being.
[00:52:38] I mean, human beings are not meant to be dealing with
[00:52:43] 16 puncture wounds a day.
[00:52:45] That's, that's not right.
[00:52:46] So what, what happens in your brain?
[00:52:49] What happened in your mind?
[00:52:50] What did you notice about your mentality and this whole business as time went on?
[00:52:55] Well,
[00:52:56] what I noticed,
[00:52:57] so again,
[00:52:58] not everybody becomes jaded,
[00:52:59] but most people do.
[00:53:00] And where where my sense of jaded
[00:53:02] developed was actually towards, you know,
[00:53:05] the patients of diabetes,
[00:53:06] the patients who had complications from being overweight.
[00:53:10] Like when those people would show up with, you know,
[00:53:13] the abscess and their foot in the middle of the night that needed to be
[00:53:15] debrided,
[00:53:16] those people I would get, again,
[00:53:18] pretty pissed at.
[00:53:20] Amazingly,
[00:53:22] the,
[00:53:23] the,
[00:53:24] you know,
[00:53:24] these, these trauma folks,
[00:53:25] like I kind of always maintained a soft spot in my heart for them.
[00:53:29] And interestingly,
[00:53:31] you know,
[00:53:33] it's, it's, it's, it's, it's, once they die,
[00:53:36] you know, so what happens is like,
[00:53:38] let's say a guy comes in,
[00:53:39] you guys been shot.
[00:53:40] You know, generally people who are dead in the field don't make it in.
[00:53:43] So, so, but, but sometimes there's this gray zone where,
[00:53:46] you know,
[00:53:47] someone comes in who's basically dead,
[00:53:49] but because they had a little bit of a pulse on the way in the door,
[00:53:52] like we're going to do everything we can.
[00:53:54] But a lot of times when those patients die,
[00:53:57] like the room has to be turned over really quickly,
[00:54:00] which means someone's got to come in,
[00:54:02] take the body, put it in a body bag,
[00:54:04] gather everything because usually these are criminal investigations.
[00:54:06] So the police are there,
[00:54:07] the housekeeping staff has to come in and mop all the blood off the floor,
[00:54:11] because depending on where the gunshot wound was,
[00:54:13] like gunshot wound at the head, for example,
[00:54:14] tons of blood,
[00:54:15] because the head's a confined space.
[00:54:17] Um,
[00:54:19] and in that moment,
[00:54:20] it's really easy to just immediately walk out the door,
[00:54:23] but I find myself, you know,
[00:54:24] I, I'd,
[00:54:24] I'd sometimes like flip through their wallets,
[00:54:26] right?
[00:54:27] And,
[00:54:28] you know,
[00:54:29] invariably you'd see something like you'd see a picture of a little kid.
[00:54:31] So you,
[00:54:32] you see this guy who's huge,
[00:54:34] who's just been killed,
[00:54:35] he's probably 25,
[00:54:37] and you'd see like this six year old girl in his wallet.
[00:54:40] And you, you know,
[00:54:41] you'd start to sort of wonder what the narrative is, right?
[00:54:43] Like,
[00:54:44] was that his daughter?
[00:54:45] Probably.
[00:54:46] Did he know her?
[00:54:47] Probably.
[00:54:48] Did she know him?
[00:54:49] Maybe not.
[00:54:50] Like, you just don't know.
[00:54:51] And all of a sudden,
[00:54:52] that's, that's sort of humanizes these,
[00:54:54] these guys.
[00:54:55] And, and again,
[00:54:56] I think because of my own understanding of what they were dealing with,
[00:54:59] because of those 16 penetrating traumas,
[00:55:01] 15 had to be drug involved,
[00:55:03] in one way or another.
[00:55:05] And so everybody who we're taking care of for the most part,
[00:55:10] was some part of the cycle that's being described in the corner.
[00:55:13] Now occasionally it wouldn't be.
[00:55:15] I mean,
[00:55:16] one of the examples that stands out that was,
[00:55:18] I would say sort of like,
[00:55:19] a top five saddest things I ever saw in residency
[00:55:23] was July 1st, 2002.
[00:55:24] I just happen to remember that day
[00:55:26] and this girl on her 16 years old,
[00:55:28] she was a girl on her 16th birthday,
[00:55:30] came in and she was just,
[00:55:32] she was just hit by a stray bullet in her neighborhood.
[00:55:34] It was her 16th birthday,
[00:55:36] stray bullet from,
[00:55:37] you know, unrelated gang violence,
[00:55:38] hit her in the head.
[00:55:39] And, you know,
[00:55:40] she's an example of someone who came in
[00:55:42] basically dead,
[00:55:43] but in situations like that,
[00:55:45] like, you know,
[00:55:46] I'm sure you can relate to this.
[00:55:47] You're just going to do something that's so,
[00:55:49] beyond her road.
[00:55:50] You want to do anything and everything to try to save her.
[00:55:52] And of course, we couldn't.
[00:55:53] So, you know,
[00:55:54] those examples are kind of rare,
[00:55:56] but the majority of the times,
[00:55:57] it's, you know,
[00:55:58] executions for people who stole money.
[00:56:00] That's,
[00:56:02] those would be hard to see, right,
[00:56:04] because you could,
[00:56:05] these girls, you know,
[00:56:06] this is like,
[00:56:07] this is a deadly game.
[00:56:08] No, even the,
[00:56:09] even the girl,
[00:56:10] the 16-year-old girl,
[00:56:11] she's part of the cycle too,
[00:56:12] because that's a stray bullet.
[00:56:13] That's right.
[00:56:14] She's in a,
[00:56:15] she's in a lousy neighborhood.
[00:56:16] You can almost guarantee that,
[00:56:17] you know,
[00:56:18] if she's living in where she's living,
[00:56:19] to get hit by a stray bullet,
[00:56:20] like, you know,
[00:56:21] she wasn't living in,
[00:56:22] you know,
[00:56:22] Roland Park.
[00:56:24] And,
[00:56:25] and when, once you did,
[00:56:27] did you,
[00:56:27] would you ever see any family?
[00:56:28] Would any family ever come in?
[00:56:30] Yeah,
[00:56:31] so there's two types of things going on, right?
[00:56:33] So, so,
[00:56:34] the,
[00:56:35] the biggest,
[00:56:36] problem we would have
[00:56:37] would be real gang on gang stuff,
[00:56:40] because,
[00:56:41] it became sort of a feed forward loop, right?
[00:56:44] So, if one guy came in and he was killed,
[00:56:47] you immediately knew the floodgates were going to open,
[00:56:50] because there's going to be retaliation that night.
[00:56:53] I don't remember that the police were pretty,
[00:56:56] good about trying to,
[00:56:59] make sure that,
[00:57:01] like, when someone came in and who was killed,
[00:57:02] like, if you weren't immediate family,
[00:57:04] you were not allowed there.
[00:57:05] And they also tried to create a little bit of a delay
[00:57:08] and letting that information out.
[00:57:10] Again,
[00:57:11] maybe that wasn't the,
[00:57:12] the,
[00:57:13] the most considerate thing to do,
[00:57:14] but their view was trying to let the violence dissipate.
[00:57:17] Um,
[00:57:18] yeah,
[00:57:19] the family stuff's hard.
[00:57:20] I mean,
[00:57:20] the hardest family interaction I ever had
[00:57:22] with it was with actually a blunt trauma,
[00:57:24] and it wasn't involving drugs at all, right?
[00:57:26] This was a,
[00:57:27] this was,
[00:57:28] um,
[00:57:30] a boy.
[00:57:31] He was 15 years old.
[00:57:33] He and his brother,
[00:57:35] his older brother,
[00:57:36] who was probably 18,
[00:57:37] had picked him up after school.
[00:57:38] They were driving home.
[00:57:40] And they were,
[00:57:42] they had the right away,
[00:57:43] and a guy ran a red light
[00:57:45] and teaboneed them on the passenger side.
[00:57:48] And this,
[00:57:49] the 15 year old boy,
[00:57:51] the older boy came in as an adult trauma.
[00:57:53] So he went to the adult side.
[00:57:54] I happened to be on pediatric surgery.
[00:57:56] Like I was the senior resident on pediatric surgery
[00:57:58] that month.
[00:57:59] So I ran the pediatric trauma,
[00:58:00] which is where the 15 year old came in.
[00:58:03] And that turned out that older,
[00:58:05] the driving sun was fine.
[00:58:06] He didn't have a scratching on his body.
[00:58:08] But this kid came in,
[00:58:09] basically dead on arrival.
[00:58:11] Though it wasn't clear why,
[00:58:12] but his pupils were blown,
[00:58:14] um,
[00:58:15] you know,
[00:58:16] little bit of a pulse,
[00:58:18] we did,
[00:58:21] you know,
[00:58:22] probably 30 minutes of everything imaginable
[00:58:26] before accepting the reality
[00:58:28] that he cheered his Aorta.
[00:58:29] So if a high enough force
[00:58:32] can actually shear the Aorta
[00:58:33] and it dishexed,
[00:58:34] and you basically bleed to death
[00:58:36] inside the wall of the Aorta.
[00:58:38] And that's why he died.
[00:58:39] And that was another example of how
[00:58:42] everybody just sort of scatters after that.
[00:58:43] But you know,
[00:58:44] his mom is in a waiting room,
[00:58:46] wondering where her boys are,
[00:58:48] who,
[00:58:49] you know,
[00:58:50] could have been an offender
[00:58:51] for all she knows.
[00:58:52] So,
[00:58:53] those were,
[00:58:55] I mean,
[00:58:56] unquestionably the most difficult
[00:58:57] discussions ever,
[00:58:58] because trauma is the one area
[00:59:00] where there's complete surprise.
[00:59:03] Like,
[00:59:04] you know,
[00:59:05] it's tragic when somebody dies from cancer.
[00:59:06] It's even tragic when somebody dies
[00:59:08] during an elective surgical operation,
[00:59:10] which happens,
[00:59:11] unfortunately, in the meantime.
[00:59:12] But at least there,
[00:59:13] you have some heads up
[00:59:14] that's something dangerous is going on.
[00:59:16] But this kid,
[00:59:17] like,
[00:59:18] you know,
[00:59:19] said goodbye to his mom that day,
[00:59:20] went to school and never came back.
[00:59:21] And now she hears,
[00:59:22] oh,
[00:59:23] he's in a car accident,
[00:59:24] and she's in the hospital,
[00:59:25] never imagining that he could be dead.
[00:59:28] And then you have to be the guy that goes in and say,
[00:59:30] you know,
[00:59:31] I'm really sorry to tell you this,
[00:59:32] but your son is dead.
[00:59:34] You know,
[00:59:35] there's actually a really interesting,
[00:59:37] article written in The New York Times
[00:59:39] on this exact topic,
[00:59:41] but I'm an interesting story.
[00:59:44] So my mentor in medical school
[00:59:46] to this day,
[00:59:46] one of the closest mentors I've ever had
[00:59:48] as a guy by the name of Steve Rosenberg.
[00:59:50] So Steve Rosenberg is the chief of surgery
[00:59:53] at the National Cancer Institute.
[00:59:54] And he's kind of one of the luminaries
[00:59:56] in immunotherapy.
[00:59:57] So I did my postdoc with him at the NIH.
[01:00:01] And I actually spent time there in medical school,
[01:00:04] and actually he just called me yesterday
[01:00:05] out of the blue.
[01:00:06] We didn't have to have a great catch up for 30 minutes.
[01:00:08] His daughter,
[01:00:09] his three daughters, his youngest daughter,
[01:00:11] is Naomi Rosenberg,
[01:00:13] who's a resident at,
[01:00:15] and I think she's an emergency room doc at Penn,
[01:00:18] which is also when a war zone in Philly,
[01:00:20] and she wrote a great piece on this,
[01:00:23] which maybe we could link to in the notes or something.
[01:00:26] It's probably like the last three months
[01:00:28] about the difficulty of having to communicate
[01:00:31] to families when tragedies like this happen,
[01:00:34] which of course you should see a lot of as well in Philly.
[01:00:37] And then that happens.
[01:00:40] So you do everything you can to save this kid's life.
[01:00:45] And then you walk in,
[01:00:47] you face the mother,
[01:00:49] you drop the most devastating,
[01:00:51] possible, imaginable news on her.
[01:00:54] And you gotta go back to work.
[01:00:57] I mean, right?
[01:00:58] I mean, don't you then have to,
[01:01:00] you have to go work again now.
[01:01:03] Yeah, that night in particular,
[01:01:05] that was, that was,
[01:01:08] I remember that day pretty well.
[01:01:10] That was April of 2003 when that boy died.
[01:01:15] And by the time we had declared time of death,
[01:01:21] and I had gone to talk to his mom,
[01:01:23] it was probably like 10 o'clock at night.
[01:01:25] You know, I probably spent an hour with her.
[01:01:28] And of course it's disruptive because you're in there
[01:01:30] and your page is going off.
[01:01:31] I've got the ER calling me about this kid,
[01:01:33] I've got the ICU calling me about this.
[01:01:35] And she's, you know,
[01:01:39] I mean, like, I gotta,
[01:01:41] I gotta sure hope I never have to know what she went through,
[01:01:44] because I can't, can't really imagine, right?
[01:01:47] I mean, she's hysterical at a level that you just,
[01:01:50] like a movie doesn't do justice to that.
[01:01:52] Like you don't see that level of hysteria normally.
[01:01:56] And I, that was certainly like one of kind of the three or four
[01:02:01] that really upset me the most.
[01:02:03] I mean, I, I had a real hard time,
[01:02:05] and I think I got lucky that night.
[01:02:07] I think that night and that I'd be in a pretty calm night.
[01:02:09] I remember I got to probably spend some time
[01:02:12] just alone in a calm room that evening, you know.
[01:02:15] And, and for me that was,
[01:02:17] so the, this is the awful thing here.
[01:02:19] We tend to project what's going on in our own life
[01:02:21] into any situation.
[01:02:22] I mean, I, I think I realized that pretty early.
[01:02:24] And so I think in the case of that particular trauma,
[01:02:28] I saw in that boy, my brother.
[01:02:30] My brother, my younger brother.
[01:02:32] And so I, so I was dealing with two things in that moment.
[01:02:35] One was,
[01:02:36] meaning from my own and not, not the immediate issue,
[01:02:40] which is this boy died.
[01:02:41] One is, I'm imagining now like this could be me
[01:02:44] and my brother in high school.
[01:02:46] Like this could have been us.
[01:02:47] And how, how your life changes after that.
[01:02:50] Like I thought his brother's life is never going to be the same.
[01:02:53] The second was, this was already after I had decided
[01:02:57] to leave medicine altogether.
[01:02:59] Which was in June of 2006.
[01:03:02] And this, this trauma was like April of 2006.
[01:03:06] So I've decided in March of that year that I was just going to finish that year and then leave.
[01:03:10] So, so the other thing that was sort of that I was struggling with,
[01:03:15] which probably makes this a little heavier than it needed to be,
[01:03:18] was,
[01:03:20] as painful as this is,
[01:03:22] it's a privilege to be this person.
[01:03:24] It's a privilege to be the guy who gets to try to save a life.
[01:03:27] And even when you fail,
[01:03:29] that interaction you're going to have with that family,
[01:03:32] which I think is something Naomi wrote about in that piece.
[01:03:35] It's so important.
[01:03:36] It seems trivial to us because you have that interaction over and over and over again.
[01:03:39] But to that family, it's so important.
[01:03:42] That will be with them forever.
[01:03:44] And I think I felt that that was a privilege.
[01:03:46] And so I think I realized like, I'll never do this again.
[01:03:49] I'll never again have that privilege to,
[01:03:52] even if I fail to try to, you know, sort of say somebody to actually then be able to,
[01:03:56] comfort that family.
[01:03:58] And that sounds really weird.
[01:04:00] It's a very morose sort of thought to have.
[01:04:02] But all of those things, I think, in that particular example,
[01:04:06] you know, made for a really difficult set of, you know, days and weeks at fall.
[01:04:13] And I went to his funeral.
[01:04:14] First patient I ever went to a funeral of a first trauma patient.
[01:04:17] Certainly went to the funeral's of patients.
[01:04:19] You've got to know through, you know, people were dying of cancer and stuff.
[01:04:22] But, you know, trauma patient, like you just wouldn't think to go to someone's funeral
[01:04:25] that you'd never known because like, I'd never known that boy, right?
[01:04:29] I stayed in touch with his mom for a few years and not surprisingly,
[01:04:33] their life just completely fell apart, you know.
[01:04:37] Does it make it that much worse that you got this,
[01:04:42] you juxtaposed the kind of this normal kid, right?
[01:04:47] Who dies this random accident?
[01:04:49] And then at the same time every night, you've got people that are killing each other.
[01:04:54] And you're seeing the results of that and you can't do anything about it.
[01:04:59] How does that also play into your thoughts about, hey,
[01:05:05] I'm here trying to save these people's lives and they're out there killing each other.
[01:05:10] For over nothing, over the street corner, over this, over that.
[01:05:13] Did you go down that road mentally?
[01:05:16] Not there. I'll tell you the one time I felt really ethically,
[01:05:20] maybe ethically, it's too strong, a word, but just to be blunt.
[01:05:23] I mean, the one time I was really pissed off that I was trying to save somebody's life
[01:05:27] was a guy that came in who killed his wife, killed his daughter,
[01:05:34] and then put the gun in his under his chin and pulled the trigger and missed.
[01:05:41] So he basically blew off the side of his face and was still alive.
[01:05:46] His brain was completely intact.
[01:05:48] This guy was going to survive after 23 face operations.
[01:05:53] And I'm taking care of this guy and the ICU and I'm kind of pissed off about it actually.
[01:05:59] And maybe I shouldn't be, who am I to judge this guy?
[01:06:02] But I'm like, you killed your wife, you killed your kid and you wanted to die.
[01:06:07] Why the hell am I putting anything into you?
[01:06:10] Now, of course, that is a slippery slope because in medicine we're never supposed to play that role.
[01:06:15] We're never, we never play God.
[01:06:18] People, some doctors want to act like they're playing God, but we never play God.
[01:06:22] We're just there to do a job.
[01:06:24] And on that day, I remember thinking, I got to do this job.
[01:06:27] I don't want to take care of this guy.
[01:06:29] I want this guy to die actually.
[01:06:31] How do they address that when you're going to medical school?
[01:06:34] That whole idea.
[01:06:37] They've got to cover it out.
[01:06:38] Or is it just so underlying the underlying theme of everything you do
[01:06:43] at the time you get done?
[01:06:45] It's there.
[01:06:46] That's a really good question.
[01:06:47] I don't know.
[01:06:48] Are there ethics classes in medical school that teach you that?
[01:06:52] I am sure there are.
[01:06:54] The fact that I can't tell you one thing about an ethics class, I took, tells you it's
[01:06:58] that whatever ethics you have are going to be independent of whatever class you're taking.
[01:07:04] And who knows, today, these pendulum swing from one end to the other.
[01:07:08] For all I know, you know, half the curriculum could be ethics today.
[01:07:12] I don't know.
[01:07:13] But the short answer is I think, you know, it's sort of internal.
[01:07:18] And the reality is, you know, if you're in a good program and the one thing I'll say,
[01:07:21] I mean, as much as Hopkins was a brutal place to exist.
[01:07:26] The camaraderie there was unbelievable.
[01:07:30] I mean, you know, the nickname for the residence was the Hallstead Marines, right?
[01:07:34] Which, again, doesn't do justice to real Marines,
[01:07:37] but that was sort of the camaraderie, right?
[01:07:39] It was like you would do anything for your, you know,
[01:07:41] that's why you'd always volunteered to stay up three nights to help somebody else out.
[01:07:46] And so, you know, I had really great friends there.
[01:07:49] In fact, to this day, like some of my closest friends, people that I'm in touch with
[01:07:52] almost every day were guys I went through that experience with.
[01:07:57] And you could talk about those things with each other, right?
[01:08:00] I mean, you know, it was okay to say, like, I really wish this mother fucker would die.
[01:08:06] Because he's taking up a bed.
[01:08:08] He's costing the state a million bucks.
[01:08:11] And I hate him.
[01:08:13] And I somehow being able to talk about that, I think, makes it a little bit easier, right?
[01:08:19] Well, absolutely.
[01:08:20] I mean, any, that's what happens in the military.
[01:08:22] You get guys that go through tough situations, tough battles,
[01:08:26] and they, they become closer going through it.
[01:08:29] And part of the thing that brings them closer together is to your talking about what's going on.
[01:08:32] Has it happening and after it happens?
[01:08:34] What did you,
[01:08:36] I mean, I think that's what I'm talking about.
[01:08:39] So a lot of times in this podcast, I say that this podcast,
[01:08:43] yeah, we talk about war and we talk about leadership and we talk about history.
[01:08:49] But I find that the actual root of what the podcast becomes about is,
[01:08:55] is really about human nature and what people, what human beings are like.
[01:09:01] Was there, I'll give you both sides of this question, did you learn anything about people about human nature?
[01:09:09] There, that was surprisingly positive.
[01:09:14] And before you answer that one, did you learn anything about human nature while you were there?
[01:09:18] That was surprisingly negative.
[01:09:24] So, so I'll give you one thing that I learned that I don't know that I would call positive or negative,
[01:09:29] but it was an observation that in retrospect seems obvious,
[01:09:34] but it never would have, I never would have thought of it before and to this day,
[01:09:39] it still serves me well to understand it.
[01:09:42] So the first observation is that when you look at a significant illness,
[01:09:50] like a completely disruptive insult, you know, cancer,
[01:09:56] you have pancreatic cancer, which means you're going to die, and you're going to die soon.
[01:10:02] There are two types of families that come into that situation.
[01:10:07] So families that show up already fractured get blown apart.
[01:10:12] Fractures that, for families that show up already tight become the tithest of any family.
[01:10:19] The same would be true when you see a kid that comes in, a burn victim,
[01:10:25] right, this kid that gets burned badly on the 4th of July, and this kid's going to spend the next two months in the hospital.
[01:10:31] You know, a couple that comes in with tension already in their marriage,
[01:10:35] they get splintered wide open.
[01:10:38] If they came in and everything was fine, they're going to be there for each other.
[01:10:42] They're going to be tighter.
[01:10:43] So that was an observation that I just saw over and over and over again.
[01:10:46] And I saw it in probably even more vivid color when I was at the NIH,
[01:10:53] because the two years I was there, you know, as mostly doing research,
[01:10:57] but you still had clinical responsibilities, and so you're basically seeing patients who are coming to receive experimental therapy for cancer.
[01:11:04] So these are patients who are all, you know, otherwise going to die within six months.
[01:11:08] And most of them will still go on to die, obviously, the subset of them we can help,
[01:11:12] but you're seeing that over and over again.
[01:11:14] So that was the first observation.
[01:11:16] And then the second was that there were just a couple of residents who I couldn't believe how amazing they could be,
[01:11:25] who how they could never sort of do the wrong thing.
[01:11:31] So there were two residents in particular.
[01:11:33] One really, he was, he, his name is Chris Sondende.
[01:11:37] He is now a, he's a transplant surgeon at the University of Michigan, amazing guy.
[01:11:42] And so Chris was two years ahead of me. And I mean, he was like that guy that I would have done anything for.
[01:11:49] And I remember when I was leaving, thinking to myself, you know,
[01:11:54] I'm really glad I'm leaving because if I stayed, I'd know I could never be as good as Chris.
[01:12:01] Like that, like how can someone be this good?
[01:12:04] And I don't mean, like he can sew this good and cut, I don't mean even medically.
[01:12:09] Good human being. Just as exactly as a human being.
[01:12:13] He is on a level. I can't get to.
[01:12:17] And, you know, I don't know anybody else who can get there either, but the fact that I can't get there is a little upsetting to me.
[01:12:26] And I'm glad I don't have to spend the rest of my life chasing him.
[01:12:30] Which of course, Chris would never think of it that way.
[01:12:32] Because that's the nature of being that guy as you, he's just completely humble, modest, unassuming guy,
[01:12:38] who just happens to be a guy.
[01:12:41] You know, it's going back to the first point that you mentioned, and it's something that I've heard people talk about as well.
[01:12:49] My buddy's talk about is, you know, the whole idea of post-traumatic stress and all that.
[01:12:56] And what war does to people?
[01:12:59] And one thing that I happen to agree with is pretty similar to what you're saying.
[01:13:03] And what is going into the war, right? If the person is got a good stable mindset and a good attitude and is a positive person,
[01:13:15] and they're going to come out of it with all those good positive things amplified.
[01:13:19] They're going to be more positive. They're going to be stronger. They're going to be mentally tougher.
[01:13:23] It's the people that go into it that are already somehow fractured.
[01:13:28] Those fractures are going to get worse through the trauma of combat.
[01:13:32] This is a broad generalization. And there's definitely great guys that see things or do things that they, that it hurts.
[01:13:39] And it takes them a while to get through it.
[01:13:41] But there's also some guys you go, you know, that guy was messed up when we showed up.
[01:13:46] And now he's worse in it. And it's that pressure that opens up those fractures even wider.
[01:13:51] And it's interesting that you got this, you saw that with family structures as well.
[01:13:56] And I could completely see how that happens.
[01:13:58] That happens. That happens. Right. That happens. And you don't even need trauma to make that happen.
[01:14:02] I mean, you get the financial trauma on a family. If they're not tight, that'll, that'll make them blow up.
[01:14:07] Yeah. Whereas if they're tight, you know, going through some financial problems, they'll get tighter.
[01:14:11] They'll buckle down. They'll save money together. They'll skip the movies. They'll start, you know,
[01:14:15] they'll enjoy cooking raw manoodles together.
[01:14:18] So that trauma can, can expose those fractures. That's why it's important to try and
[01:14:24] create the most solid foundation you can with your family and with your own mind.
[01:14:29] So that when these traumas hit, you don't get fractured.
[01:14:32] Do the seals screen for that.
[01:14:35] They try to, but you'll like this story.
[01:14:40] So we had to take a psychological screening. This isn't a 90.
[01:14:43] So it wasn't like we were super advanced on any stuff.
[01:14:46] And I'm going, and when I was going through bootcamp,
[01:14:49] they gave us a psychological screening for, for our attempt to go to to seal training.
[01:14:55] And so they asked a bunch of questions and it was complete the sentence questions.
[01:15:00] And so it would, it was really obvious what would, what would flag you.
[01:15:05] And for, and, and so I made every answer, because we, I was in bootcamp and the food sucked.
[01:15:10] And so every answer that I gave was just all about food.
[01:15:13] So for instance, they, they'd say complete the sentence.
[01:15:17] I hate when my mother, right? So it's pretty easy to think to say,
[01:15:22] you know, I hate when my mother shuns me in front of my sisters and I want to kill her.
[01:15:27] No, no, no, no. All my answers were like, you know, I hate when my mother over cooks this steak
[01:15:33] and doesn't put enough pepper on it.
[01:15:35] You know, just like every answer I gave was about food.
[01:15:38] But it was really easy. My point is that it was really good.
[01:15:41] If you were not a complete, even if you were, if you, in fact,
[01:15:45] if you were a psychopath, you would very easily say, answer all the questions correctly and get through it.
[01:15:50] And there's been plenty of guys that made it through seal training that, you know,
[01:15:53] there's, there's a bad criminals.
[01:15:55] There's, uh, there's been a couple really heinous crimes committed by guys that were seals.
[01:16:00] And just, just, if they made it through, they got screened.
[01:16:04] So yeah, they, they had a screening, but I wouldn't say it's the most effective.
[01:16:07] They've gotten better now, you know, and some of those guys that committed horrible crimes,
[01:16:11] it, you know, kind of inspired the seal teams to step up that screening process as much as possible to make sure that we're not let guys through that are,
[01:16:18] that are deranged some way that are going to do something horrible like that.
[01:16:23] Um, you kind of already talked about these, but is there any other thing that,
[01:16:31] that you learned about yourself in that situation?
[01:16:36] And, and you, I didn't really know too much about the, uh, where you went afterwards at the NIH?
[01:16:41] If you want to go into that a little bit, but what did you learn about yourself through this whole process?
[01:16:46] Obviously you learned something because at some point you decided, you know what, I don't want to, I don't want to do this.
[01:16:52] Yeah, I mean, those are, those are some of the most interesting years of my life.
[01:16:58] And I am pretty glad that I didn't have my first kid till I was 35,
[01:17:03] which on the one hand you sort of think, well, God, I'm so old, you know, like I'm not going to be,
[01:17:08] I'm not going to be like the 50-year-old grandfather, right?
[01:17:12] Um, but on the other hand, I think it's a really good thing because when I think about what was going on in my mid to late 20s,
[01:17:18] you know, the sort of really difficult decisions I had to make.
[01:17:23] I mean, leaving medicine after being in it for 10 years was a really difficult decision.
[01:17:27] Especially to go and do something that had nothing to do with medicine.
[01:17:30] I mean, when I left, I joined a consulting firm McKinsey in company,
[01:17:34] and I did credit risk modeling.
[01:17:36] Like I didn't have a think.
[01:17:38] The fact that I was a doctor was like a liability.
[01:17:41] There was no, like it was like starting all over again in life.
[01:17:44] Um, so to get to that point, yeah, I had to go through a whole bunch of stuff.
[01:17:51] So I think, I mean, I don't even know where to begin.
[01:17:55] I mean, I think one thing I learned was,
[01:17:57] so this fellow that I alluded to earlier Steve Rosenberg, who is,
[01:18:01] again, to this day probably one of the most important mentors in my life,
[01:18:05] outside of family members.
[01:18:07] Um, just an amazing human being, right?
[01:18:11] So just kind of on another level.
[01:18:13] And I remember even asking him after being in his lab for two years.
[01:18:16] Because remember, we had a couple of people in the lab who I just didn't think were that good.
[01:18:20] They really bugged me.
[01:18:22] They're existence bothered me.
[01:18:24] And I, and I finally after being in the lab for two years,
[01:18:28] worked up the courage to ask him like how he,
[01:18:31] because he's like this guy who's going to win a Nobel Prize.
[01:18:34] Like he's changing the game.
[01:18:36] And yet we had a couple people that I kind of thought were bottom feeders.
[01:18:40] And I was like, you never get upset at them.
[01:18:44] Like ever, I've never seen you get upset at these people.
[01:18:47] How?
[01:18:49] And he said, you know, Peter, I just look at everybody
[01:18:52] and I figure out at least one thing that they can do well.
[01:18:57] And I just figure out a way to empower them to do that one thing,
[01:19:00] even if they can't do the ten things that I would expect you to do.
[01:19:04] I remember thinking, I understand in theory what you're saying.
[01:19:09] I can't do that.
[01:19:11] I can't tolerate mediocrity.
[01:19:14] So that was a huge thing that I learned.
[01:19:18] And it never really hit home again until I was running a non-profit.
[01:19:24] Because there wasn't a lot of mediocrity at Hopkins.
[01:19:27] You sort of had your pick of the best residents there.
[01:19:31] Everybody there was the best at what they did.
[01:19:33] You had amazing nurses, amazing residents,
[01:19:35] amazing respiratory therapist.
[01:19:37] And like everybody there was like the best of their field, right?
[01:19:41] And then I go to McKinsey same thing.
[01:19:43] You've kind of got the best of the best all over again.
[01:19:46] But you know, fast forward five years, I'm now running a non-profit.
[01:19:49] Well, all of a sudden you don't get the best at the best anymore.
[01:19:52] You're drawing from like the third pool.
[01:19:54] And I remember coming back to that, which is, you know what?
[01:19:58] You're probably not cut out to do this.
[01:20:01] You have two choices.
[01:20:02] Don't be a leader.
[01:20:04] Just be your own dude.
[01:20:06] Or be a leader.
[01:20:07] But only with A players.
[01:20:09] But this notion of like you have the capacity to mentor the C players.
[01:20:14] And maybe turn it into a B plus player.
[01:20:17] Like I don't have those genes.
[01:20:18] I can't do it.
[01:20:19] And not only that, like I will destroy the C player.
[01:20:22] And I don't mean to, but I will bury them in the ground
[01:20:26] and become a horrible human to them.
[01:20:28] So I also realize like I can be a really bad person.
[01:20:32] If I don't, if I don't respect the work that someone's willing to do.
[01:20:38] So do you, or do you ever have to find a counter to that?
[01:20:42] Because like if you're in the military and you and I were working together,
[01:20:45] I would be like, hey Peter, you got to get, you got to get, you got to act like,
[01:20:48] what is it, what is it, whatever.
[01:20:50] You got to act like him.
[01:20:51] Because in the military, you're not getting a player.
[01:20:53] So I mean, you got some great guys.
[01:20:54] You, you know, sealed teams.
[01:20:55] You got some great guys that are stud.
[01:20:56] You got some okay guys that are in the middle.
[01:20:58] You got some losers down at the bottom.
[01:20:59] Guess what?
[01:21:00] You need everything.
[01:21:01] Go on the tongue.
[01:21:02] And they all got to give you what you everything may can.
[01:21:05] And the more you create conflict with them and the more you are talking
[01:21:08] down to them, the less they're going to do.
[01:21:10] You know how they're already a sea level player or a sea level player.
[01:21:13] Yeah, they're going down.
[01:21:14] You're not, you're not making them any better.
[01:21:16] So that's, did you ever try and correct that or you just go through and say, you know what?
[01:21:21] You've realized that that's like a weakness of yours.
[01:21:23] I want to be clear.
[01:21:24] There are two attributes that you can be a sea player in and I can cope with one,
[01:21:30] but I can't cope with the other.
[01:21:31] And I accept it fully.
[01:21:33] I can cope with someone who has a sea plus intellect.
[01:21:37] So if you think about the intellect as the CPU or the computer,
[01:21:40] I don't need everybody to have the fastest CPU.
[01:21:43] I accept the fact that like we all have different sort of innate capacities to sort of process
[01:21:49] and do and you know, we all move at different speeds.
[01:21:52] I can cope with variability there where I cannot cope with variability or maybe I've just chosen
[01:21:57] I don't want to.
[01:21:58] Is I can't cope with variability on intent, work ethic, integrity.
[01:22:04] Like when you, if you can't be an A player there, I actually don't want you in my life anymore.
[01:22:09] And I think I'm old enough now that I've just had fuck it.
[01:22:12] You know, I'm not going to deal with it anymore.
[01:22:14] Life is too short and I'm not going to deal with sea players who fail on those metrics.
[01:22:19] Right?
[01:22:20] I don't care how smart you are, but if you can't show up and work your ass off,
[01:22:24] if you can't be honest, if you can't care, if you can't want to get better,
[01:22:29] I actually don't want you in my life.
[01:22:30] So you're right.
[01:22:31] I probably, I mean, I think I'm probably not cut out to be a leader because I can't take
[01:22:36] those people who are failing on those metrics and work with them.
[01:22:40] Well, you just need to be a leader of a very high performing team,
[01:22:44] not of a regular regular team.
[01:22:49] Yeah.
[01:22:50] Yeah.
[01:22:50] I never had problems, right?
[01:22:51] So when I was a resident, you know, residency is very hierarchical, right?
[01:22:56] You know, you've got the med student, the sub by, the intern, the second your resident,
[01:22:59] the senior resident, the chief resident, the fellow, the attending.
[01:23:02] I mean, it's, it's, it's as clear as day who's in charge any moment in time.
[01:23:06] And as I'm going up through those ranks, for the most part,
[01:23:10] I never really had difficulty with the teams underneath me, but again,
[01:23:13] I had the luxury being at Hopkins.
[01:23:15] Everybody there is the best.
[01:23:16] The best student, they're the best, they're the resident, they're the best.
[01:23:19] McKinsey, same thing.
[01:23:20] You know, you're dealing with the best of the best.
[01:23:22] But yeah, running a non-profit, it was like a totally different world to me.
[01:23:27] And so I think the difference is a great leader could have succeeded in any environment.
[01:23:33] You know, they could have done it.
[01:23:34] They could have figured out like, okay, the reason this person, like, acts like a lazy
[01:23:39] sack of shit is actually because of this.
[01:23:42] And you can like figure out a way to like, touch them and help them out of that.
[01:23:47] And I was just like, yeah, I'm not doing it.
[01:23:50] So that was, so that's, that's going back to NIH.
[01:23:55] And you, that was the first time you dealt with people.
[01:23:58] That's the first time I'd sort of seen in a long-term working environment, like a couple
[01:24:03] people who weren't top agents.
[01:24:05] And again, maybe part of it's because you're in the government at that point.
[01:24:08] And you get some staff people there, maybe who, you know,
[01:24:12] and part of it, I think, was just because Steve Rosenberg was such an amazing guy.
[01:24:15] And he could get the best out of everybody that he might have just had a greater tolerance for that.
[01:24:19] I think the second thing I learned was I would never be a world-class scientist.
[01:24:28] So when you go to NIH, you're really only going for one reason.
[01:24:31] I mean, I'm sure there's some people that go there just to check the box and say,
[01:24:34] I was at the NIH.
[01:24:35] That wasn't why I went.
[01:24:36] I went because Steve Rosenberg was my hero when I was in medical school.
[01:24:39] I read his book called the Transform Cell.
[01:24:42] And I was like, that book just, you know, that book along with another book by a guy
[01:24:46] and Richard Feynman called Shirley, your joking Mr. Feynman became kind of two of the most important books.
[01:24:50] You know, I read during, you know, my 20s.
[01:24:54] And actually wouldn't date somebody.
[01:24:57] I wouldn't date a girl until she read them.
[01:25:00] I'm going to go into after the podcast.
[01:25:03] You and I'm going to go to a full on counseling session.
[01:25:09] You need help.
[01:25:12] So I went to NIH because I was like, look, this guy is my god.
[01:25:20] And like, I want to be like that, right?
[01:25:24] I want to be the best surgeon scientist that ever lived.
[01:25:30] And then I got there and I realized that surgery and science couldn't be more different.
[01:25:35] Surgery is the ultimate immediate gratification. Like, surgery, you get to fix the problem in hours.
[01:25:44] Science is a lifetime of work.
[01:25:47] A lifetime of failure before success is in fact one of the most remarkable stories from Rosenberg's book,
[01:25:53] which of course I read while in medical school, but it wasn't until a decade later when I'm living it that I really understood why he was great
[01:26:01] and why I couldn't be great was when he arrived at NIH in 1974 until he really had his first success was about 10 years.
[01:26:10] So for 10 years everything he was trying was failing and every patient died.
[01:26:16] Every single person that showed up died until this one woman in 1984.
[01:26:23] When finally they figured out how to do something called interlucantoo and they finally sort of cracked the first piece of what has turned into a very long code.
[01:26:33] That 30 years later we're just starting to make really amazing traction on.
[01:26:39] Now think about that for a second.
[01:26:41] 43 years ago he started that job for 10 straight years he just lost.
[01:26:48] It's like you're going to go pay pickup every day for 10 years and lose every day.
[01:26:55] So what I realized was actually I don't have that intestinal fortitude.
[01:27:00] I cannot fail that frequently and still be at my best the next day.
[01:27:07] And again I hated knitting that because it sounds awful.
[01:27:10] It sounds like I'm a sock and I guess I suck but I realized like I could be good.
[01:27:14] I mean I could go after easier problems to solve where you can like you know get grants and you know just play the game and that's frankly what most people do in this space.
[01:27:24] But if you want to like change the game if you want to change mankind if you want to do something seminal you have to be willing to fail forever.
[01:27:37] And I realized like I don't I find that ups again it's not that I'm addicted to the win it's not like oh I have to be told good boy good boy good boy but I need some win.
[01:27:46] I need to know that I have some control over my fate whereas in surgery you have some control over your fate.
[01:27:52] You know there is a difference between being a good surgeon and being a bad surgeon and it's not to say there's not a good scientist and a great scientist but in science.
[01:28:00] You are far less in control of what's going on than in surgery.
[01:28:04] Now he must have had some long term vision hypothesis that he absolutely believed it.
[01:28:11] He laid it out he said there are four things that have to be true if we're going to ever figure out a way to get the immune system to fight cancer.
[01:28:17] These four things have to be true and if they're not true the immune system will never be able to fight cancer.
[01:28:23] And it took ten years just to figure out the first proof of concept in a human.
[01:28:28] So yes they had a couple of successes in mice where they had demonstrated okay like at least in mice you can do this.
[01:28:35] But in cancer biology you know you don't get terribly excited about doing stuff in mice for very long.
[01:28:41] You know there's a really famous Italian cancer biologist who once famously said if you can't cure cancer in a mouse you need a new profession.
[01:28:50] That's that's pretty low hanging fruit you got to be able to do it in people.
[01:28:55] Oh, at the it was while you were there that you decide you weren't didn't want to go into medicine anymore.
[01:29:01] So that's complicated right so then I still you're still.
[01:29:04] I was still in the midterm residency so what I so then I went back to Hopkins to finish my surgical training.
[01:29:09] But then I decided you know what I think I might actually go into cardiac surgery which I'd always been interested in.
[01:29:15] So when I was in medical school I was really torn between cancer surgery and cardiac surgery.
[01:29:19] And you know to go into cancer surgery I think the real focus is going to be on research.
[01:29:25] Like you want to you have to be involved in science and and surgery whereas I thought in cardiac surgery.
[01:29:31] You know it's just pretty much the coolest surgery like it's the most technically demanding surgery by far.
[01:29:37] I shouldn't say by far and I think there are other things that are partly on part technically but I was like I also came back in the mindset of you know what I'm just going to.
[01:29:45] So become like a great technician right I just and I loved operate I mean the heart is.
[01:29:51] And one sense the simplest organ in the body like it's really simple to understand what it's doing you know unlike the brain or the liver where it's just like.
[01:29:57] Ten layers of complexity like that we kind of know what's going on with the heart and when it comes to operating on it you know it's all a mechanical problem like you know this valve doesn't work oh this pipe doesn't work oh this isn't.
[01:30:07] But that was sort of my concession of well you know what you don't have to be the best surgeon scientist why don't you just be the best surgeon.
[01:30:17] Because they are you're more in control right that's that's now just a function of how hard you want to work.
[01:30:23] And that was that was that was sort of right at my alley and so then how did that path then drift you don't want to do any of this anymore.
[01:30:31] You know I think over the next couple of years I mean just a couple of things changed I mean one was.
[01:30:39] You know I wasn't getting frustrated with these patients that we were talking about earlier wasn't the trauma patients that were getting me there was something else that was getting me that was much more frustrating which was the entire system.
[01:30:49] It seemed like everything we did was.
[01:30:53] Last ditch effort to put incredible resources into a person's life at the very end and we didn't really move the needle that much right so.
[01:31:07] It just seemed like a broken system on the other end of the spectrum there's something else that did strike me as broken which actually contrasts or contradicts a little bit of what I said earlier.
[01:31:17] I did feel that there was a subtle difference in the quality of residents. Some of the others this guy Chris Sond and day who's like the best resident that ever lived.
[01:31:25] You know I think I was a good resident I think the most of the really good residents but there were others that just you know they were good but they weren't great.
[01:31:32] And the thing about residency that really bugged me and I think part of this was I was watching my brother who was a lawyer.
[01:31:39] So he came out a law school when I came out of medical school like we were the same time and so I start residency when he starts this law practice or he joined like this law firm.
[01:31:49] And I remember seeing that it was a totally different world like their promotions seemed more merit based like they went up the ranks.
[01:31:59] They got bonuses like all these things happened that were a function of some of my brother was like you know he was like breaking every record at his law firm right like nobody could work as hard.
[01:32:08] Nobody could build as many hours like nobody could like crush it like he could and he was being rewarded for it now he ended up hating it he left he's now a public defender or he's prosecutor rather.
[01:32:17] So you know takes a huge pay cut to go and become a prosecutor because that's what he really wanted to do but the point is he could have risen all the way up that chain and I remember thinking in residency I'm like we all get paid the same we all take the same number years to get through.
[01:32:30] It seems crazy to me like there's no other system where this would be the case like I couldn't think of another system where you just had this complete total lack of meritocracy.
[01:32:40] It was really hard to get fired from residency like I saw some real knuckleheads do some real stupid things I never actually saw anybody get fired which is not say you couldn't sure you could.
[01:32:51] But I felt like I was working a lot harder than was necessary because I just wanted to be better and I thought got it still crazy this is going to take this many years to get through so so that and I also there's just a whole bunch of things about the system structurally that I thought were completely broken and then on the other side I just felt like health care was completely broken as a system right we have this idea yeah.
[01:33:19] I don't remember the exact stats but you're going to spend like you know 50 60% of your entire health care dollars and like the last year or two of your life I mean something as an I right and so at the time.
[01:33:33] Life said to me you know you are clearly upset about this system I think you have two choices you should either fix the system or leave it.
[01:33:47] What you're doing now which is staying in the system and not changing it will probably not be sustainable and so I think the toughest decision I ever made was at that point because I'm 30.
[01:34:02] I've been 32 33 I've invested 10 years into this and I'm thinking I want to do over I want to complete do over which you know everybody knows that the sunk cost fallacy is called the sunk cost fallacy for a reason but it's still a damn compelling reason to keep doing something.
[01:34:25] So that was like it that was a super difficult time and you know in part you sort of feel like you're letting your mentors down because a lot of people had invested a lot in me right Hopkins had taken me right year I was like one of the six chosen ones they only take six categoricals a year so now you're going to leave that program.
[01:34:43] And there were you know a couple of attendings I'd become really close to who really believed in me and really said like you're going to you're going to do something really special and then to say actually I'm going to leave.
[01:34:54] And I'm not even going to be a doctor anymore I'm just going to go in.
[01:34:58] So then you roll straight to McKenzie.
[01:35:01] So what I wanted to do is actually go back and get an MBA because I really the other thing I missed a lot in medicine was I missed quantitative.
[01:35:12] Stuff like I missed math like I missed being an engineer and a few times I tried to bring that into medicine I got spanked right so the you know it's one story I think I've talked about this maybe on a podcast before I don't think so though.
[01:35:26] I was like probably my first or second year in the ICU taking care of this patient and this patient's on a very very toxic drug called gentimizing this is a drug that has to be dosed very carefully so if you give too much of it you can destroy their hearing permanently and destroy their kidneys permanently if you don't give enough of it the bacteria that you're trying to kill will kill them.
[01:35:46] So you're you're you have a very narrow range in which to give the dose so there is no standard dose. It's not like oh just take 875 milligrams of this every 12 hours now it's take a first guess based on the patient's body weight so this many milligrams per kilogram give it to them and then measure a level and then.
[01:36:04] Once the level comes below a certain point give it again.
[01:36:08] And I remember thinking that doesn't even make sense like surely we know enough about the kinetics of this drug that we could build a mathematical model to predict when to give it.
[01:36:20] So I looked up you know a couple of papers a couple of books one night on call sure enough I find like there's a very predictable alpha and beta decay cycle for this drug.
[01:36:32] Like literally in Excel I build a model that uses a very simple differential equation and it needs a few inputs and it will predict the kinetic curve of this and I'm like alright let's try it out.
[01:36:43] So take one of my patients going to be on gentimizing.
[01:36:47] I do everything the standard way but I plug my numbers into the model to see would my model have predicted this better and better in the answer was unquestionably.
[01:36:54] So now I start to give a little confident in the idea so like the next night I'm like alright I'm actually going to start dosing the patient based on the model which never puts the patient in jeopardy because you're always going to check the level before you dose.
[01:37:05] But you're going to do so at the exact right moment and so my model predicted like at 431 a m this patient will nader which means that's when you need to dose them.
[01:37:16] So sure enough at like 4 in the morning I get the pass the nurse to draw the patient's blood to confirm they're just about to nader we're going to redo some in a way we go.
[01:37:25] So the next morning on rounds you know in the ICU you round is a big team I'm presenting that you know this patient is one of my patients and I start explaining that.
[01:37:34] Okay so the patient received their dose of gentimizing at 430 in the morning and the attending says well what do you mean 430 morning we never dose gentim at 430 in the morning.
[01:37:41] We dose it at 7 a.m always and I'm like yeah yeah but the patient hit their nader at 430.
[01:37:48] It's like I don't care you know and so we got into this huge fight and like you know I almost got fired.
[01:37:54] That would have got me fired by the way.
[01:37:56] Find me someone gets fired.
[01:37:58] Find me someone gets fired.
[01:37:59] And so I mean that pissed me off beyond words right it pissed me off that like it just struck me as so anti intellectual.
[01:38:10] Like maybe my model wasn't perfect I we never know but the fact that nobody even cared to say is there a better way to do this that drove me that shit crazy.
[01:38:20] And and that's just one of many stories like that that happened through residency where I was like it's almost like we want to live in the 1950s here.
[01:38:29] And so so you have that sort of pain of problem solving is not valued.
[01:38:36] At least it didn't seem valued to me was valued in the lab but I had decided now I'm not going to be in the lab.
[01:38:41] So here I live in this world where problem solving is not valued and I don't actually I'm not a quantity more like I don't do math anymore and I really loved math.
[01:38:52] So I started so tutoring kids in math I made like a little bit of free time so I could like tutor high school kids in calculus just like at my calculus on again.
[01:39:03] Missing it but it wasn't the same so so then I was like you know maybe I'll go back and get an MBA so I looked into that didn't feel like I was already drowning in debt at that point in time you know you've got med school debt is sort of painful.
[01:39:17] And you know residency you're making I think of the time I'm making about 34,000 bucks a year so it's you're not even putting a dent in your 200,000 dollar debt sort of thing.
[01:39:24] So so then I remember one night I was in I was on call and I was really pissed to be on call this night this and I you can relate to this better than I'll ever be able to relate to it because I'm sure this happened to you your whole life but.
[01:39:38] My best friend from high school tells me in February he's getting married that August and I'm the best man.
[01:39:45] He lives in Toronto.
[01:39:47] So he's like this is the day to my wife for you. It was like August fifth it's a Saturday. I want you to be the best man completely honored.
[01:39:55] So I tell my program director in February. Can I not be on call.
[01:40:00] That day or the day before.
[01:40:03] I just need to I need to be able to fly out of Baltimore in a Friday and come back on a Sunday and he's like hey that's no problem.
[01:40:10] I remind him three times no problem no problem sure enough the call schedule comes out I'm on call Saturday.
[01:40:17] I'm on call the day of the guy's wedding.
[01:40:19] He got to be kidding me. So it's two o'clock in that morning. I'm down in the ER looking at a chest CT scan on a guy who I'm worried has it was called a dissecting a order.
[01:40:31] And the radiologist. I introduced myself and she's very nice and she walks me through the CT scan and we just start shooting the breeze a little bit.
[01:40:42] She says oh yeah you seem kind of down tonight what's up and I was like I am just kind of pissed off. I mean which I wasn't here blah blah blah.
[01:40:48] And she's like yeah I can I can relate I used to be in a surgical residency myself and I was like oh really she goes yeah yeah I did my internship in surgery at the university of Seattle and I just hated it so much that I left and actually joined this company called McKinsey.
[01:41:00] You know work there for two years but then decided I wanted to come back to medicine but I wanted to do it in a kind or gentler way so that's why I'm back here doing radiology and I was like oh what's this McKinsey thing? I never heard of it.
[01:41:13] And so she told me all about it and I was like huh that sounds interesting how do I apply you know and that was sort of the beginning of it so she introduced me to some folks and you know then I had to like study all over again because the way they interview it these consulting firms is very specific.
[01:41:29] You can be the smartest dude in the world if you show up and you haven't thought through how to solve a case.
[01:41:35] Like what are called these case interviews you're gonna flail so you have to actually put in some like work and study so I you know got a bunch of books on case interviews and I'd be sitting in the trauma bay waiting for bodies to come in I'd be like reading my cases you know case interview things before so that that's that was sort of the transition.
[01:41:52] You walk you walk away from medicine you go into so we do in medicine specific consulting so I think it's rooted to do that because McKinsey.
[01:42:04] And I'm sure this is true of like Bane and BCG which are kind of the other two really big.
[01:42:10] Management consulting firms. They recruit about a third of their consultants who out of sort of what we call non typical or a typical rather.
[01:42:20] Backgrounds of people who have PhDs or JDs or MDs but who didn't go to business school and then so they send you off to do business school that summer they do this thing called a mini MBA which was.
[01:42:30] I mean it was like being a kid in a candy store again because I got to go spend a whole summer in school again learning finance like learning all of these things that you know for some people might seem kind of drive but when you're like just dying to.
[01:42:42] Get back into numbers.
[01:42:44] I was like oh my god like you know I remember the first time we learned what was called the efficient front here which is basically this differential equation that describes you know an investment philosophy.
[01:42:53] I can't believe I'm doing this again. I can't believe it. So so then we show up for orientation.
[01:43:01] I'm in San Francisco at this time. That was the other thing. I wanted to get back to California.
[01:43:05] So I was like you know San Francisco please. So during the first drink during orientation week I was approached by one of the staffers there and they said hey you know your background looks like you've done a lot of mathematics.
[01:43:19] Yeah they said well you know we know you're a physician and you're probably here to work on you know that all the medical teams are going to try to grab you to have you work on some biotech thing or whatever but we have this banking issue that is very important to some of our clients and it requires you know an ability to do stochastic calculus.
[01:43:37] I was like of course and so then you know that was basically the beginning and I never really stopped doing that stuff. So so I ended up doing what's called credit risk modeling which then which started out around this thing called the Basel 2 Accord which was a type of this was a regulation that came out in the mid 2000s that required banks to hold a certain amount of capital against unexpected losses.
[01:44:04] So banks have a long history of knowing how to hold capital for expected losses but they don't really know what to do for unexpected losses.
[01:44:12] And in particular the problem that was damning was something called asset value correlations.
[01:44:17] So if you're a bank you could have 27 lines of business. You do first mortgage, second mortgage auto, student credit card like you name it.
[01:44:28] And the problem is nobody really understood how those assets correlated. So if your loss rate is x in this what's the probability that it impacts the loss rate in that.
[01:44:40] So where that where the rubber meets the road is if I can't make my house payment I'm probably not making my car payment either.
[01:44:47] That's right.
[01:44:49] That's what nobody got to realize everything went down.
[01:44:53] Oh yeah. So that turned into as we were in the midst of that because the banks used to leverage themselves so much that they could well in when the market crashed they weren't ready for they couldn't handle it.
[01:45:07] You know it's such an I mean it's like literally one of my favorite topics actually which I'm sure your listeners don't want to get bored to tears on it.
[01:45:14] But the first of all the best movie of all the movies that have like tried to explain what's going on the big short by far does the best job because it actually explains the the sequence of events that went that took this from being just an isolated problem to a systemic problem.
[01:45:33] Most people miss the subtlety of how this thing ceased to be contained. Because technically a housing crisis shouldn't have affected the global economy.
[01:45:44] So it was these instruments called CDOs that effectively allowed this problem to become enormous.
[01:45:53] But at the time the bigger issue was, you know just a great example of hubris that exists everywhere, right, which is one we don't like looking at data that contradict our point of view.
[01:46:09] And we're all guilty of this. I'm guilty of this. I find myself doing it and I actually am now quite a muse. I'm so attuned to it now that I'm quite a muse. Like if I'm flipping through Twitter, I'll see a story that is completely against how I feel and I don't want to read it.
[01:46:22] And I'm like the next one will be like exactly how I feel, I want to read it. And I'm like, dude, look what you just did man. You've got to stop pull back, go up assume you are wrong and keep going and try to figure out if you're.
[01:46:33] But so so at the at the banking level, I mean, and we you know the the canary in the call mine here, well, there were many, but in 2000s early 2006 to 1000 yeah mid 2006.
[01:46:47] We had when we were trying to do these asset value correlations, one of the biggest problems we had is we couldn't we only had 10 years of data.
[01:46:57] The banks only had this data recorded for 10 years. We didn't have losses to model.
[01:47:04] And I remember saying to like, you know the controller at this bank, I'm like, hey man, like it's going to be really hard to build you a model of losses when you don't have any historical losses.
[01:47:15] And he goes, well, that's mortgage is mortgage is can't lose money. Right. So that was and we can laugh at that now, but at the time that was like not an unreasonable point of view.
[01:47:24] Right. Like you can't lose money on a first mortgage. Think about it. You got to put 20% down. You want to buy home for 100 grand. You better show up with 20. You better be able to document. You have a job. You better do this. You better do that. You better that.
[01:47:37] So you now the banks only on the hook for 80 on a home that's been legitimately appraised for 100 and you've shown documentation. So you're at least going to pay that thing down to 70 such that worst case scenario.
[01:47:49] Market falls by 10% houses worth 90. You lose your job. Guess who still gets paid.
[01:47:55] The bank is still get their 70. Sure, if you're in the business of creating a second mortgage, you take a little bit more risk.
[01:48:00] But there's no reason you should have been losing money on first mortgages. And so you fast forward a year.
[01:48:09] Well, especially because don't worry about the value of the house because that's going to go up.
[01:48:13] That's right. So we're good to go.
[01:48:15] Oh, well, that's where I remember even when I was in Baltimore, one of my buddies because you know, the residents were always looking for a way to make a buck on the side, right. When you're making 34k.
[01:48:24] You got it. You got to come up with the only saving grace as you can't spend money. Like your clothes is free. You're inscrubs all the time.
[01:48:32] You're kind of eating for free all the time because you eat off the patients trays, whatever they didn't finish.
[01:48:38] Like go to the nurses station, eat all this crap. So I didn't actually spend much money.
[01:48:44] You just... pens was like the only thing I wasted money on. Like I collect mollongs. And so even through residents here, I would still buy these beautiful pens.
[01:48:56] So yeah, I remember one of my buddies being like dude, we got to start buying houses in Baltimore because like there's so cheap and you can get them with no money down.
[01:49:03] You could buy a house for 200,000 bucks, put like $5,000 down.
[01:49:08] If that house goes up to 220, you just made 25,
[01:49:13] okay, you made 20, okay, on your five.
[01:49:14] We're going all the way.
[01:49:16] And no one does the math of what if it goes down to 190?
[01:49:20] You just lost everything, right?
[01:49:23] So luckily, I didn't get in any of those sweetheart deals.
[01:49:28] Although, you know, if you'd time them right,
[01:49:30] there were a lot of people did make a lot of money
[01:49:31] and those deals before the shoe fell.
[01:49:33] So when things started to become clear,
[01:49:37] so in early, in early O7, it became clear,
[01:49:43] subprime mortgages were going to be a problem.
[01:49:47] By August of O7, a very famous,
[01:49:52] then famous analyst,
[01:49:54] it's her name, Meredith, Whitney, I believe,
[01:49:59] is her name, I think she's an opera called something
[01:50:03] that the time seemed crazy.
[01:50:05] She said, city group is going to cut its dividend next month.
[01:50:09] So for city group, you know,
[01:50:10] one of the largest banks in the country
[01:50:12] to not pay a dividend for Q3 seemed impossible.
[01:50:16] But she'd done the math, she's like, yeah, there's no way.
[01:50:17] They're getting crushed on these mortgage back securities.
[01:50:21] And everyone was like, she doesn't know,
[01:50:22] she's talking about, sure enough, Q3 comes along,
[01:50:25] city cuts its dividend, Chuck prints the CEO
[01:50:28] of city gets fired.
[01:50:30] And at that point, it's like, God damn.
[01:50:32] But again, everybody was still thinking,
[01:50:36] this is just a subprime problem.
[01:50:37] It's an inch wide and yet some mild deep, but it's an inch wide.
[01:50:40] Well, in a background, we're working on another problem,
[01:50:43] which is prime mortgages.
[01:50:45] That which everybody thinks is totally fine.
[01:50:48] That which has a historical default ratio
[01:50:50] of less than half a percent.
[01:50:52] And we're seeing in the data,
[01:50:55] the data that was right in front of this bank the whole time,
[01:50:58] oh, there's a tsunami coming.
[01:51:02] Your default rate's going to hit four, five percent,
[01:51:05] which again, that might not sound like a lot.
[01:51:07] That's 10 times your default rate.
[01:51:09] It's going to be actually higher than that as we learned.
[01:51:11] And your loss given a default is going up much higher.
[01:51:15] So loss is actually the dot product
[01:51:18] of probability of default and loss given default.
[01:51:22] Okay, you guys are my only two customers.
[01:51:24] Probability you default is 50% probability you defaults 10%.
[01:51:28] If you default, you will lose 100,000.
[01:51:31] So it's 10% times 100,000.
[01:51:33] I expect to lose 10,000 on you.
[01:51:36] If you default, it's 2000.
[01:51:38] So 50% times 2000.
[01:51:40] So my total expected loss is 11,000.
[01:51:43] So this is, you know, you do this 88 million times
[01:51:46] for every account you have.
[01:51:48] And the model to predict probability
[01:51:50] to fault and loss given to fault are enormous models
[01:51:52] that each have 50 variables in them.
[01:51:54] Actually, the PD does the LGD doesn't.
[01:51:57] But what people didn't realize is the loss given
[01:51:59] to faults were skyrocketing.
[01:52:00] It was like, in fact, again, at the level of just
[01:52:04] being kind of a math idiot.
[01:52:05] Like that to me was so amazing to watch.
[01:52:10] It was like, holy shit.
[01:52:12] Watch these LGDs go.
[01:52:14] They're just like blowing up.
[01:52:15] And then you knew once the PD triggered,
[01:52:19] meaning once the probability of default went,
[01:52:21] oh, it was going to become a non-linear catastrophe.
[01:52:27] And it turned out so November 15,
[01:52:30] Thursday, November 15, 2007,
[01:52:32] was kind of the day like that was the matrix moment.
[01:52:35] So I had a team, great example.
[01:52:37] I was able to be a leader for once,
[01:52:38] because I had an amazing team.
[01:52:40] I had a team in San Francisco of four people.
[01:52:43] I had a team in India of four guys.
[01:52:46] We worked around the clock 16 hours a day, every day,
[01:52:49] except Sundays we took off, and we would pass the model
[01:52:52] back and forth through each other.
[01:52:54] Amazing.
[01:52:54] It was pure bliss to be working that hard on this problem.
[01:52:59] And on that day, we basically came up with four independent
[01:53:02] models that all predicted how bad this thing was going to be.
[01:53:06] And we presented it to the leadership of this bank.
[01:53:11] And it's really funny.
[01:53:13] I was a manager.
[01:53:14] So it McKinsey, you have these levels like Analyst Associate
[01:53:18] Manager, Junior Partner, Partner Director.
[01:53:21] For a meeting of that stature, meaning you're talking
[01:53:24] to the entire leadership of the bank,
[01:53:25] the senior partner would only be the one to predict.
[01:53:28] I'd be in the corner, work in the PowerPoint,
[01:53:30] answering a question if piped up,
[01:53:33] because there's going to be a technical question.
[01:53:35] But the senior partner would do all the talking.
[01:53:37] But on that day, we go into the meeting
[01:53:39] and the senior partner says, Peter, you should present this.
[01:53:42] And I said, are you short?
[01:53:43] Because I'm like the third most junior guy in the room here.
[01:53:46] And he said, yeah, two reasons, one, you're the only one
[01:53:49] who actually understands how all of these models work.
[01:53:51] And this is the funniest thing he said.
[01:53:53] He goes to, because of all of your experience
[01:53:56] with cancer patients, you're going to be very good
[01:54:00] at answering hard questions about bad things happening.
[01:54:04] And I was like, OK.
[01:54:06] So I stepped in and I did my best to be empathetic and non-judgmental
[01:54:11] and just as evidence, fact-based as I could.
[01:54:14] And this is what this says.
[01:54:15] And this is what you look at the run-right model
[01:54:17] and the PGD says this and the LGD says this.
[01:54:20] And the vintage model says this.
[01:54:22] And so finally, like the president of the bank says,
[01:54:26] how much money are we going to lose?
[01:54:29] Like she was kind of like, you know, like all good leaders.
[01:54:31] She's just like, just get to tell me the goddamn answer first.
[01:54:35] So I said, I had to think on my feet
[01:54:38] like pretty quickly about a way to put it in terms.
[01:54:40] So I said, you're going to lose more money
[01:54:44] in the next 18 months than you've made in the last 10 years.
[01:54:50] And see the Jaco answer to that question?
[01:54:53] How much money were we going to lose?
[01:54:55] Would have been all of it.
[01:55:00] That's the difference between you and me on Twitter.
[01:55:03] Like you always have the best answer.
[01:55:06] Like always.
[01:55:07] Because that would be like, hey, Jaco,
[01:55:09] like you just picture that on Twitter.
[01:55:10] Like, you know, see you of like the bank.
[01:55:12] Hey, Jaco, how much money were you going to do?
[01:55:14] All of it.
[01:55:15] Peter, one of three.
[01:55:18] Well, start with your event last year.
[01:55:21] Multiply that by two of them.
[01:55:22] Three of three.
[01:55:25] Three of three.
[01:55:26] Yeah.
[01:55:27] Did they listen to you at all?
[01:55:29] Yeah.
[01:55:30] They want to leave that data.
[01:55:31] They did that was impossible.
[01:55:32] That was impossible to fathom years later.
[01:55:35] Because I had it by this point left McKinsey.
[01:55:37] But I stayed in close touch with that team.
[01:55:40] And I reached back out to that senior partner
[01:55:43] who actually ran still very close with he had just got
[01:55:45] a meal from him two days ago.
[01:55:47] I said, hey, man, remember all those models?
[01:55:49] Yeah, yeah.
[01:55:51] Did we, were we roughly close?
[01:55:53] And he goes, oh, no, the models underestimated by a third.
[01:55:58] I mean, it was like, it seemed like we kept trying
[01:56:01] to tone the models down.
[01:56:02] Because they kept giving us these answers.
[01:56:03] And we were like, damn, like there's no way it can be this bad.
[01:56:08] And we were like, oh, let's make this assumption
[01:56:10] more conservative.
[01:56:11] And let's do this.
[01:56:12] You know, in the end, it was like, no, it was actually that bad.
[01:56:15] Brutal.
[01:56:16] So then now I remember, I saw you tell a story one time.
[01:56:19] It's on YouTube somewhere.
[01:56:21] But you're talking about a patient you were working on.
[01:56:24] You kind of alluded to this earlier.
[01:56:27] Either pre-diabetic or diabetic and you're sitting there
[01:56:30] going, you got to be kidding me.
[01:56:32] Because the day before you tried to save someone's life,
[01:56:34] that was a young kid.
[01:56:36] And that was sort of the first time that you started thinking
[01:56:39] about nutrition as an earlier, you talked about, hey,
[01:56:45] we do all this stuff at the end of life.
[01:56:46] It's all this prevention to prevent someone from actually dying.
[01:56:49] But if we would have invested some of that money up front,
[01:56:52] taught these people out of eat, we would have been better off.
[01:56:55] Is that sort of where it came from or not at all?
[01:56:58] I mean, I never made that connection at back time.
[01:57:00] So at that time, it was just what you describe.
[01:57:03] It was just the visceral reaction of, I'm so angry at you.
[01:57:07] How can you not take care of yourself?
[01:57:10] How can you be sitting here so fat, so diabetic?
[01:57:15] Over and over again, you come in here to have these ulcers
[01:57:19] debreed and to have these things amputated.
[01:57:22] And you know how the story is going to go.
[01:57:24] Just get it together.
[01:57:25] So this was, I didn't say those words, but that's how I'm feeling.
[01:57:29] And so that's just part of the callousness
[01:57:35] that developed towards that subset of patient.
[01:57:38] It wasn't until probably 2009, so I'm out of medicine now.
[01:57:47] But I was becoming overweight.
[01:57:49] And I was pre-diabetic.
[01:57:50] I wasn't diabetic.
[01:57:51] I was pre-diabetic.
[01:57:53] And I was, you know, that I was sort of a comphal circle.
[01:57:56] That I was like, wait, wait, wait, wait.
[01:57:57] I do everything right.
[01:57:58] I mean, I'm swimming four hours a day.
[01:58:01] I'm following that goddamn food pyramid to the core.
[01:58:04] I don't need saturated fat.
[01:58:06] I'm like, you know, I, I carb load like a band sheet.
[01:58:10] Like, why am I, why is all this stuff happening to me?
[01:58:14] And so then when I, you know, went through my whole discovery
[01:58:18] process of figuring that out, it was only then that I really
[01:58:21] thought back and reflected upon, you know, the horrible way I had
[01:58:27] treated, not just that patient, particularly, but obviously
[01:58:30] many other patients like her.
[01:58:32] I remember her case specifically, because it was probably
[01:58:34] like the absolute low point of my existence.
[01:58:39] So it, unfortunately, it took me sort of failing on my own,
[01:58:45] because at least then I could say this isn't a well-power problem.
[01:58:48] It's not like you don't care.
[01:58:49] It's not like you're not trying.
[01:58:52] You're doing what you're told to do and you're failing miserably.
[01:58:55] So either you're an outlier or maybe the advice is incorrect.
[01:59:00] So you're eating what you're being told to eat.
[01:59:02] You're car bloating and you're still getting fat.
[01:59:06] Yeah.
[01:59:06] Even though, in, at this time, you're swimming.
[01:59:08] We were just talking about it before the podcast.
[01:59:10] You're doing ultra long swims, dozens of miles worth of
[01:59:14] swimming, which, by the way, in seal training, in basic
[01:59:17] seal training, the longest you swim is five and a half
[01:59:20] nautical miles, which is six point two statute miles, which,
[01:59:24] and that's with swim fins on.
[01:59:26] So you're out there in the, and you're out there in the open
[01:59:28] ocean swimming, 12, 15, 18 miles at a time.
[01:59:33] And you're training for that, working hard, and you're
[01:59:36] quote-unquote eating right because you're not eating saturated fat.
[01:59:40] And yet you're getting fat, you go into the doctor,
[01:59:43] you get blooddred test, and they say, oh, yeah, by the way,
[01:59:45] you're pre-diabetic.
[01:59:47] And you just say to yourself, what is going on?
[01:59:49] Yeah, and truth be told, I was actually more pissed just
[01:59:53] from the vanity standpoint at being fat.
[01:59:55] I mean, I wish I could say that.
[01:59:58] If you're not, if you're losing it on the podcast,
[01:59:59] echo is not, if you're too enthusiastic, we did that.
[02:00:02] I mean, I wish I could say, oh, it didn't bother me to be fat.
[02:00:06] It did bother me to be fat.
[02:00:07] It really bothered me to be fat, right?
[02:00:09] It bothered me.
[02:00:12] It bothered me a lot, actually.
[02:00:14] And so much so that I actually wanted to get a gastric bypass.
[02:00:17] And so I went, so right now I'm about 175.
[02:00:22] I was probably 205 to 210.
[02:00:25] So once again, after this podcast, you and I,
[02:00:28] we're going to the counseling session.
[02:00:29] No, no, no, no.
[02:00:33] So I went to, I finally got my doctor to get me a referral
[02:00:36] to this guy named Ken Fujioka, who's like a very prominent
[02:00:41] bariatric physician here in San Diego.
[02:00:43] So I finally go to see Fujioka.
[02:00:45] So I'm sitting in the waiting room.
[02:00:47] And I actually, I think I told this story on Tim's podcast.
[02:00:51] I don't remember telling you.
[02:00:52] I did tell it.
[02:00:52] But it is in the book.
[02:00:55] It's in the history of the time.
[02:00:57] It's the story of the time.
[02:00:58] So I put in the spirit of assuming nobody listens to
[02:01:01] or reads multiple of the thing.
[02:01:03] So I'm in the waiting room.
[02:01:05] I'm finally waiting to see.
[02:01:06] And the nurse comes out.
[02:01:07] And before you go back to the clinic room,
[02:01:10] like you have to get weight.
[02:01:11] That's just part of the protocol, right?
[02:01:13] So like they call my name.
[02:01:15] So I walk up and I get on the scale.
[02:01:17] And the nurse comes out and weighs me.
[02:01:20] And it's like, you know, whatever, 210.
[02:01:21] And she's like, congratulations.
[02:01:25] I'm like, what?
[02:01:26] She goes, you're post-surgery, right?
[02:01:29] And I'm like, no, I'm here to be evaluated for surgery.
[02:01:33] She looks at me.
[02:01:34] Looks out at the waiting room where everybody's 400 pounds.
[02:01:38] And like, doesn't say a word.
[02:01:40] But the look in her eyes is basically like,
[02:01:43] what the hell is wrong with you?
[02:01:45] Yeah, you got serious issues.
[02:01:47] So I'm like, it's like a reasonable idea.
[02:01:54] Well, yeah, a very reasonable, very reasonable.
[02:01:56] You might want to check your reasonable ideas with me.
[02:01:59] Future.
[02:02:01] Because that is not a reasonable idea.
[02:02:03] So you don't do that surgery, obviously.
[02:02:06] But what?
[02:02:07] He, that guy had no patience for me.
[02:02:08] What clicked on your brain?
[02:02:09] Did you just, all the sudden, say to yourself,
[02:02:11] okay, how is this happening?
[02:02:12] And then you remembered your A and P class,
[02:02:14] and said this was just what's happening?
[02:02:17] I remember, clear as day.
[02:02:19] So September 7th, 2009, I did,
[02:02:26] I sort of did like one of these long swims a year.
[02:02:29] You know, you do a bunch of short ones of bunch of training.
[02:02:30] But Joey's, I got how to one main event.
[02:02:32] From a main event this year was,
[02:02:34] I went back to Catalina Island,
[02:02:35] and I wanted to swim from now LA out to Catalina.
[02:02:39] I had previously gone from Catalina to LA.
[02:02:42] And it was tough swim.
[02:02:46] I had a torn labrum.
[02:02:48] So about six hours in, you know,
[02:02:50] it just became unbearable pain.
[02:02:53] And you don't usually have a head current
[02:02:58] in the Catalina channel.
[02:02:59] So the sand paid for a channel,
[02:03:00] you know this is going to be trained out there.
[02:03:01] The currents usually running from point conception down
[02:03:04] or up.
[02:03:05] So you usually have a little bit of a cross current,
[02:03:07] very rare to get anything back or forth.
[02:03:10] And if anything, it's generally a little bit towards the island.
[02:03:14] And when I had swam four years earlier from Catalina to LA,
[02:03:20] it took 10 and a half hours.
[02:03:21] But that was only 18 months after I learned how to swim.
[02:03:25] That was a much better swimmer in 2009.
[02:03:28] And I was going in the theoretically faster direction.
[02:03:31] So a great example is expectations can kill you.
[02:03:35] So I'm expecting this to be like a nine hour swim back.
[02:03:39] And really the only thing I'm thinking about,
[02:03:41] which is the worst thing you think about in marathon swimming,
[02:03:43] you should never ever think about how long this is going to take.
[02:03:46] Because you're just setting yourself up for misery.
[02:03:48] The only real question I had is could I break nine hours.
[02:03:51] I should be able to break nine hours, right?
[02:03:53] So to make a long story short, I don't even come close.
[02:03:57] This is a total disaster scenario.
[02:03:59] The other thing you want to appreciate this,
[02:04:01] just to appreciate this stupidity.
[02:04:06] You never want to look anywhere when you're swimming,
[02:04:08] except down.
[02:04:09] It's very demoralizing when you're in the middle.
[02:04:13] Like if you're in the middle of the channel,
[02:04:15] you don't see land from the water level.
[02:04:18] You just don't.
[02:04:19] So that's the.
[02:04:19] So before you get in the water,
[02:04:21] you tell the crew and every I've crew chief for a lot of great swimmerism.
[02:04:25] I mean, it's the crew asks the swimmer,
[02:04:28] what do you want, what information do you want?
[02:04:31] So we're starting the swim in midnight at Point Facente.
[02:04:34] I said, okay, I want to know when there are exactly 10 miles.
[02:04:39] To go and exactly four miles to go.
[02:04:42] What's the total distance of the swim?
[02:04:44] Well, as a crow flies, it's 21.
[02:04:46] And if so, if you don't have a current,
[02:04:49] you're doing a 21 miles swim.
[02:04:50] If you do have a current, you're going to swim more than that.
[02:04:52] So, so that's what I said,
[02:04:54] as a guys, I want to know when there's 10 to go and forward to go.
[02:04:57] Why?
[02:04:58] 10 to go.
[02:04:58] You're just a little over half way.
[02:05:00] I'd like to just know that.
[02:05:01] At four to go, it's put your head down and swim for two hours.
[02:05:04] Don't do anything.
[02:05:05] You're there.
[02:05:06] So, start the swim in midnight.
[02:05:09] This is in September.
[02:05:10] So, I forget what time the sun was rising back then.
[02:05:13] But I knew that I would have 10 to go before the sun came up.
[02:05:18] So, in other words, I knew that once the light was up,
[02:05:21] I was going to be inside the 10 stretch.
[02:05:23] And one of the most amazing things about swimming in the middle of the ocean.
[02:05:27] I don't know if you got to experience this during training is
[02:05:30] in the Pacific, the bio-luminous is so strong.
[02:05:35] And so, on a clear night, which I was always lucky to have,
[02:05:38] every time I swim out, I've done a lot of the channel swims.
[02:05:40] Every time I've been out there, I've always been blessed with these clear nights.
[02:05:43] It's so dark, because once you get out of LA's light,
[02:05:48] under the water, so your hand is coming down.
[02:05:50] You are seeing the bio-luminoussins flare off your hands.
[02:05:54] When you breathe, you are seeing the stars.
[02:05:56] You can't tell the difference.
[02:05:58] It is so dark.
[02:05:59] You cannot see the difference between stars and bio-luminoussins.
[02:06:02] It's like being in this amazing chamber.
[02:06:04] And so, that's the reward you get for swimming at night,
[02:06:08] which is otherwise incredibly lonely.
[02:06:11] And then the first thing you notice is the bio-luminous
[02:06:14] gets harder and harder to see, which means, oh,
[02:06:16] the sun's going to be up in an hour.
[02:06:18] The sun comes up.
[02:06:20] Now the sun's like up there.
[02:06:22] I haven't heard anything, and I'm like, those guys,
[02:06:25] they forgot to tell me I've got 10 to go.
[02:06:27] That's OK.
[02:06:28] Probably down to 6 to go now.
[02:06:31] I'm swimming, I'm swimming, I'm swimming.
[02:06:32] I'm just feeling like 10 o'clock in the morning.
[02:06:34] I mean, I'm being fissacious.
[02:06:35] It's probably like 830 in the morning.
[02:06:37] And they're like, 10 to go.
[02:06:39] That was like, Jesus, who the hot.
[02:06:43] And because at that point, I had no clue what the current was like.
[02:06:46] Because the swimmer can't feel current.
[02:06:48] Swimmers can only feel relative velocity,
[02:06:50] not absolute velocity.
[02:06:52] So that coupled with the torn labrum, coupled with,
[02:06:57] it ended up being over 14 hours of swimming.
[02:07:00] And this is a very long story because your question was so simple.
[02:07:03] But I remember getting on the boat.
[02:07:05] I don't even remember my question.
[02:07:07] Your question was about nutrition.
[02:07:08] We've actually about, about like, when I finally decided.
[02:07:11] I was over here in bio-loom and essence mail.
[02:07:15] I mean, OK, so this is the day.
[02:07:17] So finish the swim.
[02:07:18] Get back to the boat.
[02:07:21] And they've got like two burgers and two coax waiting for me.
[02:07:25] And I mean, like I couldn't have eaten those things quicker.
[02:07:28] Like the biggest juiciest burgers you've ever seen.
[02:07:30] Like the coax, like they tasted so good, right?
[02:07:33] Because your mouth is so salty.
[02:07:35] Like you actually really want some sweet.
[02:07:37] And my wife, my wife hates when I tell this story
[02:07:40] because she denies that she said it, but she completely said it.
[02:07:45] She, I'm just sitting there.
[02:07:46] Like, I remember this.
[02:07:47] I haven't picked it up.
[02:07:48] Enjoy the burger fatty.
[02:07:49] All right.
[02:07:50] I've got like a USA towel wrapped around my waist
[02:07:53] and hailing like I'm two-fisting burgers
[02:07:56] drinking my coax.
[02:07:57] And she just looks at me and she goes, and again,
[02:08:00] just in the sweetest way possible.
[02:08:02] She said, you should probably work on being a little less not thin.
[02:08:08] Wow.
[02:08:09] Wow.
[02:08:10] It's less.
[02:08:13] Is that like the kindest way to just tell somebody
[02:08:16] you're kind of getting a little fat?
[02:08:18] Wow.
[02:08:19] Post 14 hours swim.
[02:08:20] You're hoping that it's get some.
[02:08:23] So that was the last time I had a coke.
[02:08:26] I've never had a coke since.
[02:08:28] Tame.
[02:08:29] And all I did, frankly, at the time, was just said,
[02:08:31] like I'm just going to try and experiment.
[02:08:33] Because I was like, look, at that time,
[02:08:35] I still thought it was just calories and calories out.
[02:08:37] I thought it was really just simple arithmetic.
[02:08:38] And my view was, all right, I can't do anything more
[02:08:41] on the calories outside.
[02:08:43] There's only 168 hours in a week.
[02:08:45] I'm not willing to exercise more than 28 of them.
[02:08:47] So calories out.
[02:08:49] I don't get to change that anymore.
[02:08:51] And frankly, I didn't really want to change the calories
[02:08:53] inside because I hated being hungry.
[02:08:54] Every time I tried to eat less,
[02:08:55] I would just be so hungry I didn't know what to do with myself.
[02:08:58] So it was like, I'm going to try a new experiment.
[02:08:59] What if it's the type of calorie that might matter?
[02:09:04] Sugar strikes me as not great for you.
[02:09:07] Even though I can't tell you why,
[02:09:10] I'm going to stop having sugar.
[02:09:12] So that was my first experiment in September of 09.
[02:09:14] And that led to everything that's come since that time.
[02:09:18] Which obviously ultimately led to me coming back to medicine
[02:09:20] as well.
[02:09:21] Yeah.
[02:09:22] And that's where you're at now.
[02:09:24] And by the way, listen to Tim Tim's podcast.
[02:09:28] What else did people listen to to get all that nutritional
[02:09:31] information the rest of the story?
[02:09:35] I think it's Tim's.
[02:09:36] Yeah.
[02:09:37] I mean, a couple of things with Tim.
[02:09:39] I did a podcast with Chris Krasser earlier this year.
[02:09:44] Talked about longevity a little bit.
[02:09:46] I did one.
[02:09:46] I probably have a, maybe, oh, you know what?
[02:09:48] Probably get more into nutrition.
[02:09:49] There's an IHMC video I did.
[02:09:52] Probably like three or four years ago.
[02:09:53] That one's like an hour long.
[02:09:55] And you go pretty detailed in it.
[02:09:56] Yep.
[02:09:57] OK.
[02:09:57] Yeah.
[02:09:57] I've watched that one.
[02:09:59] Yeah, those are good.
[02:10:00] Those are good.
[02:10:03] And again, if you had to kind of tell people that aren't going
[02:10:09] to go listen to those podcasts,
[02:10:09] and aren't going to watch that video, what would you tell them?
[02:10:14] You know, what would you tell them to eat overall?
[02:10:19] You know, I generally don't like talking about nutrition
[02:10:22] because, don't worry, I will answer this question.
[02:10:25] But I don't at least preface it.
[02:10:26] Why I don't like it.
[02:10:27] I don't like talking about this stuff.
[02:10:32] Nutrition is kind of a pseudo science that masquerades
[02:10:36] as a religion for many people.
[02:10:39] And so I find it difficult to have a discussion
[02:10:43] about biochemistry when it's so cloaked in emotion, religion,
[02:10:48] and dogma.
[02:10:50] No, that's not to say I don't have a strong point of view.
[02:10:52] I certainly do.
[02:10:53] It's also an evolving point of view.
[02:10:55] I feel different today than I felt four or five years ago.
[02:10:58] I feel different today than I felt two years ago.
[02:11:01] And also, my life is one big experiment.
[02:11:03] So we were joking before I came in here.
[02:11:06] I've got a glucose meter buried within me at the moment.
[02:11:08] I've got all these heart rate variability things.
[02:11:11] Like everything I'm doing, actually, just check.
[02:11:16] Actually, didn't experiment before I came here today.
[02:11:17] I ate something and I want to see how much it raised my blood sugar.
[02:11:24] That's not bad.
[02:11:26] What did you eat?
[02:11:27] So I ate this product that I've been doing some research on.
[02:11:31] It's called no KNOW like no foods.
[02:11:36] And I was introduced to this product by one of my patients
[02:11:40] who said, hey, Peter, I want you to kick the tires
[02:11:42] on this a little bit.
[02:11:44] It uses a sugar substitute called aliulose.
[02:11:49] And it tastes amazing and apparently, like,
[02:11:52] it doesn't raise your blood sugar at all.
[02:11:54] And I was like, yeah, I'm familiar with aliulose
[02:11:57] for those who might not know.
[02:11:59] Aliulose is a sugar that occurs in nature
[02:12:04] in very small quantities that looks exactly like this sugar
[02:12:09] called fructose, which is fructose,
[02:12:10] the sweet component of sugar with one small exception.
[02:12:14] But that one small exception carries with it some very important things.
[02:12:17] One, it's not quite as sweet as fructose.
[02:12:20] It's about 70% of sweet.
[02:12:22] But by giving up that little bit of that sweetness,
[02:12:24] you get a whole bunch of stuff in return.
[02:12:25] First of all, it's not metabolized by the liver,
[02:12:27] which is the real problem of fructose, too.
[02:12:29] You barely absorb it.
[02:12:31] So 99% of it or more or less is excreted by the kidneys.
[02:12:35] And three, it actually seems to lower blood glucose.
[02:12:39] So this company, no foods, is putting this,
[02:12:44] like, making stuff out of this,
[02:12:46] but stuff that is like, carb-y, bread and waffles
[02:12:50] and muffins and stuff.
[02:12:51] So anyway, to make a long story short,
[02:12:54] I'm at this patient's house,
[02:12:55] and he's force feeding me these things,
[02:12:56] which is really my way of saying,
[02:12:58] he's left the bag open, and I'm inhaling them.
[02:13:00] And he's like, yeah, yeah, you've got to,
[02:13:02] you've got to tell me if this stuff's legit.
[02:13:04] So to make a long story short,
[02:13:05] he plugs me into the guy that flew down to the company.
[02:13:08] And he has sent me a bunch of this stuff
[02:13:10] to just play with, because he knows what I do.
[02:13:13] And so that's what I've been doing.
[02:13:14] So today, I normally don't eat breakfast.
[02:13:17] So I worked out this morning, and then before I came here,
[02:13:20] I had a big piece of their toast,
[02:13:22] covered in almond butter,
[02:13:24] and then two of their huge waffles
[02:13:26] covered with almond butter and bananas.
[02:13:28] Like I made a big sandwich out of that.
[02:13:30] So the almond butter, not gonna have a huge glycemic response
[02:13:34] because it's got so much fat and protein.
[02:13:35] But the bananas should skyrocket my blood sugar.
[02:13:37] I can't imagine the two freaking waffles
[02:13:39] the size of my head and the piece of toast.
[02:13:41] So interestingly, so that was at nine o'clock
[02:13:45] that I ate those.
[02:13:47] Now I've been up since 330, but I didn't eat anything.
[02:13:50] I worked out from seven to eight.
[02:13:53] So admittedly, there's a bit of a glycogen debt.
[02:13:55] So at nine o'clock, when I ingested,
[02:13:58] my blood glucose was 65, and at its peak,
[02:14:04] which was 11, 18 AM, it was up to 90.
[02:14:07] And it's now down to 83.
[02:14:09] What would real waffles have done to you?
[02:14:11] I think they would have sent me to like 140.
[02:14:14] Three huge pieces of bread slash waffle with the full banana.
[02:14:19] So anyway, I've been doing these experiments all week,
[02:14:22] which is just a great excuse to eat this stuff.
[02:14:24] And I'm actually surprised.
[02:14:25] I'm kind of blown away.
[02:14:26] So okay, with all that said,
[02:14:28] what's my advice for what people should eat?
[02:14:33] In an ideal world, everybody would have this thing embedded
[02:14:36] in them like I do.
[02:14:37] This thing is called a Dexcom G5.
[02:14:39] It's a continuous glucose monitor.
[02:14:43] Typically, only used by people with type one diabetes.
[02:14:47] We're now starting to see people with type two diabetes
[02:14:49] where of them, but I was really completely lucky
[02:14:53] one day sitting on an airplane next to a dude,
[02:14:55] who happened to be into watches.
[02:14:57] I'm into watches.
[02:14:58] We've got talking about watches.
[02:14:59] I find out he's the CEO of the company
[02:15:01] that makes this thing the rest of history, right?
[02:15:04] I'm obsessed with this stuff.
[02:15:05] And so because the answer is this, right?
[02:15:10] If you were a computer program, I would say,
[02:15:11] Jaco, eat whatever you want to eat,
[02:15:15] such that your average blood glucose remains below 85
[02:15:19] milligrams per desoliter and your standard deviation,
[02:15:22] below 10 milligrams per desoliter.
[02:15:25] So translate that into English.
[02:15:26] Okay.
[02:15:27] So eat in whatever way your genetics and epigenetics
[02:15:31] permit you to, such that your glucose levels
[02:15:34] stay low and the variability stays low.
[02:15:37] And those two things will ensure
[02:15:40] that your insulin level stay low.
[02:15:41] So what I'm trying to do is optimize for something called
[02:15:44] the insulin AUC or area under the curve.
[02:15:47] Now we can't measure that test clinically.
[02:15:49] Now let me make it measure that as put you in a hospital,
[02:15:52] put a central line in your neck
[02:15:53] and excuse me, sample your blood every 30 minutes
[02:15:56] over the course of a day where you somehow act normally.
[02:16:00] And every day.
[02:16:01] So then I'd have a time axis, y-axis,
[02:16:03] sorry, the x-axis would be time, the y-axis would be
[02:16:06] insulin level and we'd generate a curve
[02:16:07] and we'd calculate the area under that curve
[02:16:10] and we want that number to be as low as possible.
[02:16:12] So we can't do that outside of the research setting.
[02:16:15] So then the next best thing is keep your average glucose
[02:16:18] as low as possible and the variability.
[02:16:20] So you could have an average glucose of 100
[02:16:23] with low variability and that actually wouldn't produce
[02:16:26] that much insulin or you could have a glucose of 100
[02:16:30] with high variability, same average glucose,
[02:16:34] higher variability is gonna have higher insulin
[02:16:36] all things equal.
[02:16:37] So just through empirical testing in myself
[02:16:40] over the past year and a half,
[02:16:43] I've realized that an average blood glucose
[02:16:45] and this thing tells me every time I hit click,
[02:16:49] like it gives me my last 14 days,
[02:16:52] I just realized like for my average to be below 85
[02:16:55] and my standard deviation to be below 10 is like super dialed in.
[02:16:59] So what you can eat to achieve that varies tremendously
[02:17:05] by individual.
[02:17:06] You know, there are some people who just dispose
[02:17:08] of glucose from our company.
[02:17:09] So that blood test we're gonna do in you next week
[02:17:11] is going to be our best test at measuring that.
[02:17:16] And so glucose disposal is mostly a function
[02:17:20] of the insulin sensitivity of the muscle
[02:17:22] because the muscle is where we dispose
[02:17:25] of the majority of glucose.
[02:17:26] But it's more a little more complicated than that, right?
[02:17:30] Sleep impacts that.
[02:17:32] So sleep deprivation makes us more insulin resistant.
[02:17:37] So this has been experimentally demonstrated
[02:17:39] even with two weeks of sleep deprivation.
[02:17:42] So there's a, it's a small but very well controlled experiment
[02:17:45] that was done out of University of Chicago
[02:17:48] price six years ago.
[02:17:49] They took a very small number of subjects,
[02:17:51] like I said, about eight subjects
[02:17:53] and for two weeks let them only sleep four hours a night
[02:17:57] and they did a very invasive test called a Uglysi
[02:18:01] McKinsey-Lun Clamp at the beginning and at the end
[02:18:03] of the experiment and their insulin sensitivity,
[02:18:07] their glucose disposal deteriorated by 50%.
[02:18:10] And with no change in what they were eating.
[02:18:13] Yeah.
[02:18:14] So it's highly variable, right?
[02:18:18] So that's theoretically the answer.
[02:18:20] On a practical level, I would say the answer is this, right?
[02:18:25] If it comes in a package, you're probably better off not eating it,
[02:18:29] right?
[02:18:31] If your ancestors couldn't have eaten this even 200 years ago,
[02:18:36] it's probably not worth eating.
[02:18:39] So if you just followed that advice,
[02:18:42] think about how many things you'd eliminate from your diet,
[02:18:46] right?
[02:18:46] If you just took packaged foods away from your diet,
[02:18:49] and again, notice I'm agnostic.
[02:18:51] You want to be a vegan, not yourself out.
[02:18:53] You want to be the paleo man of the century?
[02:18:55] Go for it.
[02:18:56] I don't get a shunt.
[02:18:57] Okay.
[02:18:58] I couldn't care less, right?
[02:19:00] But if you can largely adhere to those principles,
[02:19:03] you're kind of going to be fine.
[02:19:05] Do you want, you know, you're going to get 70% of the way there.
[02:19:08] You want to get 80, 90, 100% of the way there?
[02:19:10] Yeah, well then there is no simple answer.
[02:19:11] Now at that point, you got a dial in
[02:19:13] and you got to go full immersion into
[02:19:16] how do you tweak to your biochemistry?
[02:19:18] How much protein, what's the timing of the meals?
[02:19:20] When do we fast?
[02:19:21] I mean, all of the stuff that is my world
[02:19:25] and maybe soon to be your world,
[02:19:28] that's the stuff for which you cannot provide,
[02:19:33] you know, systemic advice.
[02:19:34] But at the societal level or at the just the most basic level,
[02:19:38] yeah, I mean, think about that advice.
[02:19:40] Like you don't eat sugar anymore.
[02:19:41] You won't eat refined carbohydrates anymore.
[02:19:44] You're not going to eat processed crappy foods anymore.
[02:19:47] What are you going to eat?
[02:19:48] You're going to eat fruits.
[02:19:48] You're going to eat vegetables.
[02:19:49] You're going to eat meat.
[02:19:50] You're going to eat grain.
[02:19:52] What kind of grains are you going to eat?
[02:19:53] Well, you're not going to really eat these refined crappy grains
[02:19:57] that people eat.
[02:19:58] You're going to, you know, your starches, I'm sorry, not grains.
[02:20:00] Your starches are probably going to be in the form of potatoes
[02:20:02] and rice.
[02:20:03] So again, I just, I sort of, I think the reason I like talking
[02:20:07] about nutrition anymore is I don't find it to be
[02:20:10] intellectually honest, discussion anymore.
[02:20:12] I find it to be just a discussion of dogma, right?
[02:20:14] So if you're a low carb camp, you're a low carb camp.
[02:20:16] If you're in the, you know, whatever the vegan camp, you're in the vegan camp.
[02:20:20] Like there's that you can't even have a discussion about this stuff.
[02:20:24] And at least not with most people.
[02:20:27] Yeah.
[02:20:28] So I, you know, you ever read the book called Diet Cults?
[02:20:31] I know.
[02:20:32] So it's getting to the non-sense.
[02:20:33] What you said right there?
[02:20:35] That's the whole book.
[02:20:36] Really so interesting.
[02:20:38] Fondery too.
[02:20:39] So good.
[02:20:40] I will have to check that out.
[02:20:42] Diet Cults.
[02:20:43] Now I kind of open with this and since we're, since we're
[02:20:46] a little over two hours right now, I said that you're probably the most
[02:20:54] responsible individual for this podcast.
[02:20:58] And because you originally through Kirk set me up to do a podcast with
[02:21:06] Tim Ferriss, which sent me up to do a podcast with Joe Rogan, which was just
[02:21:10] all awesome.
[02:21:11] And both of those guys told me I should do my own podcast.
[02:21:13] So anyone that's listening to this podcast, say
[02:21:16] thanks to Peter for that.
[02:21:18] Thanks.
[02:21:19] Actually, they should thank Kirk, right?
[02:21:20] Yeah, Kirk.
[02:21:21] Kirk was the man.
[02:21:22] You know, I mean, Kirk is, I don't need to tell you, but Kirk's one of those
[02:21:25] guys where like he doesn't have to justify an ask, right?
[02:21:30] So when he introduced me to you, he didn't have to explain.
[02:21:33] He was just like, I want you to meet Jocco, Jocco as my friend.
[02:21:36] It was like, that's good enough.
[02:21:37] And so to me, like, that's the measure of when life is good.
[02:21:41] And because I feel that way with all of my friends, like if Tim introduces me to
[02:21:44] somebody, like Tim's introduced me to like a dozen people, it doesn't
[02:21:47] amazing relationships have come out of that, right?
[02:21:50] And so, you know, really it was just very easy for me to sort of take Kirk
[02:21:55] on his word that like, if Jocco's great guy, then that's all I need to know.
[02:21:59] I knew you're going to be a great guy.
[02:22:00] And then similarly, like I could tell Tim, like, hey, you got to meet Jocco.
[02:22:04] And you know, Tim gets quote unquote pitched all day long.
[02:22:07] Yeah, it does.
[02:22:08] But, you know, he knows that I'm not going to send him somebody that's not
[02:22:12] you know, going to be really interesting and going to benefit his listeners, not
[02:22:16] just, you know, whatever agenda that person might have.
[02:22:19] Yeah.
[02:22:20] Yeah.
[02:22:21] No, it was awesome.
[02:22:22] And that really did him in the way, Tim, the way Tim advised the way he was going
[02:22:28] to release the podcast to know and support the public.
[02:22:30] I mean, he just nailed it.
[02:22:31] It was kind of ridiculous the way he understands that stuff.
[02:22:36] And how helpful it was to, you know, get in our book out there and get in its
[02:22:40] old and all that and get in all these people on board and then, you know, that turned
[02:22:44] into this podcast, which, you know, he definitely has promoted the podcast and a fantastic
[02:22:49] way along with Joe.
[02:22:51] So that's both been awesome.
[02:22:52] But again, start with Kirk, connect to me with you and then you connect to me with
[02:22:56] Tim.
[02:22:57] So I appreciate that.
[02:22:59] And speaking of this podcast, my almost silent partner over here at Coach Charles, if
[02:23:09] somebody wants to support the podcast, how would you recommend they go ahead and do that?
[02:23:14] You always have a question.
[02:23:17] Oh, how'd you hurt your back originally?
[02:23:21] You know, I don't think we ever really have a diagnosis.
[02:23:25] There was certainly nothing on that day that I did that day I've ride my bike to the gym.
[02:23:31] I, you know, I think about the sins of my youth.
[02:23:35] You know, I was really into martial arts in addition to boxing and I used to spend a ton
[02:23:41] of time.
[02:23:42] I was really obsessed with spinning back kicks.
[02:23:45] Now, I don't know if that could have done it or not.
[02:23:48] But I used to practice 75 spinning back kicks with each leg every single day for probably
[02:23:53] about six years, seven years.
[02:23:57] It's possible, even though in theory, it's spinning back kick if done correctly, it should
[02:24:00] really not put any torque on the lower back.
[02:24:02] It's much more in your hips and technically the flexibilities and the thoracic spine, not
[02:24:06] the lumbar spine.
[02:24:07] But, you know, God knows, maybe I just wasn't doing those things correctly.
[02:24:12] I did squat and deadlift really heavy growing up.
[02:24:14] I did powerlifting and sort of a side sport.
[02:24:16] But, you know, certainly never hurt myself doing that.
[02:24:21] I rode crew for a year.
[02:24:23] And so I always, I'm always wondering if that was the most destructive thing I did because
[02:24:28] in an eight man boat, it's eight year asymmetric.
[02:24:30] Right?
[02:24:31] All your symmetric when you sweep you're not.
[02:24:34] And so I was like, I was a sweeper.
[02:24:36] And so I'm always wonder if that's the most destructive thing I ever did.
[02:24:40] Yeah.
[02:24:41] And then you figure if you're asymmetrical like that, your everyday life is asymmetric.
[02:24:45] Really?
[02:24:46] Because you have a little bit of overdevelopment on the side.
[02:24:48] I don't know, I might have been there.
[02:24:49] So I guess I've never really known.
[02:24:51] But I take it really seriously.
[02:24:52] Today, in fact, you know, Jack, you'll dig this.
[02:24:56] Two weeks ago, I did a video in New York with a friend of mine named Jesse Schwarzman.
[02:25:02] And he's like, I call him the Savant of Movement.
[02:25:05] This guy's like, just like the kinesthetic man.
[02:25:08] And I wanted to put a video together of how do you train to train?
[02:25:14] How do you prepare your body to train?
[02:25:16] So it's basically three sections.
[02:25:18] It's what's the sort of dynamic?
[02:25:22] Well, the sort of tissue preparation, the static prep and the dynamic prep.
[02:25:26] It took us eight, not even six hours to shoot this video.
[02:25:31] It'll be edited down into probably three, ten minute videos.
[02:25:35] And as soon as they're done editing, I'm just going to throw them up on YouTube and my blog.
[02:25:37] So I'll make sure you've got a copy.
[02:25:39] Awesome.
[02:25:40] It's, I mean, Jesse's just, you know, he walks me through all the exercises.
[02:25:45] But I get the sense like if I had done that stuff all the way in my life, I probably never
[02:25:49] would've been hurt.
[02:25:50] And luckily, knock on wood to this day.
[02:25:51] I mean, I never thought I'd be able to squat and deadlift again after going through
[02:25:55] that year of my life.
[02:25:56] But amazingly, I'm totally fine.
[02:25:59] And it was a herniated disc that pops off the...
[02:26:01] Yeah, so it was an L5S1 really big herniation.
[02:26:06] But then a four or five centimeter fragment broke off and then floats down the canal.
[02:26:10] And that was sitting on the nerve root.
[02:26:12] And then I developed a few other problems after.
[02:26:14] So I developed this thing called a fissette arthropathy, which resulted in the feeling
[02:26:19] of having my testicles torn out from the inside.
[02:26:22] I'm not even joking.
[02:26:23] It's just so, it's just unbearable.
[02:26:25] Yeah, I would imagine that's unbearable.
[02:26:27] I don't recommend that.
[02:26:28] No.
[02:26:29] All right.
[02:26:31] Well, that being said, yes, we can talk about it.
[02:26:36] So we can talk about on it.
[02:26:39] I was talking with Greg and Terry.
[02:26:43] And I was showing them the warrior bars.
[02:26:46] Right.
[02:26:47] These are dope.
[02:26:48] And then he was like, oh yeah, like what else is there?
[02:26:51] There's some good stuff on it.
[02:26:52] This is good stuff.
[02:26:53] So I brought out that that new pre workout on, which is good by the way, every part of
[02:26:57] that.
[02:26:58] So that one comes out and then the krill oil comes out, oh yeah, this is good for this.
[02:27:02] So we're talking about this big table of like all the stuff.
[02:27:05] It's not a lot of like four things that worry bar, krill oil and the pre workout.
[02:27:10] And three things.
[02:27:12] And work like yeah, this does this and this does this.
[02:27:14] And then I kind of step back and I'm like yeah, we're those guys with all our supplements
[02:27:19] talking about supplements, talking about supplements, right?
[02:27:21] Which I've never done.
[02:27:22] And Greg goes, yeah, if we weren't such nice guys, this would be a real douchey conversation.
[02:27:28] So the kind of the irony there is him saying that he's the one having the douchey conversation,
[02:27:36] but he is the nice guy.
[02:27:40] You get it?
[02:27:41] I guess so.
[02:27:42] Anyway.
[02:27:43] Point there or actually the second point there is on it is good supplement.
[02:27:46] So if you do talk about them while you're taking them, you're not having a douchey conversation.
[02:27:51] I heard Joe Rogan talking the other day about how hard it is when you're a stand up comedian
[02:27:56] and you tell a joke and it just flat.
[02:27:58] Yeah, I just got it.
[02:27:59] Yeah, but that one here's the thing.
[02:28:01] That's the thing.
[02:28:02] There were, there were.
[02:28:03] I was going to go mercy last.
[02:28:04] But I didn't do it.
[02:28:05] There's a lot of merciful brosod.
[02:28:06] That one, that had joking elements, but this is true in this part of a bigger point that
[02:28:10] I'm making.
[02:28:11] I hope so.
[02:28:12] I don't expect you to laugh at everything I say.
[02:28:15] Even though you create a much too.
[02:28:18] Anyway.
[02:28:20] The reason that it's not a douchey conversation here's the point is because on its supplements,
[02:28:25] the krill oil, all that stuff is actually good quality.
[02:28:29] It's not like, hey, I'm a meathead.
[02:28:30] I'm going to get buffing all this stuff.
[02:28:32] It actually helps your performance.
[02:28:34] Anyway, so in the event of you wanting on it stuff and supporting this podcast, while
[02:28:40] at the same time supporting yourself, go to on it.com slash.
[02:28:43] So 10% off, boom, second way to support Amazon click through.
[02:28:50] Christmas is over, but we still need stuff duct tape, whatever.
[02:28:55] Nice, et cetera.
[02:28:58] If you want to support this podcast, just go to the website, chocopodcast.com, click through
[02:29:02] the Amazon banner link before you do your shopping.
[02:29:07] You can support that way.
[02:29:10] It's a good way to support.
[02:29:14] Yeah, you're in to chemistry, right?
[02:29:16] Sodium, when you put a little piece of sodium in the water, it makes this big commotion.
[02:29:21] So that's what the Amazon click through does.
[02:29:23] It seems like this small little thing, but applied properly, it makes a big impact in
[02:29:29] the podcast.
[02:29:30] Support ways.
[02:29:31] Anyway, thought you'd get...
[02:29:32] Can we verify that, doctor?
[02:29:34] I will have to go and look at the Amazon click through.
[02:29:39] I tell Jocca that he typically doesn't really understand because he doesn't know what sodium
[02:29:43] does.
[02:29:44] It might be in potassium or both actually.
[02:29:46] So now this whole thing has been a lie.
[02:29:49] No, I'm not sure.
[02:29:50] Not an on pretty sure.
[02:29:52] I'm actually fairly sure.
[02:29:54] Pretty sure goes a long way back or I guess.
[02:29:57] Yeah.
[02:29:58] Anyway, you can subscribe to the podcast on iTunes, which seems obvious because typically
[02:30:05] the podcast you listen to, you subscribe to.
[02:30:07] But sometimes you don't subscribe if you have not already and you want to support the
[02:30:13] podcast.
[02:30:14] Google Play, Stitcher, also in the game.
[02:30:16] Yeah.
[02:30:17] And iTunes.
[02:30:18] Yeah, it's kind of unfair that I don't think about that as much.
[02:30:21] You don't want to have an iPhone, like you kind of forget all this other stuff.
[02:30:24] I'm here to help out.
[02:30:25] Yeah, man.
[02:30:26] Good thing you're here on this podcast.
[02:30:30] YouTube, of course.
[02:30:32] We're working on putting more videos on there.
[02:30:34] Aside from the whole podcast.
[02:30:37] So some of those videos and I have gotten like messages saying like those shorter clips
[02:30:43] are helpful.
[02:30:44] They are helpful.
[02:30:45] Rather than listening to the whole podcast.
[02:30:47] And there's been people that have been submitting to you on Twitter, which excerpts
[02:30:52] are in high demand out there in the world.
[02:30:55] Yeah.
[02:30:56] Yeah, I've been following now.
[02:30:57] In fact, to have them all like it's a process.
[02:31:01] But yeah, we're working on that.
[02:31:02] So subscribe to YouTube.
[02:31:03] We are working on that.
[02:31:04] We are.
[02:31:05] We are.
[02:31:06] Collective.
[02:31:07] Just say you guys know I'm not working on it.
[02:31:09] But echo of Barrett Vs, which is cool.
[02:31:11] Well, technically you say, hey, but put this one out.
[02:31:14] Okay.
[02:31:15] I'm hard to tell you.
[02:31:16] Yeah, man, exactly.
[02:31:17] And then in the event of you wearing like what, like a t-shirt or something or hoodie,
[02:31:22] Jockel has a store.
[02:31:24] It's called Jockel Store.
[02:31:26] The URL is Jockel Store.
[02:31:27] Yeah, exactly.
[02:31:28] Is that a calculator watch you there?
[02:31:30] I was going to get to that.
[02:31:32] You mentioned, see now we've got to change subject real quick, which I like, by the way.
[02:31:36] Remember you're talking about your inter watches.
[02:31:38] Yeah.
[02:31:39] I was going to show I didn't want to interrupt what you're saying.
[02:31:42] That is your appreciate.
[02:31:44] That is ridiculous.
[02:31:47] I just ring incorporated this one back.
[02:31:50] What is it, a calculator watch?
[02:31:52] Yeah.
[02:31:53] Actually, one of the first pictures I posted on Twitter was up before the enemy.
[02:31:56] And it was like, you know, Jockel is always like, yeah, 430.
[02:31:59] Which one is at the Casio?
[02:32:00] Yeah, Casio.
[02:32:01] Oh, cool.
[02:32:02] 2, 3, 4, 4, 5.
[02:32:07] That watch when I was a kid.
[02:32:09] Like, I would have flizzled some for that.
[02:32:11] Only the cookies had the calculator one.
[02:32:13] Oh, usually if you had a watch, it was just the regular Casio.
[02:32:16] And the cookies had the Calkey.
[02:32:18] I had the first Iron Man.
[02:32:21] Did you?
[02:32:22] Yeah.
[02:32:23] It was black with like a little red trim on it.
[02:32:25] I asked for it for Christmas.
[02:32:27] My parents got it for me, but I knew where they hid presents.
[02:32:30] So every day after school I would go into their room and I would take it out of the box.
[02:32:35] And I would set the time.
[02:32:37] I would wear it.
[02:32:38] I would just hang out there.
[02:32:40] And then before I go to bed, I'd like sneak back, put it in.
[02:32:43] And so like on Christmas Day, it was like I'd been wearing the watch for a month.
[02:32:46] Those are your watch.
[02:32:48] Actually, I think you got it.
[02:32:50] I'm in the watch as soon.
[02:32:51] Yeah.
[02:32:52] Yeah.
[02:32:52] Well, I got one.
[02:32:54] Actually, I got quite a few of these.
[02:32:56] I guess you should have your own brand of watch.
[02:32:58] Yeah.
[02:32:59] We'll see how all that turns out.
[02:33:00] Yeah.
[02:33:01] Yeah.
[02:33:02] I'm not going to listen.
[02:33:03] Yeah.
[02:33:04] I am very proud of this Calkey layer watch.
[02:33:07] Back to the store though.
[02:33:08] Jockel store.
[02:33:09] No watches.
[02:33:10] Yeah.
[02:33:11] Yeah.
[02:33:12] Yeah.
[02:33:13] But there are some cool shirts.
[02:33:14] In my opinion, I think they're cool.
[02:33:16] Displinicals freedom of all these things.
[02:33:18] Jockels had good, written in backwards.
[02:33:20] Various layers to these shirts.
[02:33:23] Not just like, oh, picture that's it.
[02:33:27] So if you like any of that stuff, I'm not even saying go buy this stuff.
[02:33:32] I'm not saying that.
[02:33:33] Just go to the Jockel store.com.
[02:33:35] See, if you like it, if you like it, you won't want to buy one.
[02:33:38] And that's a person podcast.
[02:33:41] You know, it's a systemic thing.
[02:33:44] Good.
[02:33:45] There you go.
[02:33:46] Patches on there as well.
[02:33:47] Rashcards.
[02:33:48] Oh, you know what you didn't mention?
[02:33:50] That you should have mentioned, because apparently it's been pretty cool out there in the world.
[02:33:54] Lain on me.
[02:33:55] Psychological warfare.
[02:33:56] Yeah.
[02:33:57] I didn't mention it this time, but I mentioned it last time.
[02:34:01] And in my everyday life.
[02:34:03] And I use it.
[02:34:04] So there you go.
[02:34:05] Psychological warfare.
[02:34:07] You use it?
[02:34:08] I use it.
[02:34:09] Every day?
[02:34:10] When needed.
[02:34:11] Here's the thing.
[02:34:12] You can't use it every day.
[02:34:13] You know, you can't actually.
[02:34:14] You can't.
[02:34:15] I'm like a say, you can't use it every day.
[02:34:16] But the reason, the whole reason that I was like, hey, Jockel, what do you say?
[02:34:20] You know, when you're.
[02:34:21] Okay, you don't need every day.
[02:34:22] I don't need it every day.
[02:34:23] Okay.
[02:34:24] But it varies, you know, from season to season.
[02:34:27] So like, you know.
[02:34:30] So if you are coming up against moments of weakness, we have a little method to get you over
[02:34:37] to those haunts.
[02:34:38] Yeah.
[02:34:39] It's kind of like coaching a little bit.
[02:34:42] Psychopathic coach.
[02:34:43] Yeah.
[02:34:44] Psychoprosha.
[02:34:45] Yeah.
[02:34:46] Psychoprosha.
[02:34:47] Because it kind of.
[02:34:48] I played one of them from my seven year old daughter the other day.
[02:34:51] Because she's about to eat some candy or something.
[02:34:53] I was like, come here for a minute.
[02:34:54] Yeah.
[02:34:55] So I played her that one, you know, the snack time one.
[02:34:57] Yeah.
[02:34:58] She was.
[02:34:59] Yeah, sugar coated lies.
[02:35:00] She was.
[02:35:01] She was pretty impressed.
[02:35:02] But we'll impress me as later in the evening.
[02:35:04] She was kind of saying it.
[02:35:05] Yeah.
[02:35:06] I was.
[02:35:07] See?
[02:35:07] And that's what I was going to say where.
[02:35:09] You explain.
[02:35:10] It's like, cool.
[02:35:11] It's Jockel.
[02:35:12] Tell me to do this.
[02:35:13] So yes, I'll do it or not do it whatever.
[02:35:15] But you explain some some some good stuff like to to remember.
[02:35:19] You know, like then it's sugar coated lies.
[02:35:22] And that's kind of catchy too.
[02:35:23] So it sticks in your mind.
[02:35:24] Poison.
[02:35:25] So you can buy that on iTunes.
[02:35:29] Yes.
[02:35:30] It's somewhere else too, right?
[02:35:31] Google play.
[02:35:32] If you want it.
[02:35:33] And also everyone that asks for an alarm tone to wake up.
[02:35:36] That's it.
[02:35:37] That's it.
[02:35:38] It's there now.
[02:35:39] You don't have to ask anymore.
[02:35:40] You can just go to iTunes and get that cycle.
[02:35:41] Clear it with your wife or whoever you sleep with.
[02:35:43] Yeah, we've gotten something to be going to speak back on that one.
[02:35:45] Yeah.
[02:35:46] Because what happens is the alarm goes off if you haven't set then it's going to be my voice.
[02:35:50] And it's going to be weird because it sounds like there's some strange man in your room.
[02:35:54] It's a flood there in the morning.
[02:35:55] Which is kind of weird.
[02:35:56] Yeah.
[02:35:57] It's the only work at 430 a.m.
[02:35:59] Like, no, it's just it's just it's just an album.
[02:36:03] It's an album of tracks.
[02:36:06] And each track talks about some moment of week generally a moment of weakness that you have.
[02:36:13] Like, there's a one to wake up in the morning.
[02:36:15] There's ones to you know what you don't feel like going to the gym.
[02:36:19] There's ones you feel like you don't know.
[02:36:22] Don't eat the donut.
[02:36:23] There's one.
[02:36:24] I'm going to put this off for a while.
[02:36:26] I'm going to procrastinate.
[02:36:27] No, you're not going to procrastinate.
[02:36:28] So all the little moments of weakness that we all have as humans can be countered using psychological warfare.
[02:36:35] Yeah, there's there's actually two on there.
[02:36:38] There's one called like, I think it's called like no more.
[02:36:40] It's basically like I'm not doing this in there.
[02:36:42] Yeah, no more.
[02:36:43] It's good one.
[02:36:44] That one's good because it puts in towards exactly like what you want to think.
[02:36:48] Like you know, because you always feel that like, you know how likely you know you're gaining some weight or I mean a lot of times you know why you're gaining weight.
[02:36:54] And so it's a little bit different.
[02:36:55] But you're like, you know what I'm not doing.
[02:36:57] I'm drinking is one where you wake up kind of hung over and you're like, I'm not drinking anymore.
[02:37:01] You know, like that thing, but you never really execute.
[02:37:04] Yeah, you know, and it's perfect because it sticks with you.
[02:37:07] You're like no more and then the other one was when you're talking about everyday.
[02:37:12] It's called everyday.
[02:37:13] Everyday.
[02:37:14] Everyday is a Monday that that one.
[02:37:16] Now it's dope.
[02:37:18] So you can get after that also.
[02:37:21] If you want to get some tea, if you're tea drink or if you're not a tea drink or you can get some chocolate, you can get it on Amazon.
[02:37:28] It's fully in stock.
[02:37:29] Y'all, those days of being out of stock, I think we've got them under control for now.
[02:37:34] And I won't make any promises because last time I made a promise.
[02:37:37] You guys went psycho.
[02:37:39] So I'm not going to make a promise, but you can get the chocolate tea.
[02:37:42] I figured out again, it doesn't.
[02:37:44] It doesn't taste like tea.
[02:37:47] Really, it doesn't taste like coffee.
[02:37:49] And for a long time, I was at a loss for words to describe what it tasted like.
[02:37:53] And I figured it out.
[02:37:55] I was responding to someone and I figured it out what it tastes like.
[02:37:58] And it's pretty simple.
[02:38:00] The chocolate tea tastes like victory.
[02:38:05] So if you need to.
[02:38:09] And we need to trade.
[02:38:10] I need to trade market.
[02:38:12] What?
[02:38:13] The fact that jocquoise tea tastes like victory.
[02:38:16] Boom.
[02:38:17] So get some of that.
[02:38:19] If you need to deadlift more, if you need to overhead squat more weights, this will increase all those numbers beyond anything you could have pulled for.
[02:38:28] You can drink it from a jocco mug.
[02:38:31] It says get after it on it.
[02:38:33] That's good.
[02:38:34] Oversize, by the way.
[02:38:35] Yeah, it's big.
[02:38:36] It's big.
[02:38:37] It's not.
[02:38:38] Somebody made the comment that it's not.
[02:38:39] It's not a joke.
[02:38:42] Yeah, it's not like clown shoes.
[02:38:43] No, it's not like clown shoes.
[02:38:44] No, it's not like clown shoes.
[02:38:45] It's not like clown shoes.
[02:38:46] It's big enough to, you know, it's like a pair of work.
[02:38:49] Boots as big as a pair of work.
[02:38:50] Boots as big as a pair of work.
[02:38:51] It will kick you in the ass.
[02:38:53] So it's that big.
[02:38:55] If you haven't got the book Extreme Ownership, you can pick that up there.
[02:38:59] It's about leadership.
[02:39:00] It's about combat leadership.
[02:39:01] I'm going to give my friend Peter T about three copies of it.
[02:39:05] Just to make sure he reads it.
[02:39:06] So if he has to deal with any sea players, you're going to step up his game of a little bit.
[02:39:10] Hopefully.
[02:39:11] I really have a free publication.
[02:39:13] That's right.
[02:39:14] I really missed that.
[02:39:15] We worked with a pre-pub, what does that mean before the book came out?
[02:39:19] Hey, here's what the book is.
[02:39:21] Okay, but it's still that's it.
[02:39:23] That's it.
[02:39:24] Yeah, it's not like you have the pretty stuff.
[02:39:25] It's a paper bag.
[02:39:26] Yeah, yeah.
[02:39:27] Yeah.
[02:39:28] It's a VIP.
[02:39:29] Yeah.
[02:39:30] Yeah.
[02:39:31] Hey, speaking of Extreme Ownership, we're having another monster.
[02:39:34] If you don't know what it is, check out the website, Extreme Ownership.com.
[02:39:38] It's going to be a New York City.
[02:39:40] So everyone can come because if you're on the East Coast, no matter where you're on the world,
[02:39:45] it's easy to get to New York.
[02:39:47] And May 4th and 5th, if you're a leader or you want to be a leader, come and get it.
[02:39:54] There's every level of leaders there, CEOs, middle-level managers.
[02:40:00] Every industry you can think of too.
[02:40:02] People that manufacture and finance and construction and health and pharmaceutical, and there's police there and fire and military and oil industry and entities to everybody.
[02:40:12] All working on leadership, talking about leadership.
[02:40:16] So, and I've said, it's going to sell out.
[02:40:19] We're moving in that direction quickly.
[02:40:21] And Echo hasn't even released his videos yet because he's on Hawaii in time.
[02:40:24] No, no.
[02:40:25] Oh, you're not.
[02:40:26] No, I'm working diligently.
[02:40:28] And I'm going for quality.
[02:40:29] Not, you know.
[02:40:33] You're not going to put out any scrub material.
[02:40:35] Right.
[02:40:37] Once those videos come out, my feeling is going to sell very quickly.
[02:40:39] So get there now, sign up for it.
[02:40:41] If you need a police or fire discount or military discount or if you're going to be a group of people, I think the biggest group we had at the last one for one company was around 16 people.
[02:40:47] From one company or 12 people.
[02:40:49] But there's some pretty big numbers of companies that are showing up there.
[02:40:52] Come and get it.
[02:40:54] Echo, you got any closing comments.
[02:40:57] My pleasure.
[02:40:59] Oh, no.
[02:41:00] Other closing comments.
[02:41:01] Thank you.
[02:41:02] Other than it was your pleasure.
[02:41:03] Peter.
[02:41:04] Any closing comments?
[02:41:05] I would only echo Echo's comment.
[02:41:08] And that didn't even get planned until it came out.
[02:41:12] Perfect.
[02:41:14] And if you want to continue these conversations with Peter.
[02:41:18] On Twitter, your Peter T.M.D.
[02:41:22] What are you on Facebook?
[02:41:25] Um, I don't know.
[02:41:28] Probably.
[02:41:30] You still have eating academy?
[02:41:32] Yeah.
[02:41:33] Probably.
[02:41:34] I don't do a lot.
[02:41:35] So Twitter is your most Twitter's pride.
[02:41:37] And I've been berated into doing something on Instagram.
[02:41:41] I just can't cope at the moment.
[02:41:44] Yeah.
[02:41:45] There's a way to connect the two.
[02:41:47] I've tried it.
[02:41:48] I don't like it.
[02:41:49] I do them separately.
[02:41:50] Yeah.
[02:41:51] You don't really connect Twitter to the Instagram.
[02:41:53] Yeah.
[02:41:54] I don't have any.
[02:41:55] I don't have any.
[02:41:56] I don't have any pictures to show.
[02:41:57] Right.
[02:41:58] I don't have anything to tell.
[02:41:59] Don't you have a bunch of watches?
[02:42:01] Yeah.
[02:42:02] I'm showing the same watch every day.
[02:42:04] Show that ring.
[02:42:06] How you were excited?
[02:42:07] I think it was all that.
[02:42:08] You could do like.
[02:42:10] Both pictures just on the right.
[02:42:11] I don't know.
[02:42:12] I don't know.
[02:42:13] What if my whole Instagram stick became this?
[02:42:15] Like my blood glucose.
[02:42:17] Yeah.
[02:42:18] That'd be pretty cool.
[02:42:19] And you kind of be interested.
[02:42:20] You could just, you could just, you could just,
[02:42:22] save that screen and post it up there.
[02:42:25] It's hard labor to save that thing and press submit to it.
[02:42:30] It actually has a little switch that you can just make it go.
[02:42:33] It's not that much work.
[02:42:35] I don't think about it.
[02:42:36] For somebody that's swimming 18 miles a year.
[02:42:38] I know.
[02:42:39] Talk about how you can see what you're going to do.
[02:42:40] It's a work to post.
[02:42:41] It's the grand picture.
[02:42:42] You got it.
[02:42:43] You got it.
[02:42:44] You got it.
[02:42:45] You got it.
[02:42:46] You got it.
[02:42:47] You got it.
[02:42:48] You got it.
[02:42:49] You got it.
[02:42:50] You got it.
[02:42:51] You got it.
[02:42:52] You got it.
[02:42:53] You got this.
[02:42:54] You got it.
[02:42:55] You know.
[02:42:56] So if you're going to be looking around that face.
[02:42:58] bulky.
[02:42:59] Not easy.
[02:43:00] We're going to be there.
[02:43:01] Echo is at Echo Charles and I am at Jackson Willink and again,
[02:43:06] I would like to thank you Peter for coming on and more important for everything
[02:43:11] You've done for me, which really the way it's connected all together getting me through
[02:43:17] to Tim Ferris, which was the book and get me on Jill Rogan, which led to this podcast.
[02:43:23] It's been awesome, so to you, and to Doc Kirk Parsley, for introducing us, but thank you
[02:43:31] and him for what you guys done for me.
[02:43:34] So, we've met in women in uniform out there holding the line.
[02:43:40] Thanks for your service and your sacrifice to the police on the corner, fighting crime, the
[02:43:49] firemen, fighting fires.
[02:43:50] Thanks for keeping us safe.
[02:43:52] To the medical people in the medical professions, like Peter, doctors, nurses, physicians,
[02:44:01] assistants, EMTs, all of you working to save lives.
[02:44:06] Thank you for your commitment to service, and it's obviously a massive commitment when you hear
[02:44:11] about the hours and the emotional trauma that it takes to go into any one of those
[02:44:19] industries and services.
[02:44:23] And to everybody else that's listening, thank you.
[02:44:28] That's your communications, your questions, your participation, your feedback and your
[02:44:36] spreading of the word that makes this possible, and it's what makes this worthwhile.
[02:44:44] So thank all of you for all of that.
[02:44:50] And finally, thanks to all of you for getting out there and getting after it.
[02:44:59] So until next time, this is Dr. Peter Etia, and Eko and Jocco.
[02:45:07] All of you staying out.