Jocko Podcast - 56: Overcoming Stress, Sleep Deprivation, and The Darkness with Peter Attia

Episode Date: January 6, 2017

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 ClosingSupport this podcast at — https://redcircle.com/jocko-podcast/exclusive-content

This is Jocko podcast number 56 with Echo Charles and me Jocker Willink. Good evening, Echo. Good evening. Silent screams and broken dreams. Addics, junkies, pushers, and fiends. Crowded spaces and sad faces never look back as the police chase us. Consumed slowly by chaos. a victim of the streets,

hungry for knowledge, but afraid to eat. A life of destruction, it seems no one cares, a man-child alone with burdens to bear. Trapped in a life of crime and hate, it seems the ghetto will be my fate.

If I had just one wish, it would surely be that God would send angels, to set me free Free from the madness Of a city running wild Free from the life Of a ghetto child

And that is a poem Written by a young DeAndre McCullough A Criminal drug dealer Who when he wrote that poem Was doing time After

being one of the main subjects in a book called The Corner, which is written by David Simon and Edward Burns, which documents the violent drug trade in Baltimore, Maryland. And that sort of morphed into an HBO series that was called The Corner as well, which paved the way for another series, which is called The Wire, which is just an outstanding mini-series.

that came out on HBO. But the wire is fictional, even though it's based on kind of the same situation in Baltimore. But the corner is real. The book, The Corner's Real, and it gives a very clear and a very grim view at the life of drugs and crime in the inner city, namely in Baltimore. And I'm going to go back to the book now. We can't stop it. Not with all the lawyers, guns, and money in this world. Not with guilt or morality or righteous indignation.

Not with crime summits or task forces or committees. Not with policy decisions made in places that can't be seen from the lost corner of Fayette and Monroe. 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. No peace can come from kingpin statutes and civil forfeiture laws and warrantless searches and whatever the hell else is about to be tossed into next year's crime bill. Down on Fayette Street, they know. Today, as on every other day, the shop will be open by mid-morning, and the touts will be on the corners chirping out product names as if the stuff is street legal.

The runners will bring a little more of the package down and the fiends will. will queue up to be served, a line of gaunt, passive supplicants stretching down the alley and around the block. The corner is rooted in human desire, crude and certain and immediate. And the hard truth is that all the law enforcement in the world can't mess with desire. Down at Fayette and Monroe and every corner like it in Baltimore, the dealers and fiends have won because they are legion. They've won because the state of Maryland

and the federal government have imprisoned thousands and arrested tens of thousands and put maybe 100,000 on parole and probation rolls and still it isn't close to enough. By raw demographics, the men and women of the corners can claim victory. 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 50,000, perhaps 60,000 strong. Three of them available for every prison bed in the entire state of Maryland. 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. And the fiends are chasing down that blast 24-7. In neighborhoods where no other wealth, exists. They've constructed an economic engine so powerful that they'll readily sacrifice everything to it. And make no mistake, that engine is humming, no slacking profit margins, no recessions,

no bad quarterly reports, no layoffs, no naturalized unemployment rate. Get it straight. They're not just out here to sling and shoot drugs. In drug market, in cities across the nation, lives without any obvious justification are given definition through a simple self-sustaining capitalism. The corner has a place for them every last soul. Touts, runners, lookouts, mules, stick-up boys, stash-stealers, enforcers, fiends, burn artists, police snitches, all necessary in the world of the corner. Each is to be used, abused, and ultimately devoured with unfailing precision. It's about the fiends, thousands of them who want that good dope.

They need it the way other souls need to breathe air. 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 of material success. They are working the package with the hidden knowledge that they will fall, that with rare exception, the money won't last, and the ride will be over in six months,

or four, or three. Violence. Violence is no longer the prerogative of the professional, but a function of impulse and emotion. The contract killers and the well-planned assassinations of earlier eras are mere myth on these corners. Now, the moment of truth generally comes down to some man-child with hurt feelings,

waving a 38-a-round, spraying bullets up and down the block. The accidental shooting of bystanders is now commonplace. Even 15-year-old hoppers have loaded 38s hidden in the alley. The job is a little better than a death wish. And in the end, the corner best serves the hardcore, the junkyard dogs with neither the time nor the inclination for pity. The corner proves itself every day. It destroys whatever it touches. And eventually, the corner destroyed D'Andre McCullough.

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. You got some other jobs in the entertainment industry as well, but the coroner called them back. That guy, DeAndre, who wrote that poem, he ended up dead of a heroin overdose in 2012 at the age of 35. Now, there's a reason I'm bringing all this up, and that is because we have a guest tonight,

a guest that is actually more, responsible for this podcast than anyone, and we'll get to that later. But his name is Peter Atia. And he grew up a boxer, has been a long-distance athlete, got his degree in medical engineering and applied mathematics, and then got his doctorate as an MD from Stanford. And did his residency in surgery. 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, which is about three miles from the actual corner of Fayette Monroe Street.

The war zone that's pictured in the book, the place where DeAndre McCullough lived and where violence was and in many ways still is just a part of life and Peter was at ground zero in the war zone and saw more darkness and suffering probably than any person should have to and learned a lot from it to get to that in a bit but first of all Peter Atia welcome to the show thank you for having me sir glad to have you on finally and you grew up. We'll get right into it. Tell us a little bit about just growing up.

You grew up in Canada. And I know you've covered, for those of you that hasn't listened to the Tim Ferriss's interview with you, listen to them. What is there, three of them? Yeah, I think so.

I think there's three of them. You can listen to those and get more details on, you know, Peter, his whole background. But for those that are just listening right now, you grew up in Canada, just a little,

little statement about that. Yeah, 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. 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. And meaning it's just a dump. It's not like a war zone or anything. And I have. have lived now in the United States for about half my life. So I, high school and college was in Canada and then everything from med school beyond has been here. And I am now a dual citizen. How did that transition work? Because you didn't, you, you obviously got applied mathematics degree. And then you worked in the civilian world a little while with that degree, right?

So my plan was always to do a PhD in aerospace engineering. And so I, that's why I, did the mechanical engineering and applied math. 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. And then I had just a complete change of heart and decided I wanted to go into medicine. And so that,

so what I had to do for a year then was you got to take this thing called the MCAT, which of course I didn't have any of the courses to take it. So I had to sort of teach myself the chemistry and biology that summer, took the MCAT. A lot of times that's what I do in the summertime. I'll teach myself, you know, chemistry and biology in the summer. I didn't do that well. And then I had to do what's called a postback year where you go back and you're in the

process of applying to medical school without actually having the courses to get in. So if you get in, it's conditional. And so that year, because I'd already graduated, I just taught calculus. So I, you know, was like a, you know, adjunct lecturer at the university. and taught calculus, which I always enjoyed. I mean, because I taught it for a couple of years before. And so that's why you're waiting to get into med school. Applying and then and getting my courses.

Like I forget what I had to take biology and psychology, biochemistry. I had to take a few prerequisites to get it because in engineering and math, I'd never taken a single course. In fact, the day before I took the MCAT, this is only going to be funny for geeks who get biology. So I'll clarify a moment. That won't be me. Yeah, I'm studying for the MCAT. this summer that I'm supposed to take the test.

And the whole time I'm studying, I'm like, you know, I can't believe how sloppy these textbooks are. They keep confusing meiosis and mitosis. Like, why can't they just spell it the same way both times? Like they, I didn't realize that it was two separate things, right? Myosies is when a cell separates, but doesn't replicate its DNA. Mitosis is when it creates an equal copy. And I literally not until the day before the MCAT realized that those are two separate things.

I mean, that's how clueless I was going into this test. Yeah. And the only reason I knew that was because I was helping one of my daughters study for their biology something. Yeah, anybody who took any biology course should know that. But I hadn't taken any. So then you get in med school. Yeah.

You go there, what's that, four years, another four years of school? Uh-huh. And then you get done with that. And now it's time to do your residency. So do you get to pick where you're going to go? Not. Sort of. So it's a funny system called the match.

system. So when you're in your, I guess you're beginning your fourth year of medical school, by that point you have to figure out what you want to do. Do you want to be a surgeon? Do you want to be an internist? Do you want to be a pediatrician, a radiologist, whatever you want to do? Because all of those have different programs. And then you have to apply to those programs. So let's say you wanted to do orthopedic surgery. You would send out your application to all the orthopedic programs in the country. Hopefully you'd get interviews to a good number of them. You'd go do the interviews. And then you would submit to a match system, a rank order of the places you'd want to go. And you don't put something on there that you don't want to take. So if you, you know, if you

applied to 30 programs, you got interviewed at 15 and you liked 10, you rank those 10 in order. Similarly, the programs, after they interview everybody, do the same exercise. They do the rank. and then a computer matches you one to one. That's actually pretty squared away. Yeah, so you, the only way you're going to guarantee you know where you're going is rank one program and hope you get it. So in my case, I think I ranked five programs, and I ranked Johns Hopkins first for surgery, not because I wanted to live in Baltimore, though in many ways I think it was a blessing to do so. But, you know, because 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.

And that was a combination of two things. One is you had these kind of legendary surgeons there that had pioneered some of the most complicated, what are called hepatobiliary surgeries, surgeons, you know, surgery of the pancreas and the liver and stuff like that. But at the same time, as you alluded to, it was in a war zone. And so the other aspect of training to be a good surgeon is having great. exposure to penetrating trauma. So trauma, you always want to divide into blunt and penetrating. Blunt trauma is not often operative. So people that get hit by cars and things like that, you know,

it ends up being more orthopedic. 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, it's penetrating trauma. It's you want knife and gunfight. Not that you want it. But that's the training ground to be in. And sort of Baltimore would have been, you know, probably in the top five. What year was this?

2000? 2001. Yeah, 2000, I think. Okay. And when you were, what was the thing that slipped, or this is going backwards a little bit, what was the thing that transitioned in your mind where you all of a sudden wanted to do medicine?

Well, yeah, it's funny. I don't think I've ever talked about this publicly. So when I was in engineering school, in my second year, I started doing some volunteer work. And I, the reason, and why is too complicated, but I started volunteering with some kids that were in a shelter that had been abused. So it was a home for sexually abused kids. And that got me interested in sort of volunteering in a hospital. So I was volunteering at a hospital that had, you know,

it was a pediatric cancer ward. 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. And so between that experience and then I was still doing this volunteer work with these kids who had been sexually abused. A lot of those kids were suicidal. So I also found myself in the hospital a lot with these kids after they'd attempted to kill themselves. 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.

I don't think it's an existential crisis as much as maybe a nervous breakdown, but just a bunch of things were kind of going on, probably some undiagnosed psychiatric issues on my part. But I realized like I love engineering and math intellectually, but there's no emotional connection outside of the joy of solving a problem, which by the way is probably plenty enough. But I wondered if there was something else that I'd be more interested in that could scratch two itches, right? It could scratch sort of the intellectual itch, but also maybe an emotional itch. And so I spent the majority of my senior year thinking about was there something else? else I ought to do. 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, you're going to go off and do the best PhD program. So at the very end, when I sort of declined to do that and I turned down a bunch of scholarships, it seemed a little odd that I would go and do medicine. But that's really the reason. It was, you know, it was kind of this epiphany I had one day, actually, while I was in the hospital when I was sort of had this actually it's really funny we just moved as we were talking about earlier and you know one of the things moving is great for is cleaning up stuff and actually found my essay that I wrote when I applied to medical school back in you know whatever 95 or 96 and it was

really interesting to go back and read the story because it's exactly kind of how I remembered it right which was like this moment I had this sort of insight that is what I wanted to do so so that's that's kind of the the series of events that led me to have that seemingly orthogonal change in direction. Okay, so now you go through that, you end up, you get your accepted to your residency at John Hopkins. You show up there. What's that like? Well, I remember when I interviewed at Hopkins for medical school as well, and I was lucky enough to get in there for medical school. And at the time, I think Hopkins was technically the best medical school in the country.

it was Harvard and Hopkins were the best two, and Stanford was, you know, maybe third, fourth, fifth. But I remember when I interviewed there for medical school, at the end of the interview, like I had to spend a night there. And so they put us up in the dorms for the med students, which is a great idea you get to meet your upper classmates. And I remember I said that Friday night, I said, hey, I'm going to go walk down to the harbor. It's like a mile and a half down the road. And they're like, oh, no, no, you can't do that.

I said, what do you mean? 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. There's a guard in full armor with an automatic weapon. And so I remember at the time thinking, yeah, I probably don't want to go here for med school. And of course, Stanford's sort of for a guy

who'd never been to California and who'd lived in miserable cold weather his whole life. I was like, it could have been the hundredth ranked medical school. I was still going there. Yeah, I have some actual stats that I pulled up. So war zone, in 1993, there was 48 murders for every 100,000 people. There's, what, 700,000 in the city. The next highest was in 2015, 55.

And in 1993, again, there was 353 homicides. Yeah, almost one a day. And so, you know, I have to put this in there just, you know, because we're sitting here calling it a war zone. So when I was in Ramadi in 2006, the 1-1-A-D, which is the Ready First Brigade, you know, 5,600 soldiers, while we were there with them for six months, they lost 61 guys. So what I'm saying is now that doesn't count the enemy casualties, but it counts the friendly casualties that are showing up at our med center, right? So there, you know, you're talking three or four hundred, well, you just said,

one a day. Yeah, about one a day. Okay. So, um, so you knew how bad it was when you got, I mean, I mean, I sort of knew it was dangerous, but, but I think when I decided that, you know, for this, that season of my life, you got to sacrifice everything and you have to go to the place where you're going to get the best training. And I didn't want to leave California because, you know, four years in California for the first time was, you know, I mean, you know, you guys know what it's like. I mean, it was like, I don't ever want to leave. this place. But I also knew I just couldn't get that level of training on the West Coast. And it was, you know, you basically had to go to a place like Hopkins, Brigham and Wobbins in Boston,

maybe Wash You in St. Louis was going to offer a very similar environment. So then, you know, so then I ended up ranking it first. They ranked me first. So away we go. We get lucky. It's a match made in heaven. And that's like kind of February of your senior year. And then reality sits in, which is you've got sort of four months until you have to show up. And, And that was kind of like the, oh, shit moment, right? Like I really just signed up for this. And a good friend of mine who was two years ahead of me in medical school, his name is Brian Dunham.

He's now a pediatric head and neck ear, nose and throat surgeon at CHOP in Philadelphia. He was at Hopkins, which was at the time the best ear, nose and throat program in the country. And he actually recommended I read this book, The Corner. 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 he's a great surgeon he's like a gifted artist his side job is medical illustration like you can't believe what this guy can do

but he's introspective right and he was he said look you know you're you're going to sign up to be in this war zone and you're going to be taking care of people that it's going to be very easy to despise so he said you need to read this book to gain a sense of their perspective. Because very, like I said, you know,

so at the time, I can't remember the stats. I feel like at the time that I was there, we averaged about 16 penetrating traumas a day. Now, to put that in perspective, in general surgery, you're on call every second to every fourth night. So average about every third. That means every third night,

120 times a year. You will spend the night in the hospital, not sleeping, waiting to take care of any trauma patient. So if every third day and night, you know, 16 of these people are getting shot and stabbed, you're going to have a lot of time in the ER, in the trauma bay dealing with that.

And it's really easy to get jaded really quickly. It's fun for the first month. And then all of a sudden, every time somebody gets shot, it's preventing you from sleeping. Which when we're sitting here all well rested, sounds like a very callous thing to say. But all of a sudden, you're sort of like,

damn it, man. I'm like, I can't eat because the trauma pager just went off again. To this day, I still eat shockingly fast, and it drives my wife nuts, but she doesn't understand. I said, I think it's just, I'm a victim of you never know when you're going to have to stop what you're doing, and that might be your last meal. Even I shaved quickly, because the worst thing that could happen is you've got shaving cream all over, and the trauma page goes off, and you've got to run down half shaved. You know, you've got one side of your beard down on the other side. So it's stupid things like that. So that was Brian's recommendation.

So I got the book immediately, devoured it, found it to be the most depressing thing I had ever read. It is. It's heavy. Made more depressing by the fact that they pull no punches, no names are changed. So every person you read about, you were reading about it in a completely uncensored, uncensored, unfiltered way. And, I mean, you read it. You know, there's nothing happy about this book. Like you just finish it and you think, yes, you have more empathy and you understand where these folks are going to be coming from. But it's like I don't, it's not like you finish that book and go, ah, here's the solution.

We need a six point plan that's going to do X, Y. It's like, I don't. That's kind of why I read that one excerpt. We can't win, which is an awful thought. And that's the impression the book gives you is we can't win. And the way he phrases it of being, look, it doesn't matter how many police. and whatever you do, you're going against human desire. Well, the stat that you reiterated,

and I remember it very well from when I read this book, the first time was you couldn't take every junkie and put them away. If you took every federal and state prison bed in Maryland, you'd have three people for it if you just looked at the users. Never mind the guns, the money, and everything that comes with it. So, yeah, that's not a solution. Now, there's a second reason that I don't think Brian knew, because I don't think anybody knew, that that book really hit home, which was, it's, it's, it sounds tangential to this story, but it becomes highly related. And at the beginning of, end of my third year of medical school, I'm going to the gym one day, riding my bike, as I always do.

I get to the gym, I get off my bike, go to lock it up, and I was like, my back really hard. hurts, like really hurt, not like, oh, it's a little stiff. Like something feels horrible. So I started walking down the steps to the gym and I was like, not going to happen today. Like, I mean, I couldn't do anything. I couldn't time my shoot. So I just went back, got on my bike, rode back to my apartment, told my roommate. I was like, hey, man, I'm going to go lay down upstairs.

The next morning I woke up, I couldn't get out of bed. And to make a very long story short. over the next two weeks, I completely deteriorated. You know, I was at the point where I could get in and go to the hospital, but I had to, like, have the nurses. This is back in the Wild West days where you could just sort of get anything you needed at the pharmacy. You know, I'd get nurses or residents to inject hortol into me, which is a really strong inset.

I could only sleep if I laid in an L shape over the nurses station. And it just wasn't getting any better. and then one day the pain changed immediately. I realized in retrospect what happened, a herniated disc had fragment had broken off. So the pain in my back dissipated, but now I had this, what turned out to be a four centimeter fragment

sitting on my S-1 nerve root. So now it felt like my left foot was being skinned from the bottom. But that was constant. So that was an unrelenting pain. And it could only be sort of brought under control if I could put my foot into a bag of ice because then I could make my foot go numb.

and then I could take some pain medicine. So this went on for another week, and then the dean of the medical school saw me limping through the hospital. He said, what's wrong? And I told him, and he dragged me down to the ER. We got an MRI that showed all of this, and I was in surgery the next morning.

This was a Sunday night. Monday morning, I'm in the OR. It turned into a disaster. The guy who operated on me, operated on the wrong side. So I woke up. The left issue was still present, but now I had what's called a foot drop

on the right side. So foot drop is when the no, nerve that holds your foot up, which we take for granted when we walk. But if you don't have the ability to what's called dorsiflex, your foot would drop. You can't walk. You'll end up dragging your toe when you keep tripping. This story, I mean, we could spend three hours on the story because it's so idiotic. The punchline is I eventually needed many trips back to the operating room.

This guy refused to believe there's anything wrong with me. It took another amazing doctor and neurologist to actually intervene on my behalf. and three months later, I'm unable to walk. I'm unable to do anything. My mom actually had to fly down from Toronto to look after me. And I'm sort of, you know, you go through the checklist, right? So there's, I don't know if you've ever heard of Elizabeth Kubler-Ross. I don't think she's alive anymore, but she wrote a very famous book on the stages of dying.

and it goes through like anger and denial and finally acceptance at the end, right? And so, you know, bargaining, like, it's something that would make sense if you, and I'm sure you've watched. I've heard of that before, yeah. And you've probably watched it on really small scales. Yeah.

You know, like in combat, you might see these things over the course of... I've seen it compressed and dealt with it. And with a cancer patient, you might see this stretched out over a year. And so I was kind of going through this on my own, right? Where initially it was like, oh my God, what if I don't finish this rotation

I'm doing right now? What's called a surgical subinter? to, well, what if I don't graduate on time, to what if I can't be a surgeon? And then it was, what if I don't walk ever again? So somewhere along the way, I don't remember exactly when, probably like a month and a half into this, I finally caved in and started taking pain medicine. I thought that's where the story was going. I was like, at some point, he's going to get on the opiates. Yep.

And I had been so reluctant to do so initially. I'd been so stoic, you know, just taking my inseds and even using Benadryl, which is a horrible pain medication, of course, but it sedates you through some of the pain. And so I, you know, I started taking Percocet. And Percocet is, it's typically 10 milligrams of oxycodone. So oxycodone is the fast acting version. and it's stronger than, say, a vik. So a vikidin is Tylenol and hydrocodone, immediate acting,

but hydrocodone is not as strong as oxycodone. So percocet is stronger than vikidin. They both have Tylenol. It's just the opiate is stronger. And so, you know, if you take a percocet, which would have 500 milligrams of Tylenol and 10 milligrams of oxycodone, you know, I probably was taking, you know, start taking two, three, four, five, six of those a day.

You develop a tolerance. and eventually there's a longer-acting version called Oxycontin, which is just a time-released version of Oxycodone. So then you would take that twice a day. So at my peak, I was probably taken 80 milligrams of OxyContin a day plus another 120 milligrams of oxycodone. I just got rid of the Tylenol altogether. You can just get straight oxycodone.

And so I'm about 200 milligrams a day of oxycodone. equivalent. And again, if, you know, if I took that today, I would just die. You just stop breathing. But at the time, you know, you build up this tolerance. But it also, there was this point where I realized that I wasn't just taking it for the physical pain, right? And I think this is the single most important insight I had that when coupled with reading that book, six months later, was the, I think the single most important realization I ever had with respect to, to this problem, which was, At some point, I was just so depressed that I couldn't walk and I was so worried that, you know, I'd never be able to do anything again, that at least the drug gave me a high that took me away from that. And so then it got to the point where I was just taking that drug all the time and I just stopped engaging, like wasn't engaged with anyone, anything. And then I sort of had this realization that that was happening. And I was like, I want to stop. So at the time I was dating This girl, she was an anesthesiology resident

She was a few years older than me Just the coolest, coolest person And I said to her She was kind of the only one that knew what was going on Because at the time, even the doctors Who were prescribing this Like this just wasn't on people's radar As a problem back then.

I think today people would be like Homeboy's got 200 milligrams of Oxycontinent Day That's probably not good But at the time it was just like It was like Tic Tacs, right? So that would legitimately kill like if I took 200 milligrams, that would that would really jack someone up? I would think, I think if I took 200 today, I would stop breathing, yeah, because that's how

opiates kill you. They repress, they inhibit respiratory drive. That's what, whenever, whenever someone overdoses on heroin, they just stop breathing. So, yeah, I think 200 would, I don't know, we'd have to, I'd have to look at the pharmacic check. We don't have to, actually. I'll just take your word forward on this one. So the girl you're dating.

She said, you can't just stop, right? The withdrawal is so painful that you have to taper off. You have to probably go on methadone. And then you'd have to start some pretty potent antidepressants, like M-A-O-Is or T-CA. So you have to go on a drug like nortripylene, which is in and of itself kind of a crazy thing. And I was like, yeah, but I think I'm just going to stop cold turkey. Now, unlike alcohol, so if you took an alcoholic, you know, you took someone who's drinking 20 alcohol, you know, alcoholic beverages a day.

And they've been doing that forever. And you stop them, they will die. They will get something called delirium tremens, and they will die a horrible cardiac death. They will break into arrhythmias and they will die. So when we had alcoholics in the hospital, let's say we had to operate on somebody who happened to be an alcoholic, we would actually just put them on an ethanol IV. We weren't even trying to detox them. We just wanted to make sure they didn't die and go into these delirium tremens.

But heroin and opiate is not like that. It is not physiologically lethal to stop cold turkey. It's just unbearable. And so I was like, I'm going to do it. So against her better judgment, I just stopped one day. And she could not have been more right. It was the darkest. I mean, I can laugh about it now.

It was the darkest month of my life. It was a month? Oh, at least. I mean, it was, I would just sit on a park bench for the whole afternoon. Like, complete flat affect. But it's all mental. It's not a physical thing? No, there's physical stuff going on.

I mean, but, but no, it's, yeah, you're, you know, you, you sort of, like, you know, opiates make you itch like crazy. You get constipated. So there's like a reversal of a whole bunch of physical stuff. But the biggest thing is the craving and the depression. And so the depression of coming off this thing was brutal. In many ways, and I don't tell that story to say, well, look at how special I am, that I detox. That's not the point at all.

I had two things going for me that virtually no junkie has going for them, right? The first is I didn't have a network of people around me that were doing the same thing. So I was sort of the only guy doing it. So for me to go and be around my friends was to be around people who weren't doing this. we always used to joke that if you really want to kick a heroin habit, you have to get a whole bunch of new friends. You don't get to decide you're not doing heroin and then go back and hang with your friends that are doing heroin. They need to watch train spotting to learn that. The second thing and perhaps the more important thing is I finally did connect with a doctor who was able to put me on the right path.

So I ended up going back to the operating room probably half a dozen times over the course of the year to have all these problems corrected. And then I found something else to fixate on, which was physical therapy. started to, you know, even though it didn't seem like exercise, it wouldn't seem like exercise today at the time. It was the first activity I was able to do. And so, you know, within six months, I could, like, walk like a reasonable distance again. And so I would be spending three hours a day at physical therapy just doing like the most trivial exercises. But basically the root cause of my depression was getting better. So that's really the only reason I think I was able to kind of detox off this stuff. Whereas I think for many people, A, it's not clear what the root cause.

is or B, it's not getting better if it is clear. And so that's why I think it's really, it's a brutal addiction. And it seems like also you had a future, right? You had a life. You were in medical school. You're going to, you know, you're going to do something. Whereas a lot of these people that are drug addicts, what do they, they have no life that are looking forward to.

They're just looking forward to nothing. Absolutely. And so in February of that senior year, when I had to submit my rank list, I think we match in March and misspoke earlier, I was still not. functional perfectly. Like there was no way in February of 2001 that I could have withstood a surgical residency, but I had to make a decision at that point, which was, will I be ready on July 1st? And if I won't be, I should not submit my rank. I should defer a year, sit out a year at medical school, whatever. And I remember that was the

hardest decision I had to make. And I just gambled. I was like, you know what, I'm going to be ready and I'm going to make it happen no matter what. And so I submitted, matched. And then in addition to now reading the corner to prepare for Baltimore and reflecting on my own sort of struggle with addiction which was completely fresh in my mind I'm also like rehabbing like it's my day job and going through like as and I most people take the last quarter of med school off but I didn't have the ability to do that now because I had to I had to go straight through till graduation day because I'd missed so much time during my injury so when I showed up in Baltimore a couple of days before July 1st.

I mean, it still wasn't crystal clear to me that I could go, you know, two days without sleeping, stand in an OR for eight hours at a time, all those sorts of things. Now, that's one of the things, the sleep deprivation, because people always, obviously, I take a lot of flack because I don't sleep a lot, and the sleep deprivation. So what did that, what's that like when you're going through residency? And you're just saying, I mean, there's days where you're going 24, 48 hours, no sleep. and how did that affect you? What did you think of that?

What do you think looking back at it? What's your opinion of it now? Well, you know, when I decided that I was going to go into surgery, I mean, I always, I'm pretty insecure in general. Most people don't necessarily appreciate that on the outside, but always thinking, I don't know if I've got what it takes here, how do I figure it out? And so my whole MO in life is test the system hard.

So when I was in medical school still deciding this, I figured, well, every Thursday night, I'm going to pull an all-nighter in my room standing up, not allow myself to eat, sleep, drink, pee, do anything. And I'm going to stand at my desk for eight hours and practice suturing. You know, sort of try to mimic what it would be like to be in an operating room all night, not being able to go pee, not being able to drink, not being able to do this thing. And so I had a little bit of confidence. You know, I figured, okay, I can do this. Like, I can pull an all night or 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.

Right. So then you show up, but there's no preparing you for what you're in store for. Now, I got to point out, this is not the way it is anymore. So in 2000, I want to say like four. It's almost like labor laws came in. Exactly. A whole bunch of laws came in that we could spend hours talking about how it turns out the laws haven't, they haven't fixed the underlying root problem.

But nevertheless, a whole bunch of work requirement hours stuff got fixed, right? So you couldn't work more than 80 hours in a week or 88, depending on if your program had an exemption. And you couldn't work more than 24 hours consecutively and stuff like that. But by the time those laws really kicked in, I was already gone. And so I don't really know what it's like today, but I would imagine it's less demanding from a sleep deprivation standpoint. But at the time, there were no such rules and you were at the sort of every second, every third, or every fourth night call, but then your post-call day, you would still work. So our mutual friend, Kirk Parsley, which of course is how we met, this is one of his favorite stories about me.

He loves this story because it's so crazy. So this is July of 2001. So I am one month into being a doc, right? And I'm on an every third night call rotation at this hospital called Bayview, which is about five miles from what we call the mothership, which is Hopkins. And it's out in like East Baltimore. It's in a real crappy part of town. Not that there's a real, I mean, I hate saying this, but they're not that many good parts of town, at least back then in Baltimore. And so I'm, so I show up on a Monday at five o'clock in the morning.

So I slept in my own bed Sunday night. So Monday morning I show up at five to round. We do our whole thing. And that night I'm supposed to go home. So that's my off call. That's you called your swing day. You show up at five. You'll be home by 7 p.m. that night if all goes well.

So you work your 14 hours. And then you sleep in your own bed and then you get to come back the next day. And then you're going to be on call. So we're rounding that afternoon. So and the one of the, One of the senior residents says, hey, so-and-so didn't show up for their shift in the ER. The ER always staffs one surgical resident full-time. And this guy just didn't show up.

And she's like, and it's a 7 p.m. to 7 a.m. 2.7 a.m. shift. Can you cover it? And, you know, this would be like if you asked the most junior guy, you know, to do something. Like, he'd be kicking his own ass to say yes. Like, he couldn't wait to do that, right? So I was like, hell yes, I will do that. So then I go down to the ER and I work all night, seven to seven. And then the next morning is now my on-call day. So now I'm 7 a.m. cranking away until that night.

And then I'm up all night on call. So, and then it's now Wednesday. And it's my post-call day. And I'm there till 5 or 6 p.m. So I've basically been up from about 4 a.m. Monday, and it's now 5 or 6 p.m. Wednesday. And I get in my car to drive home. And I have to make it, I have to go down this miserable street called Eastern Avenue to hit the 83 to drive up to my place. And I'm driving along Eastern Avenue, which is like red light after red light after red light or stop sign or whatever.

And every time I'm at a stoplight, I fall. asleep, my foot pops off the clutch, and I stall. Like, I am so tired. I can't even, you know, handle like the gradual, you know, easing off the clutch and the gas just to move up and up and up. I can't do it. So finally, in one moment of lucid clarity, I'm like, you can't get on the freeway. You're going to die.

So I was like, what's the solution? I was like, you got to get over and take a nap. So I pull over my car on the side of Eastern Avenue right in front of this park called Patterson Park, which at the time, I don't think I fully understood that that was an open-air drug traffic market. So I got out, but here's the best part of the story. The logical thing to do would have been just been stayed in the car and take a nap. But I was like, you know, I haven't seen the sunlight in like days and the sun is still out.

Like, I'm going to go nap in the park. So I get out of the park. I'm in green scrubs that are covered in, you know, bloodstains because I was too dumb to not change, I go lay down in the park, I take my page off and I clip it to my neck and I set the alarm to go off in one hour. So at like 7pm

it'll wake me up and I'll feel perfectly rested and I'll be able to drive home. So I lay down in middle of Patterson Park and the next thing I know I wake up, it's like one in the morning, two in the morning. There's needles everywhere.

I have like bites on my arm that look like they're from rats because they're like nothing I've ever seen before, like these bites all over me. And I'm just thinking myself like, how did I not get killed here? Like, the only thing that prevented me from dying was how ridiculous the sight was. You know, if something's so strange, like, you know. So I was like, God damn it, man. So I get back in my car and drove home.

And when I tell Parsi that story, he loves it because he's like, that's the classic example of how complete deprivation of sleep impairs your judgment. So, you know, there were a couple stories in residency where I had to do like those three night back to back to backs. Another time it happened, I remember, was in 05. Did you feel like, though, okay, driving a car is kind of boring, right? Stoplights. But when you're really tired, but then all of a sudden something happens, like boom, I feel like when that happens, I feel I can 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. Absolutely. Is that true for you too?

Yeah. No, I think, I think an adrenaline. and rush in the moment can provide any amount of clarity and focus that's necessary. The problem is very few things are life or death that way. Now, in your world, there were plenty of things, but in my world not, and this is the extra sure I was going to tell was in probably my third year, I think it was my third year. I was the same, same sort of deal. I ended up covering for somebody and then covering for two people and two consecutive nights, and then it was my turn. So that was like three straight nights of not sleeping.

And it's the middle of the night and this guy comes in the ER who's, you know, got a really diseased gallbladder. And in retrospect, it should have never come out that night. But a lot of times the dirty little secret is surgeons want to operate at night because they can get better OR time electively as opposed to waiting the next day if it's not emergent. So sure enough, we're in the middle of the operating room doing a laparoscopic gallbladder removal at two in the morning when we don't really need to be there at two in the morning. We could have slept and done it the next day.

And sure enough, so removing the gallbladder is a two-surgeon procedure. So there's the main surgeon, which, because we're at teaching hospital, I'm the main surgeon. I'm actually doing the operation. And then there's the attending who's holding the camera and retracting for me. So I'm, you know, like I'm doing this. And yeah, that's a stimulating activity. But of course, I've done a hundred of them. So it's not that stimulating.

Well, I can't stay awake. And I finally somehow managed to follow. asleep on this patient. Like I face plant into the patient. Luckily it was laparoscopic so I didn't contaminate the surgical. But so even something as stimulating as surgery. Because look, if the guy's aorta was bleeding. Right, right.

I'm sure I would have your game. Yeah, exactly. But all you were doing was pulling out of his gallbladder is no big thing. Yeah, yeah. It wasn't stimulating enough to overcome three days of sleep debt. Did you do, did you figure out any tricks? Any, you know, for instance, I can. when I was going through seal training and even my whole career and even to this day,

I take these, I take little power knots. If I'm feeling that tired, I elevate my feet and I sleep for like six to eight minutes. And it totally recharges me. Did you, do you take power naps? No.

Aside from your power nap, you had parked that lasted seven hours and almost got you killed. I did. I once took a power nap in my car. Again, same thing. I was like, it was like eight o'clock at night.

I got to the pool. I had a rule, which was after you left the hospital, you never went home. Because I knew if I went home, I wasn't going to leave. So I would always go from the hospital to the gym or the pool or whatever I was doing. And on this particular night, I get there. It's 8 o'clock at night. I am so tired.

I'm nauseous. So you didn't want to go home just because you knew you'd go home and go to sleep? And you didn't want to go to sleep? Because you've been awake for three days. Why didn't you want to go and fall asleep? Well, because it's really funny. A good friend of mine who, again, a couple of years ahead of me, gave me interesting advice, whether it was right or wrong.

I don't know. He said, look, you're going to be tired no matter what in residency. Don't stop doing all the other things in your life because you'll still be tired. Now, I don't know that that was the right advice, but I took it to heart. And my view was, I'm going to continue to work out every day I'm not on call. I'm going to do all the stuff I want to do. And unfortunately, sleep always took the brunt of it. So, yeah, so it would be to the pool.

And so same thing. I got there. But on this particular night, I was so tired. I was so nauseous. Like I couldn't suppress the desire to vomit. And I was like, I'm not going to, I can't, if I puke in the pool, they'll kick me out. I won't get to swim. It's just not going to be worth it.

So I was like, just sit here for like 30 minutes and take a quick nap. So same thing. Took the page route, which normally could wake me up, clip it here. And it was freezing because it was like the winter. So I left. No, it wasn't cold, but I remember I wanted to leave the radio on, like a dumbass. So the car is off. So alternator's off.

Radio's on. You know how the story ends. I wake up a two in the morning. Battery's dead. I'm in the middle of the parking lot. I can't, you know, had to call my girlfriend to get jumper cables to get me out. That's a one.

That girlfriend went on to become my wife, by the way. So short answer, no. I didn't have a great strategy. I did have a friend who, and I never tried this, but he told me he would put coffee grounds in his eyelids. Apparently it hurts so much that you couldn't close your eyes. I'm kidding. You know, that's, I mean, I would, not that, but I've told people this all the time, too.

You know, do do a little bit of physical exercise if you're super tired. That definitely picks you back up. There's got to be some reality or some scientific reason for that happening. So that's another thing you can do. But, so, okay, we know it sucks. You're not sleeping and you're dealing with these patients. And how do you start to detach from this reality? that's around you so you're not getting you know because you you said already you like the kind of

the emotional involvement with people but then at the same time you said it didn't take long before you despise these patients that are coming in because they're interrupting your sleep and bothering you that's got to be a crazy balance to try and strike as a human being i mean human beings are not meant to be dealing with 16 puncture wounds a day that's that's not right so what what happens in your brain What happened in your mind? What did you notice about your mentality in this whole business as time went on? Well, what I noticed, so again, not everybody becomes jaded, but most people do. And where my sense of jaded developed was actually towards, you know, the patients of diabetes,

the patients who had complications from being overweight. Like when those people would show up with, you know, the abscess in their foot in the middle of the night that needed to be debreded, those people I would get, again, pretty pissed at. Amazingly, these trauma folks, like, I kind of always maintained a soft spot in my heart for them.

And interestingly, you know, it's easy, once they die, so what happens is, let's say a guy comes in, you guys been shot. You know, generally people who are dead in the field

don't make it in. So, so, but sometimes there's this gray zone where, you know, someone comes in who's basically, dead, but because they had a little bit of a pulse on the way in the door, like, we're going to do everything we can. But a lot of times when those patients die, like the room has to be turned over really quickly, which means someone's got to come in, take the body, put it in a body bag, gather

everything, because usually these are criminal investigation, so the police are there. The housekeeping staff has to come in and mop all the blood off the floor because depending on where the gunshot wound was. Like gunshot wound of the head, for example, tons of blood because the head's a confined space. And in that moment, it's really easy to just immediately walk out the door. But I find myself, you know, I'd sometimes like flip through their wallets, right? And, you know, invariably, you'd see something like you'd see a picture of a little kid. So you see this guy who's huge, who's just been killed, he's probably 25. And you'd see like this six-year-old girl in his wallet.

And you, you know, you'd start to sort of wonder what the narrative is, right? Like, was that his daughter. Probably. Did he know her? Probably. Did she know him? Maybe not. Like, you just don't know. And all of a sudden, that stuff sort of humanizes these guys. And again, I think because of my own understanding of what they were dealing with, because of those 16 penetrating traumas, 15 had to be drug involved in one way or another. And so everybody who were taken care of, for the most part, was some part of the cycle that's being described in the corner. Now, occasionally it wouldn't be. I mean, one of the examples that stands out that was,

I would say sort of like the top five saddest things I ever saw in residency, was July 1st, 2002. I just happened to remember that day. And this girl on her 16th birthday came in, and she was just hit by a stray bullet in her neighborhood. It was her 16th birthday, stray bullet from, you know, unrelated gang violence, hit her in the head. And, you know, she's an example of us.

someone who came in basically dead, but in situations like that, like, you know, I'm sure you can relate to this. You're just going to do something that's so beyond heroic. You want to do anything and everything to try to save her. And of course, we couldn't. So, you know, those examples are kind of rare, but the majority of the times, it's, you know, executions for people who stole money. That's, those, those would be hard to see, right? Because you can, these are, you know, this is like, this is a deadly game. Oh, and even the, even the girl, the 16 year old girl, She's part of the cycle too because that's just a stray bullet. That's right.

She's in a lousy neighborhood. You can almost guarantee that if she's living in where she's living to get hit by a stray bullet, like, you know, yeah, she wasn't living in, you know, Roland Park. And once you, did you, would you ever see any family? Would any family ever come in? Yeah. So there's two types of things going on, right? So, so the biggest problem we would have would be real gang on gang stuff because, it became sort of a feed-forward loop, right?

So if one guy came in and he was killed, you immediately knew the floodgates were going to open because there was going to be retaliation that night. I don't remember. The police were pretty good about trying to make sure that, like when someone came in and who was killed, like if you weren't immediate family, you were not allowed there. And they also tried to create a little bit of a delay

in letting that information out. again, maybe that wasn't the most considerate thing to do, but their view was trying to let the violence dissipate. Yeah, the family stuff's hard. I mean, the hardest family interaction I ever had was with actually a blunt trauma, and it wasn't involving drugs at all, right? This was a boy. He was 15 years old.

He and his brother, his older brother, who was probably 18, had picked him up after school. They were driving home. and they had the right away and a guy ran a red light and teaboned them on the passenger side. And this, the 15-year-old boy, both of them came in as separate traumas, but the older boy came in as an adult trauma. So he went to the adult side. I happened to be on pediatric surgery. Like I was the senior resident on pediatric surgery that month.

So I ran the pediatric trauma, which is where the 15-year-old came in. And it turned out the older, the driving son was fine. He didn't have a scratch on his body. But this kid came in basically dead on arrival, though it wasn't clear why. But his pupils were blown, you know, a little bit of a pulse. We did, you know, probably 30 minutes of everything imaginable before accepting the reality that he sheared his aorta. So if a high enough force can actually shear the aorta and it dissects and you basically bleed to death inside the wall of the aorta, and that's why he died. And that was another example of how everybody just sort of scatters after that.

But, you know, his mom is in a waiting room wondering where her boys are who, you know, could have been an offender bender for all she knows. So those were, I mean, unquestionably the most difficult discussions ever because trauma is one area where there's complete surprise. Like, you know, it's tragic when somebody dies from cancer. It's even tragic when somebody dies during an elective surgical operation, which happens, unfortunately, from time to time. But at least there, you have some heads up that something dangerous is going on. But this kid, like, you know, said goodbye to his mom that day, went to school and never came back. And now she hears, oh, he's in a car accident and she's in the hospital, never imagining that he could be dead. And then you have to be the guy that goes in and say, you know, I'm really sorry to tell you this, but your son is dead.

You know, there's actually a really interesting article written in the New York Times on this exact topic by, so it's kind of an interesting story. So my mentor in medical school, to this day, one of the closest mentors I've ever had is a guy by the name of Steve Rosenberg. So Steve Rosenberg is the chief of surgery at the National Cancer Institute. And he's kind of one of the luminaries in immunotherapy. So I did my postdoc with him at the NIH. And I actually spent time there in medical school. And actually, he just called me yesterday out of the blue. We ended up having a great catch up for 30 minutes.

His daughter, his three daughters. His youngest daughter is Naomi Rosenberg, who's a resident at, in, I think she's an emergency room doc at Penn, which is also in a war zone in Philly. And she wrote a great piece on this, which maybe we could link to in the notes or something. It's probably like the last three months about the difficulty of having to communicate to families when tragedies like this happen, which, Of course, she would see a lot of as well in Philly. And then that happens.

So you do everything you can to save this kid's life. And then you walk in, you face the mother, you drop the most devastating possible, imaginable news on her. You've got to go back to work. I mean, right? I mean, don't you then have to, don't you have to go work again now? Yeah. That night in particular, that was, you know, that was, that was, I remember that day pretty well.

That was April of 2003 when that boy died. And by the time, you know, by the time we had declared time of death and I had gone to talk to his mom, it was probably like 10 o'clock at night. You know, I probably spent an hour with her. And of course, it's disruptive because you're in there and your page is going off. I've got the ER calling me about this kid and I've got the ICU calling. calling me about this and you know um and she's you know i mean like i i i sure hope i never have to know what she went through because i can't can't really imagine right i mean she's hysterical at a level that you just like a movie doesn't do justice to that like you don't

see that level of hysteria normally um and i that was certainly like one of kind of the three or four that really upset me the most i mean i i i had i i a real hard time. And I think I got lucky that night. I think that at night ended up being a pretty calm night. I remember I got to probably spend some time just alone in a call room that evening, you know. And for me, that was a, so this is the awful thing here is we tend to project what's going on in our own life into any situation. I mean, I think I realized that pretty early. And so I think in the case of that particular trauma, I saw in that boy my brother, my younger brother. And so I, so I was dealing.

with two things in that moment. One was, meaning from my own end, not not the immediate issue, which is this boy died. One is, I'm imagining now, like, this could have been me and my brother in high school. Like, this could have been us. And how your life changes after that. Like, I thought his brother's life is never going to be the same. The second was, this was already after I had decided to leave medicine altogether, which was in June of 2006. And this, this trauma, was like April of 2006. I had decided in March of that year that I was just going to finish that year and then leave.

So the other thing that was sort of that I was struggling with, which probably makes this a little heavier than it needed to be, was as painful as this is, it's a privilege to be this person. It's a privilege to be the guy who gets to try to save a life.

And even when you fail, that interaction you're going to have with that family, which I think is something Naomi wrote in that piece. It's so important. It seems trivial to us because you have that interaction over and over and over again, but to that family, it's so important. That will be with them forever. And I think I felt that that was a privilege. And so I think I realized, like, I'll never do this again. I'll never again have that privilege to, even if I fail to try to, you know, sort of

save somebody, to actually then be able to comfort that family. And that sounds really weird. And it's a very morose sort of thought to have. But all of those things, I think, in that particular example, you know, made for a really difficult set of, you know, days and weeks that followed. I went to his funeral. It was the first patient I ever went to a funeral of a first trauma patient. Certainly went to the funerals of patients you got to know through, you know, people who were dying of cancer and stuff. 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 the boy, right?

I stayed in touch with his mom for a few years and not surprisingly their life just completely fell apart You know Does it make it that much worse that you got this You juxtapose the The kind of this normal kid right Who dies this random accident And then at the same time every night

You've got people that are killing each other And you're dealing and you're seeing the results of that And you can't do anything about it. How does that also play into your thoughts about, hey, I'm here trying to save these people's lives and they're out there killing each other for over nothing, over the street corner, over this, over that. Did you go down that road mentally? Not there. I'll tell you the one time I felt really ethically, maybe ethically is too strong a word, but just to be blunt, I mean, the one time I was really pissed off that I was trying to save somebody's life was a guy that came. I was a guy that

came in who killed his wife, killed his daughter, and then put the gun in his, under his chin, and pulled the trigger and missed. So he basically blew off the side of his face and was still alive. His brain was completely intact. This guy was going to survive after 23 face operations. And, you know, I'm taking care of this guy in the ICU. And I'm kind of pissing. off about it actually, right? And maybe I shouldn't be, right? Who am I to judge this guy? But I'm like, you know, you killed your wife, you killed your kid and you wanted to die. Why the hell am I putting anything into you? Now, of course, that is a slippery slope because in medicine, we're never supposed to play that role, right? We're never, we never play God. Right? People, you know, some doctors

want to act like they're playing God, but we never play God. We're just there to do a job. And on that day, I remember thinking, I don't want to do this job. I don't want to, I don't want to take care of this guy. I want this guy to die, actually. How do they address that when you're going to medical school? That whole idea. They've got it covered on, or is it just so underlying, the underlying theme of everything you do that by the time you get done, it's there? That's a really good question. I don't know the answer. Are there ethic, ethics classes in medical school that teach you that? I am sure there are. The fact that I can't

tell you one thing about an ethics class I took tells you it that whatever ethics you have are going to be independent of whatever class you're taking. And who knows, you know, today, you know, these pendulums swing from one end to the other. For all I know, you know, half the curriculum could be ethics today. I don't know. But the short answer is I think, you know, it's sort of internal. And the reality of it is, you know, if you're in a good program and the one thing I'll say, I mean, as much as Hopkins was a brutal place.

to exist, the camaraderie there was unbelievable. I mean, you know, the nickname for the residence was the Halstead Marines, right? Which, again, doesn't do justice to real Marines, but that was sort of the camaraderie, right? It was like you would do anything for your, you know, that's why you'd always volunteer to stay up three nights to help somebody else out. And so, you know, I had really great friends there. In fact, to this day, like some of my closest friends, people that I'm in touch with almost every day were guys I went through that experience with.

And you could talk about those things with each other, right? I mean, you know, it was okay to say, like, I really wish this motherfucker would die. Because he's taking up a bed. He's costing the state a million bucks. And I hate him. And somehow being able to talk about that, I think, makes it a little bit easier, right? Well, absolutely. I mean, that's what happens in the military.

You get guys that go through tough situations, tough battles, and they become closer going through it. And part of the thing that brings them close together is you're talking about what's going on as it's happening and after it happens. What did you, so a lot of times in this podcast, I say that this podcast, yeah, we talk about war and we talk about leadership and we talk about history. but I find that the actual root of what the podcast becomes about is is really about human nature and what people, what human beings are like. Was there, I'll give you both sides of this question. Did you learn anything about people about human nature there that was surprisingly positive? And before you answer that one, did you learn anything about human nature while you were there?

that was surprisingly negative. So I'll give you one thing that I learned that I don't know that I would call positive or negative, but it was an observation that in retrospect seems obvious, but it never would have, I never would have thought of it before, and to this day it still serves me well to understand it. So this is the first observation is that when you look at a significant illness, like a completely disruptive insult, you know, cancer. You know, you have pancreatic cancer,

which means you're going to die, and you're going to die soon. There are two types of families that come into that situation. So families that show up already fractured get blown apart. Families that show up already tight become the tightest of any family. The same would be true

when you see, you know, a kid that comes in, you know, a burn victim, 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. You know, a couple that comes in with tension already in their marriage, they get splintered wide open. If they came in and everything was fine, they're going to be there for each other. They're going to be tighter. So that was an observation that I just saw over and over and over again.

And I saw it in probably even more vivid color when I was at the NIH because the two years I was there, you know, is mostly doing research, but you still had clinical responsibilities. And so you're basically seeing patients who are coming to receive experimental therapy for cancer. So these are patients who are all, you know, otherwise going to die within six months. And most of them will still go on to die. Obviously, a subset of them we can help. But you're seeing that over and over again. So that was the first observation. And then the second was that there were just a couple of residents who I couldn't believe how amazing they could be, how they could never sort of do the wrong thing.

So there were two residents in particular. One, really. His name is Chris Sonday. He is now a transplant surgeon at the University of Michigan. Amazing guy. And so Chris was two years ahead of me. And I mean, he was like that guy that I would have done anything for. And I remember when I was leaving, thinking to myself, you know, I'm really glad I'm leaving because if I stayed, I'd know I could never be as good as Chris.

Like that, like, how can someone be this good? And I don't mean like he can sew this good and cut. I don't mean even medically. Good human being. Just as a human being. He is on a level I can't get to 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 And I'm glad I don't have to spend the rest of my life chasing him Which of course Chris would never think of it that way because that's the nature of being that guy as you He's just completely humble modest unassuming guy who just happens to be a god You know it's it's going back to the first point that you mentioned and it's something that I've heard people talk about as well my buddies talk about is you know the whole idea of post-traumatic stress and all that and and what war does to people and one thing that I happen to agree

with is pretty similar to what you're saying and that is going into the war right if the person is got a good stable mindset and a good attitude and is a positive person and they're going to come out of it with all those good positive things amplified. They're going to be more positive. They're going to be stronger. They're going to be mentally tougher. It's the people that go into it that are already somehow fractured. Those fractures are going to get worse through the trauma of combat. Again, this is a broad generalization. And there's definitely great guys that see things or do things that it hurts them. And it takes them a while to get through it. But there's also some guys you go, you know, that guy was messed up

when we showed up. And now he's worse. And it's that pressure that opens up those fractures even wider. And it's interesting that you got to, you saw that with family structures as well. And I could completely see how that happens. And that happens. Right. That happens. And you don't even need trauma to make that happen. I mean, you get the financial trauma on a family. If they're not tight, that'll, that'll make them blow up. Whereas if they're tight, you know, going through some financial problems, they'll get tighter. They'll buckle down. They'll save money together. They'll skip the movies. They'll start, you know,

they'll enjoy cooking ramen noodles together. So that trauma can can expose those fractures. That's why it's important to try and create the most solid foundation you can with your family and with your own mind so that when these traumas hit, you don't get fractured. Do the SEALs screen for that? They try to. But you'll, like this story. So we had to take a psychological screening. This is in the 90s, so it wasn't like we

were super advanced on any of this stuff. And I'm going, and when I was going through boot camp, they gave us a psychological screening for our attempt to go to seal training. And so they asked a bunch of questions and it was complete the sentence questions. And so it would, it was really obvious what would flag you for, and so I made every answer, because I was, I was in boot camp and the food sucked. And so every answer that I gave was just all about food. So for instance, they'd say, complete this sentence. I hate when my mother, right?

So it's pretty easy to say, you know, I hate when my mother shuns me in front of my sisters and I want to kill her. No, no, no, no. All my answers were like, you know, I hate when my mother overcooks the steak and doesn't put enough pepper on it. You know, just like every answer I gave was about food. but it was really easy. My point is that it was really obvious.

If you were not a complete, even if you were, in fact, if you were a psychopath, you would very easily say, answer all the questions correctly and get through it. And there's been plenty of guys that made it through seal training that, you know, there's some bad criminals. There's been a couple really heinous crimes committed by guys that were seals. And just, just, they made it through. They got screened. So, yeah, they had a screening, but I wouldn't say it's the most effective. if 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 letting guys through that are, that are deranged some way that are going to do something horrible like that. You kind of already talked about these, but is there any other thing that that you learned about yourself in that situation? And I didn't really know too much about where you went afterwards at the NIH. If you want to go into that a little bit. But what did you learn about yourself through this whole process? Obviously, you learned something because at some point you decided, you know what?

I don't want to do this. Yeah. I mean, those are some of the most interesting years of my life. And I'm pretty glad that I didn't have my first kid until 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? 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, you know, the sort of really difficult decisions I had to make. I mean, leaving medicine after being in it for 10 years was a really difficult decision, especially to go and do something that had nothing to do with medicine.

I mean, when I left, I joined a consulting firm, McKinsey and company, and I did credit risk modeling. Like I didn't have a thing The fact that I was a doctor was like a liability There was no like it was like starting all over again in life So to get to that point Yeah, I had to go through a whole bunch of stuff So I think I mean I wouldn't even know where to begin

I mean I think one thing I learned was So this fellow that I alluded to earlier Steve Rosenberg who is again to this day Probably one of the most important mentors in my life outside of family members. Just an amazing human being, right? So just kind of on another level. And I remember even asking him after being in his lab for two years.

Because remember, we had a couple of people in the lab who I just didn't think were that good. It really bugged me. Their existence bothered me. And I finally, after being in the lab for two years, worked up the courage to ask him, like, how he, because he's like this guy who's going to win a Nobel Prize. Like he's changing the game. And yet we had a couple people that I kind of thought were bottom feeders. And I was like, you never get upset at them.

Like ever, I've never seen you get upset at these people. How? And he said, you know, Peter, I just look at everybody and I figure out at least one thing that they can do well. And I just figure out a way to empower them to do that one thing, even if they can't do the 10 things that I would expect you to do. I remember thinking, I understand in theory what you're saying. I can't do that. I can't tolerate mediocrity. So that was a huge thing that I learned.

And it never really hit home again until I was running a nonprofit. Because there wasn't a lot of mediocrity at Hopkins, right? You sort of had your pick of the best residents there. Everybody there was the best at what they did. You had amazing nurses, amazing respiratory therapist. And like everybody there was like the best of their field, right? And then I go to McKinsey. Same thing.

You've kind of got the best of the best all over again. But, you know, fast forward five years. I'm now running a nonprofit. Well, all of a sudden, you don't get the best at the best anymore. You're drawn from like the third pool. And I remember coming back to that, which is, you know what? You're probably not cut out to do this. You have two choices.

don't be a leader, just be your own dude or be a leader, but only with A players. But this notion of like you have the capacity to mentor the C players and maybe turn them into a B plus player, like I don't have those genes. I can't do it. And not only that, like I will destroy the C player. And I don't mean to, but I will bury them in the ground and become a horrible human to them. So I also realize like I can be a really bad person. if I don't, if I don't respect the work that someone's willing to do. So do you, did you, or do you ever have to find a counter to that?

Because if you were in the military and you and I were working together, I would be like, hey, Peter, you got to get, you got to act like Rosen, what is it, Rosenberg? You got to act like him. Because in the military, you're not getting A players. I mean, you got some great guys. In the SEAL teams, you got some great guys that are studs, you got some okay guys that are in the middle. You got some losers down at the bottom.

Guess what? You need every single one of them to go on deployment with you. And they all got to give you what you, everything they can. And the more you create conflict with them and the more you are talking down to them, the less they're going to do. You know how they're already a C level player or a D level player? They're going down. Yeah, they're going down.

You're not making them any better. So that's a, did you ever try and correct that? Or do you just go through and say, you know what? You've realized that that's like a weakness of yours. I want to be clear. There are two attributes that you can be a C player in. And I can cope with one, but I can't cope with the other. and I accept it fully.

I can cope with someone who has a C plus intellect. So if you think about the intellect as the CPU of the computer, I don't need everybody to have the fastest CPU. I accept the fact that we all have different sort of innate capacities to sort of process and do, and we all move at different speeds. I can cope with variability there. Where I cannot cope with variability,

or maybe I've just chosen I don't want to, is I can't cope with variability, on intent, work ethic, integrity. Like, if you can't be an A player there, I actually don't want you in my life anymore. And I think I'm old enough now that I've just said, fuck it. You know, I'm not going to deal with it anymore. Life is too short,

and I'm not going to deal with C players who fail on those metrics. Right, right. I don't care how smart you are. But if you can't show up and work your ass off, if you can't be honest, if you can't care, if you can't want to get better, I actually don't want you in my life.

So you're right. I probably, I mean, I think I'm probably not cut out to be a leader because I can't take those people who are failing on those metrics and work with them. Well, you just need to be a leader of a very high performing team, not of a regular. Regular team. Yeah. Yeah, I never had problems, right? So when I was a resident, you know, residency is very hierarchical, right? You know, you've got the med student, the subi, the intern, the second year resident, the senior resident.

the chief resident, the fellow the attending. I mean, it's as clear as day who's in charge at any moment in time. And as I'm going up through those ranks, for the most part, I never really had difficulty with the teams underneath me. But again, I had the luxury of being at Hopkins. Everybody there is the best. The med student. They're the best.

The resident are the best. McKinsey, same thing. You know, you're dealing with the best of the best. But, yeah, running a nonprofit, it was like a totally different world to me. And so I think the difference is a great leader could have. succeeded in any environment. You know, they could have done. 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 you can like figure out a way to like touch them and help them out of that.

And I was just like, yeah, I'm not doing it. So that was, so that's, that's going back to NIH and you, that was the first time you dealt with people. You, you, that's the first time I'd sort of seen in a. long-term working environment, like a couple people who weren't top agents. And again, maybe part of it's because you're in the government at that point. And you get some staff people there, maybe who, you know. And part of it, I think, was just because Steve Rosenberg was such an amazing guy, and he could get the best out of everybody that he might have just had a greater tolerance for that.

I think the second thing I learned was I would never be a world-class scientist. So when you go to NIH, you're really only going to, going for one reason. I mean, I'm sure there's some people that go there just to check the box and say I was at the NIH. That wasn't why I went. I went because Steve Rosenberg was my hero. When I was in medical school, I read his book called The Transform Cell. And I was like, that book just, that book, along with another book by a guy,

Richard Feynman called Shirley You're Joking, Mr. Feynman, became kind of two of the most important books. You know, I read during, you know, my 20s. And I actually wouldn't date somebody. I wouldn't date a girl until she read them. I'm going to, we're going to go into a, after the podcast, you and I're going to a full, full on counseling session. You need help. So.

So I went to NIH because I was like, look, this, you know, this guy is my God. And like, I want to be like that, right? I want to be the best surgeon scientist that ever lived. And then I got there and I realized that surgery and science, couldn't be more different. Surgery is the ultimate immediate gratification. Like, surgery, you get to fix the problem in hours. Science is a lifetime of work, a lifetime of failure before successes.

In fact, one of the most remarkable stories from Rosenberg's book, which, of course, I read well in medical school, but it wasn't until a decade later when I'm living it that I really understood why he was great and why I couldn't be great was, from when he arrived at NIH in 1974, until he really had his first success was about 10 years. So for 10 years, everything he was trying was failing. And every patient died.

Every single person that showed up died. Until this one woman in 1984, when finally they figured out how to dose something called interleukin-2, and they finally sort of cracked the first piece of what has turned into a very long code, that 30 years later we're just starting to make really amazing traction on. Now, think about that for a second.

43 years ago, he started that job. For 10 straight years, he just lost. It's like, you're going to go pay pickup every day for 10 years and lose every day. So what I realized was, actually, I don't have that intestinal fortitude. I cannot fail that frequent. and still be at my best the next day.

And again, I mean, I hate admitting that because it sounds awful. It sounds like I suck and I guess I suck. But like I realize like I could be good, meaning 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. 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.

And I realize, like, I don't, I find that 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. I need to know that I have some control over my fate, whereas in surgery, you have some control over your fate. 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 difference between being a good scientist and a great scientist, but in science, you are far less in control of what's going on than in surgery. Now, he must have had some long-term vision hypothesis that was out there.

He believed it. 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. These four things have to be true. And if they're not true, the human immune system will never be able to fight cancer. And it took 10 years just to figure out the first proof of concept in a human. So yes, they had a couple of successes in mice where they had demonstrated, okay, like at least in mice you can do this.

But in cancer biology, you know, you don't get terribly excited about doing stuff in mice for very long. 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. That's pretty low-hanging fruit. You've got to be able to do it in people. So, it was a little bit of the, it was a little bit of the, it was a little bit of a new profession. while you were there that you decided you didn't want to go into medicine anymore? No, so then it gets complicated, right? So then I decided, you're still, you're still in the trauma.

I was still in the trauma. So what I, so then I went back to Hopkins to finish my surgical training. But then I decided, you know what? I think I might actually go into cardiac surgery, which I'd always been interested in. So when I was in medical school, I was really torn between cancer surgery and cardiac surgery. And, you know, to go into cancer surgery, I think the real focus is going to be on research. Like, you want to, you know, you have to be involved in science.

and surgery, whereas I thought in cardiac surgery, you know, it's just pretty much the coolest surgery. Like, it's the most technically demanding surgery by far. I shouldn't say by far. I mean, I think there are other things that are partly on par technically. But I was like, I also came back in the mindset of, you know what, I'm just going to become like a great technician, right? I just, and I loved operating.

I mean, the heart is, in 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 10 layers. of complexity like 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 oh this valve doesn't work oh this pipe doesn't work oh this thing doesn't work 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 because there you're more in control right that's that's now just a function of how hard

do you want to work and that was that was that was sort of right at my alley and so then how did that path then drift to you don't want to do any of this anymore? You know, I think over the next couple of years, I mean, just a couple of things changed. I mean, one was, you know, I wasn't getting frustrated with these patients that we were talking about earlier. It wasn't the trauma patients that were getting to me. There was something else that was getting to me that was much more frustrating, which was the entire system. It seemed like everything we did was this 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. So 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. I did feel that there was a subtle difference in the quality of residents.

So remember there was this guy Chris Sonday who's like the best resident that ever lived. You know, I think I was a good resident. I think there were some other really good residents. But there were others that just, you know, they were good, but they weren't great. 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. So he came out a law school when I came out of medical school, like we were at the same time. And so I start residency when he starts this law practice or he joined like this law firm.

And I remember seeing that it was a totally different world. Like their promotions seemed more merit-based. They went up the ranks They got bonuses Like all these things happened That were a functioner So my brother was like You know

He was like breaking every record At his law firm Right like nobody could work as hard Nobody could bill as many hours Like nobody could 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 a prosecutor rather 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 of years to get through. 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. 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 to say you couldn't. I'm sure you could. But I felt like I was really. working a lot harder than was necessary because I just wanted to be better. And I thought, God, it's still crazy that this is going to take this many years to get through. So, so that, and I also, there was 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 healthcare was completely broken as a system, right?

So we have this idea. I don't remember the exact stats, but you're going to spend like, you know, 50, 60% of your entire health care dollars in like the last. year or two of your life. I mean, something asinine, right? And so at the time, my wife 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. But I think that 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 probably 32 33 I've invested 10 years into this and I'm thinking I want to do over I want a 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 so so that was like 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? 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. 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. And I'm not even going to be a doctor anymore. I'm just going to go in, you know. So then you roll straight to McKenzie?

Well, 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 stuff. Like I missed math. I missed being an engineer. And the few times I tried to bring that into medicine, I got spanked, right? So there's one story. I think I've talked about this maybe on a podcast before. I don't think so, though. this is actually probably my first or second year.

I'm in the ICU taking care of this patient, and this patient's on a very, very toxic drug called gentimicin. 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. So 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. No, 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 once the level comes below a certain point, give it again. 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.

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. So 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, all right, let's try it out. So take one of my patients, going to be on gentimicin. 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?

And the answer was unquestionably. So now I start to get a little confident in the idea. So like the next night, I'm like, all right, I'm actually going to start dosing the patient based on the model, which never puts the patient in jeopard. Because you're always going to check the level before you dose, but you're going to do so at the exact right moment. And so my model predicted like at 4.31 a.m., this patient will nadir, which means that's when you need to dose them. So sure enough, at like 4 in the morning, I ask the nurse to draw the patient's blood to confirm, they're just about to nadir. We're going to redose them, and away we go. So the next morning on rounds, you know, in the ICU, you round as a big team.

I'm presenting that, you know, this patient is one of my patients. And I start explaining that, okay, so the patient received their dose of gentemicin at 4.30 in the morning. And the attending says, well, what do you mean 430 in the morning? We never dose gent at 4.30 in the morning. We dose it at 7 a.m. always. And I'm like, yeah, yeah, yeah. But the patient hit their nadir at 4.30.

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. That would have got me fired, by the way. Finally someone gets fired. Finally someone gets fired. 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. Like, maybe my model wasn't perfect.

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. And that's just one of many stories like that that, that has. through residency where I was like, it's almost like we want to live in the 1950s here. And so you have that sort of pain of problem solving is not valued. At least it didn't seem valued to me. It was valued in the lab, but I had decided now I'm not going to be in the lab. So here I live in this world where problem solving is not valued.

And I don't actually, I'm not a quant anymore. Like I don't do math anymore. And I really loved math. So I started tutoring kids in math. I made like a little bit of free time so I could like tutor high school kids in calculus just to like get my calculus on again, missing it. But it wasn't the same. 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. And you know, residency you're making, I think at the time we're making about $34,000 a year. So it's you're not even putting it. dent in your $200,000 debt sort of thing. So then I remember one night I was on call and I was really pissed to be on call this night. And 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 my best friend from high school tells me in February he's getting married that August and I'm the best man. He lives in Toronto. So he's like, this is the date of my wedding. I forget it was like August 5th. It's a Saturday. I want you to be the best man.

I'm completely honored. So I tell my program director in February, can I not be on call that day or the day before? I just need to be able to fly out of Baltimore on a Friday and come back on a Sunday. And he's like, yeah, yeah, that's no problem. I remind him three times. No problem, no problem, no problem. Sure enough, the call schedule comes out.

I'm on call Saturday. I'm on call the day of the guy's wedding. Like, you've got to be kidding me. So it's 2 o'clock that morning. I'm down in the ER looking at a chest CT scan on a guy who I'm worried has what's called a dissecting aorta. And the radiologist, you know, I introduced myself and she's very nice and she sort of walks me through the CT scan. And then we just start shooting the breeze a little bit. And she says, oh, yeah, you seem kind of down tonight.

What's up? And I was like, I'm just kind of pissed off. I mean, I wish I wasn't here, blah, blah, blah, blah. And she's like, yeah, 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 up at the University of Seattle. And I just hated it so much that I left and actually joined this company called McKinsey,

you know, worked there for two years, but then decided I wanted to come back to medicine. So I wanted to do it in sort of a kinder gentler way. So that's why I'm back here doing radiology. And I was like, oh, what's this McKinsey thing? I'd never heard of it. And so she told me all about it. And I was like, huh, that sounds interesting. How do I apply?

And that was sort of the beginning of it. So she introduced me to some folks. And then I had to like study all over again because to the way they interview at these consulting firms is very specific. And it's not you, you can be the smartest dude in the world. If you show up and you haven't thought through how to solve a case, like what are called these case interviews, you're going to flail. So you have to actually put in some like work and study.

So I 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 was sort of the transition. And then you walk, you walk away from medicine, you go into, so were you doing medicine specific consulting? So I was recruited to do that because McKenzie, and I'm sure this is true of like Bain and BCG, which are kind of the other two really big management consulting firms, they recruit about a third of their consultants who out of sort of what we call non-typical or atypical, rather, background.

So 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, 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 dry. But when you're like just dying to get back into numbers, I was like, oh my God. I remember the first time we learned what was called the efficient frontier, which is basically this differential equation that describes an investment philosophy. I was like, I can't believe I'm doing this again.

I can't believe it. So then we show up for orientation. I'm in San Francisco at this time. That was the other thing. I wanted to get back to California. So I was like, you know, San Francisco, please. So during the first, during orientation week, I was approached by one of the staffers there And they said, hey, your background looks like you've done a lot of mathematics.

I said, yeah, they said, well, you know, we know you're a physician and you're probably here to work on, you know, 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. Would you be up for doing that? And I was like, of course. And so then, you know, that was basically the beginning. and I never really stopped doing that stuff.

So I ended up doing what was called credit risk modeling, which started out around this thing called the Basel II 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. 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. And in particular, the problem that was damning was something called asset value correlations. 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. 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? So where the rubber meets the road is, if I can't make my house payment, I'm probably not making my car payment either. That's right. And that's what nobody kind of realized. Everything went down. Oh, yeah.

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, when the market crashed, they weren't ready for, they couldn't handle it. 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. But 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 sequence of events that went, that took this from being just an isolated problem to a systemic problem. 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. So it was these instruments called CDOs that effectively allowed this problem to become enormous. But at the time, the bigger issue was 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. And we're all guilty of this. I'm guilty of this. I find myself doing it. And I actually am now quite amused.

I'm so attuned to it now that I'm quite amused. 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. And then 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 got to stop. Pull back.

Assume you are wrong and keep going and try to figure out. But so at the banking level, I mean, and we, you know, the Canaryian, in the coal mine here, well, there were many, but in 2000, early 2006, yeah, mid-2006, 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. The banks only had this data recorded for 10 years. We didn't have losses to model. And I remember saying to like, you know, the controller at this bank, I'm like, hey,

And like, it's going to be really hard to build you a model of losses when you don't have any historical losses. And he goes, well, that's mortgages. Mortgages 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. Right. Like, you can't lose money on a first mortgage. Think about it.

You got to put 20% down. You want to buy a home for $100,000. 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 do that. So you now, the bank's 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, market falls by 10%. House is worth 90. You lose your job. Guess who still gets paid? The bank. They still get their 70. Sure, if you're in the business of creating a second mortgage, you take a little bit more risk. But there's no reason you should have been losing money on first mortgages.

And so you fast forward a year. Well, especially because don't worry about the value of the house because that's going to go up to. Always going to go up. That's right. So we're good to go. Oh, well, that's where, and 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 a year, you got to come up with.

And the only saving grace is you can't spend money. Like your clothes is free. You're in scrubs all the time. you're kind of eating for free all the time because I eat off the patient's trays whatever they didn't finish I'd like go to the nurses station and eat all this crap

so I didn't actually spend much money pens was like the only thing I wasted money on like I collect Mont Blancs and so even through residency I would still buy these beautiful pens so yeah I remember one of my buddies being like dude we got to start buying houses in Baltimore because like they're so cheap and you can get them with no money down.

So you could buy a house for $200,000, put like $5,000 down. If that house goes up to $220, you just made $20K. You made $20K on your $5. We're going all the way. And no one does the math of what if it goes down to $190? You just lost everything, right? So luckily, I didn't get in on any of those sweetheart deals. Although, you know, if you time them right,

A lot of people did make a lot of money on those deals before the shoe fell. So when things started to become clear, so in early, in early 07, it became clear subprime mortgages were going to be a problem. By August of 2007, a very famous, then famous analyst, what's her name, Meredith Whitney, I believe, is her name. I think she was at Oppenheimer, called something. that at the time seemed crazy. She said Citigroup is going to cut its dividend next month. So for Citigroup, one of the largest banks in the country, to not pay a dividend for Q3 seemed impossible.

But she'd done the math. She's like, yeah, there's no way. They're getting crushed on these mortgage-backed securities. And everyone was like, she doesn't know what she's talking about. Sure enough, Q3 comes along. City cuts its dividend. Chuck Prince, the CEO of City, gets fired. And at that point, it's like, God damn.

But again, everybody was still thinking, this is just a subprime problem. It's an inch wide. And yeah, it's a mile deep, but it's an inch wide. Well, in the background, we're working on another problem, which is prime mortgages, that which everybody thinks is totally fine. That which has a historical default ratio of less than half a percent. And we're seeing in the data, the data that was right in front of this bank the whole time, oh, there's a tsunami coming.

your default rate's going to hit four, five percent, which, again, that might not sound like a lot. That's 10 times your default rate. It's going to be actually higher than that, as we learned. And your loss given a default is going up much higher. So loss is actually the dot product of probability of default and loss given default. Okay? You guys are my only two customers. Probability you default is 50%.

The probability you default is 10%. If you default, you will lose 100,000. So it's 10% times 100,000. I expect to lose 10,000 on you. If you default, it's 2,000. So 50% times 2,000, a thousand. So my total expected loss is 11,000. So you do this 88 million times for every account you have.

And the model to predict probability default and loss given default are enormous models that each have 50 variables in them. Actually, the PD does, the LGD doesn't. But what people didn't realize is the loss given defaults were skyrocketing. it was like, in fact, again, at the level of just being kind of a math idiot, like that to me was so amazing to watch, right? It was like, holy shit, watch these LGDs go. They're just like blowing up like, and then you knew once the PD triggered, meaning once the probability of default went,

oh, it was going to become a nonlinear catastrophe. And it turned out, so November 15th, Thursday, November 15th, 2007, it was kind of the day, like, that was the Matrix moment. So I had a team, great example. I was able to be a leader for once because I had an amazing team. I had a team in San Francisco of four people. I had a team in India of four guys. We worked around the clock 16 hours a day, every day, except Sundays we took off.

And we would pass the model back and forth to each other. Amazing. It was like, it was pure bliss to be working that hard on this problem. And on that day, we basically came up with four independent models that all predicted how bad this thing was going to be. And we presented it to the leadership of this bank. And it's really funny. I was a manager. So at McKinsey, you have these levels like analyst, associate, manager, junior partner, partner director.

For a meeting of that stature, meaning you're talking to the entire leadership of the bank, the senior partner would only be the one to predict. I'd be in the corner working the PowerPoint answering a question if piped up because there's going to be a technical question. But the senior partner would do all the talking. But on that day, we go into the meeting and the senior partner says, Peter, you should present this. And I said, are you sure? Because I'm like the third most junior guy in the room here. And he said, yeah, two reasons. One, you're the only one who actually understands how all of these models work.

And this is the funniest thing he said. He goes, two, because of all of your experience with cancer patients, you're going to be very good at answering hard questions about bad things happening. Wow. And I was like, okay. So I stepped in and I did my best to be empathetic and non-judgmental and like just as evidence fact-based as I could. And this is what this says and this is what this. When you look at the run rate model and the PGD says this and the LGD says this and the vintage model says this.

And so finally like the president of the bank says, how much money are we going to? to lose. Like she was kind of like, you know, like all good leaders. She's just like, just tell me the goddamn answer first. So I said, I had to think on my feet like pretty quickly about a way to put it in terms. So I said, you're going to lose more money in the next 18 months than you've made in the last 10 years. See the Jocko answer to that question, how much money we're going to lose would have been all of it. That's the difference between you and me on Twitter, right?

Like, you always have the best answer. Like, always, because that would be, like, hey, Jock. Like, you just picture that on Twitter. Hey, like, you know, the CEO of like the bank. Hey, Jocco, how much money we're going to lose? All of it. Peter, one of three. Well, start with your EBITDA last year.

Multiply that by two of three. Three of three. Yeah. Did they listen to you at all? No. Didn't want to believe that data, huh? That was impossible. That was impossible to fathom.

Years later, because I had it by this point left McKinsey, but I stayed in close touch with that team, and I reached back out to that senior partner who, actually, I'm still very close with you. I just got a meal from him two days ago. I said, hey, man, remember all those models? Yeah, yeah, yeah. Did we, were we roughly close? And he goes, oh, no, the model.

Undermestimated by a third I mean it was like it seemed like we kept trying to tone the models down because they kept giving us these answers and we were like God damn like there's no way it can be this bad and we were like oh let's make this assumption more conservative and let's do this and let's you know in the end it was like nope it was actually that bad Brutal so then now I remember I saw you tell a story one time it's on it's on YouTube somewhere but you're talking about a patient you were working on, you kind of alluded to this earlier, you know, either pre-diabetic or diabetic, and you're sitting there going, you've got to be kidding me, because the day before you tried to save someone's life

that was, you know, a young kid. And that was sort of the, was that the first time that you started thinking about nutrition as a, you know, and earlier you talked about, hey, we do all this stuff at the end of life, it's all this prevention to prevent someone from actually dying. But if we would have invested some of that money up front, taught these people how to eat,

we would have been better off. Is that sort of where it came from? Not at all. I mean, I never made that connection at that time. Right. So at that time, it was just what you described. It was just the visceral reaction of, I'm so angry at you.

How can you not take care of yourself? How can you be sitting here so fat, so diabetic? You know, over and over again, you come in here to have these ulcers debried and to have these things, amputated and you know how the story is going to go like just get it together so so this was I mean I didn't say those words but that's how I'm feeling right and so that's that's just part of like the the callousness that developed towards that subset of patient it wasn't until probably 2009

so I'm you know out of medicine now but I was becoming overweight and I was pre-diabetic I wasn't diabetic but I was pre-diabetic I was pre-diabetic And I was, you know, that I was sort of come full circle, right? That I was like, wait a minute, wait a moment. I do everything right. I mean, I'm swimming four hours a day. I'm following that goddamn food pyramid to the core. I don't eat saturated fat.

I'm like, you know, I carb-load like a banshee. Like, why am I, why is all this stuff happening to me? And so then when I, you know, went through my whole discovery process of figuring that out, it was only then that I really thought back. and reflected upon, you know, the horrible way I had treated, not just that patient in particular, but obviously many other patients like her. I remember her case specifically because it was probably like the absolute low point of my existence. So unfortunately, it took me sort of failing on my own because at least then I could say this isn't a willpower problem. It's not like you don't

care. It's not like you're not trying. You're doing what you're told to do and you're failing miserably. So either you're an outlier or maybe the advice is incorrect. So you're eating what you're being told to eat. You're carb loading and you're still getting fat. Even though at this time you're swimming, we were just talking about it before the podcast, you're doing ultra long swims, dozens of miles worth of swimming, which by the way, in seal training, in basic seal training, The longest you swim is five and a half nautical miles, which is six point two statute miles, which, and that's with swim fins on. So you're out there in the, and you're out there in the open ocean swimming 12, 15, 18 miles at a time.

And you're training for that, working hard, and you're quote unquote eating right because you're not eating saturated fat. And yet you're getting fat. You go into the doctor. You get blood test. And they say, oh, yeah, by the way, you're pre-diabetic. and you just say to yourself, what is going on? Yeah, and truth be told, I was actually more pissed just from the vanity standpoint at being fat.

I mean, you know, I wish I could sit here. For those of you on the podcast, Echo is nodding his head enthusiastically to that. I mean, I wish I could say like, oh, it didn't bother me to be fat. It did bother me to be fat. It really bothered me to be fat, right? It bothered me a lot, actually. And so much so that I actually wanted to get a gastric bypass.

And so I went, I was like, so right now I'm about 175. I was like probably 205 to 210. Oh, dang. So once again, after this podcast, you and I, we're going into counseling session. I know, brother. I said to. So I went to, I finally got my doctor to get me a referral to this guy named Ken Fugioca, who's like a very prominent bariatric physician here in San Diego.

So I finally go to see Fugioca. So I'm sitting in the waiting room. and actually I think I told this story on Tim's podcast. I don't remember telling it. You did tell it. But it is in the book. It's in the his book. I think this story is.

Yeah, yeah. So I, but in the spirit of assuming nobody listens to or reads multiple of the names. So I'm in the waiting room. I'm finally waiting to see. And the nurse comes out and before you go back to the clinic room, like you have to get weighed. That's just part of the protocol.

Right. So like they call my name. So I walk up. And I get on the scale and the nurse comes out and weighs me and it's like, you know, whatever, 210. And she's like, congratulations. And I'm like, what? She goes, you're post-surgery, right? And I'm like, no, I'm here to be evaluated for surgery.

She like looks at me, looks out at the waiting room where everybody's 400 pounds and like doesn't say a word, but the look in her eyes is basically like, what the hell is wrong with you, kid? You got serious issues, you son. But it seems like a reasonable idea. Well, yeah, very reasonable, very reasonable. You might want to check your reasonable ideas with me in the future, because that is not a reasonable idea. So you get done, you don't do that surgery, obviously. Yeah, that guy had no patience for me.

What clicked in your brain? Did you just all of a sudden say to yourself, okay, how is this happening? And then you remembered your A&P class and said this is the, So I just, so I remember clear as day. So September 7th, 2009, I did, I sort of did like one of these long swims a year. You know, you do a bunch of short ones, a bunch of training. But I always had one main event. So my main event this year was I went back to Catalina Island and I wanted to swim from now, L.A.

out to Catalina. I had previously gone from Catalina to L.A. And it was a tough swim. I had a torn labrum. So about six hours in, you know, it just became unbearable pain. And you don't usually have a head current in the Catalina channel. So the San Pedro channel, you know this, you're probably trained out there. The current's usually running from point conception down or up.

So you usually have a little bit of a cross current. Very rare to get anything back or forth. and if anything, it's generally a little bit towards the island. And when I had swum four years earlier from Catalina to L.A., it took 10 and a half hours, but that was only 18 months after I learned how to swim. I was a much better swimmer in 2009. And I was going in the theoretically faster direction. So a great example is expectations can kill you.

So I'm expecting this to be like a nine-hour swim back. And really, the only thing I'm thinking about, which is the worst thing you think about in marathon swimming, you should never, ever, ever think about how long this is going to take because you're just setting yourself for misery. The only real question I has, could I break nine hours? You know, I should be able to break nine hours, right? So to make a long story short, I don't even come close. This is a total disaster scenario. The other thing you'll appreciate this just because you'll appreciate the stupidity.

you never want to look anywhere when you're swimming except down. It's very demoralizing when you're in the middle. Like if you're in the middle of the channel, you don't see land from the water level. You just don't. So before you get in the water, you tell the crew, and every, I've crew chiefed for a lot of great swimmers. I mean, the crew asks the swimmer, what do you want? What information do you want? So we're starting to swim at midnight at Point Vicente.

I said, okay, I want to know when there are exactly 10 miles to go and exactly four miles to go. What's the total distance of the swim? Well, as the crow flies, it's 21. And so if you don't have a current, you're doing a 21 mile swim. If you do have a current, you're going to swim more than that. So that's why I said. So guys, I want to know when there's 10 to go and 4 to go. Why?

10 to go, you're just a little over halfway. I'd like to just know that. At four to go, it's put your head down and swim for two hours. Don't do anything. You're there. So we start the swim at midnight. This is in September. So I forget what time the sun was rising back then.

But I knew that I would have 10 to go before the sun came up. So in other words, I knew that once the light was up, I was going to be inside the 10 stretch. And one of the most amazing things about swimming in the middle of the ocean. I don't know if you got to experience this during training is, is in the Pacific, the bioluminescence is so strong. Totally. And so on a clear night, which I was always lucky to have,

every time I swim out, I've done a lot of the channel swims. Every time I've been out there, I've always been blessed with these clear nights. It's so dark. Because once you get out of L.A.'s light, under the water, so your hand is coming down, you are seeing the bioluminescence flare off your hands. When you breathe, you were seeing the stars. You can't tell the difference. It is so dark.

You cannot see the difference between stars and bioluminescence. It's like being in this amazing chamber. And so that's the reward you get for swimming at night, which is otherwise incredibly lonely. And then the first thing you notice is the bioluminescence gets harder and harder to see, which means, oh, the sun's going to be up in an hour. And the sun comes up. Now the sun's like up there. I haven't heard anything. And I'm like, those guys, they forgot to tell me I've got 10 to go.

That's okay. probably down to six to go now. I'm swimming, I'm swimming, I'm swimming. It must be like 10 o'clock in the... I mean, I'm being facetious. It's probably like 8.30 in the morning. And they're like, 10 to go. And I was like, Jesus, what?

Because at that point, I had no clue what the current was like. Because a swimmer can't feel current, right? Swimmers can only feel relative velocity, not absolute velocity. So, you know, that coupled with the torn labrum, coupled with like it ended up being over 14 hours of swimming and there's a very long story because your question was so simple but I remember getting on the boat I don't even remember

what my question was about nutrition about about like when I finally decided I was I was over here in bio-aluminescence bill okay so this is the day so finish the swim get back to the boat and they've got like two burgers and two coax waiting for me and I mean like I couldn't have eaten those things quicker. Like the biggest, juiciest burgers you've ever seen, like the Cokes, like they tasted so good, right?

Because, you know, your mouth is so salty, like, you actually really wants something sweet. And my wife, you know, my wife hates when I tell this story because she denies that she said it,

but she completely said it. She, I'm just sitting there, like, I remember this. I have a picture of you. Enjoy the burger, fatty. I've got like a USA towel

wrapped around my waist inhaling, like I'm two-fisting burgers. drinking my coax and she just looks at me and she goes and again just in the sweetest way possible she said you you should probably work on being a little less not thin wow is that like the kindest way to just tell somebody you're kind of getting a little fat wow post 14 hour swim open ocean get some so that was the last time i had a coke yeah i've never had coke since And all I did, frankly, at the time, was just say, like, I'm just going to try and experiment.

Because I was like, look, at that time, I still thought it was just calories and calories out. I thought it was really just simple arithmetic. And my view was, all right, I can't do anything more on the calories outside. There's only 168 hours in a week. I'm not willing to exercise more than 28 of them. So calories out, I don't get to change that anymore. And frankly, I didn't really want to change the calories inside because I hated being hungry. Every time I tried to eat less, I would just be so hungry.

I didn't know what to do with myself. So I was like, I'm going to try a new experiment. What if it's the type of calorie that might matter? Sugar strikes me as not great for you, even though I can't tell you why. I'm going to stop having sugar. So that was my first experiment in September of 2009. And that led to everything that's come since that time, which obviously ultimately led to me coming back to medicine as well. Yeah.

And that's where you're at now. And by the way, listen to Tim. Tim's podcast. What else should people listen to to get all that nutritional information, the rest of the story? I think it's Tim's. Yeah, I mean, a couple things with Tim. I did a podcast with Chris Cressor earlier this year, talked about longevity a little bit. I did one.

I probably have a maybe, oh, you know what, probably get more into nutrition on that. There's an IHMC video I did probably like three or four years ago. That one's like an hour long and you go pretty detailed in it. it. Yep. Okay. Yeah, I've watched that one. Yeah, those are good. Those are good. And again, if you had to kind of tell people that aren't going to go listen to those podcasts, aren't going to watch that video, what would you tell them, you know, what would you tell them to eat overall? You know, I generally don't like talking about nutrition because, and don't worry, I will answer this question, but I don't at least preface it why I don't like it.

I don't like talking about this stuff. Nutrition is kind of a pseudoscience that masquerades is a religion for many people. And so I find it difficult to have a discussion about biochemistry when it's so cloaked in emotion, religion, and dogma. Now, that's not to say I don't have a strong point of view. I certainly do. It's also an evolving point of view. I feel different today than I felt four or five years ago. I feel different today than I felt two years ago.

And also my life is one big experiment. Right. So, you know, like we were joking before I came in here. I've got a glucose meter buried within me at the moment. I've got like all these heart rate variability things. Like everything I'm doing, actually, let me just check. I actually did an experiment before I came here today. I ate something and I want to see how much it raised my blood sugar.

That's not bad. What did you eat? So I ate this product that I've been doing some research on. It's called no. K-N-O-W, like no foods. And I was introduced to this product by one of my patients who said, Hey, Peter, I want you to kick the tires on this a little bit. It uses a sugar substitute called allulose.

And it tastes amazing. And apparently like it doesn't raise your blood sugar at all. And I was like, yeah, I'm familiar with alulose. for those who might not know. Allulose is a sugar that occurs in nature in very small quantities that looks exactly like this sugar called fructose, which is fruit sugar, the sweet component of sugar, with one small exception. But that one small exception carries with it some very important things. One, it's not quite as sweet as fructose.

It's about 70% as sweet. But by giving up that little bit of that sweetness, you get a whole bunch of stuff in return. First of all, it's not metabolized by the liver, which is the real problem if it goes to, you barely absorb it. So 99% of it or more or less is excreted by the kidneys. And three, it actually seems to lower blood glucose. So this company, No Foods, is putting this, like making stuff out of this, but stuff that is like carbide, like bread and waffles and muffins and stuff. So anyway, to make a long story short, I'm at this patient's house. and he's force-feeding me these things,

which is really my way of saying, he's left the bag open, and I'm inhaling them. And he's like, yeah, yeah, yeah, you got to, like, tell me if this stuff's legit. So to make a longster short, he plugs me into the guy who founded the company, and he has sent me a bunch of this stuff

to just play with because he knows what I do. And so that's what I've been doing. So today, I normally don't eat breakfast. So I worked out this morning, and then before I came here, I had a big piece of their toast covered in almond butter, and then two of their huge waffles

covered with almond butter and bananas. Like I made a big sandwich out of that. So the almond butter, not going to have a huge glycemic response because it's got so much fat and protein in it, but the bananas should skyrocket my blood sugar. Not to mention the two freaking waffles the size of my head and the piece of toast.

So interestingly, so that was at 9 o'clock that I ate those. Now I've been up since 3.30, but I didn't eat anything. I worked out from 7 to 8. So admittedly, there's a bit of a glycogen debt. So at 9 o'clock when I ingested,

my blood glucose was 65. And at its peak, which was 11, 18 a.m., it was up to 90. And it's now down to 83. What would real waffles have done to you? I think they would have sent me to like 140. Three huge pieces of bread slash waffle with the full banana.

So anyway, I've been doing these experiments all week, which is just a great excuse to eat this stuff. And I'm kind of surprised. I'm kind of blown away. So, okay, with all that said, what's my advice for what people should eat? In an ideal world, everybody would have this thing embedded in them like I do. This thing is called a Dexcom G5. It's a continuous glucose monitor.

Typically only used by people with type 1 diabetes. We're now starting to see people with type 2 diabetes wear them. But I was really completely lucky one day sitting on an airplane next to a dude. who happened to be into watches. I'm into watches. We got talking about watches. I find out he's the CEO of the company that makes this thing.

The rest is history, right? I'm like obsessed with this stuff. And so, because the answer is this, right? If you were a computer program, I would say, Jock, eat whatever you want to eat, such that your average blood glucose remains below 85 milligrams per deciliter and your standard deviation below 10 milligrams per decaliter. So translate that into English.

Okay. So eat in whatever way your genetics and epigenetics permit you to, such that your glucose levels stay low and the variability stays low. And those two things will ensure that your insulin levels stay low. So what I'm trying to do is optimize for something called the insulin AUC or area under the curve. Now, we can't measure that test clinically. The only way I could measure that is put you in a hospital, put a central line in your neck, and excuse me, sample your blood every 30 minutes over the course of a day where you somehow act normally. And every day, so then I'd have a time axis, the x-axis would be time.

The y-axis would be insulin level and we'd generate a curve and we'd calculate the area under that curve and we want that number to be as low as possible. So we can't do that outside of the research setting. So then the next best thing is keep your average glucose as low as possible and the variability. So you could have an average glucose of 100 with low variability. and that actually wouldn't produce that much insulin. Or you could have a glucose of 100 with high variability. Same average glucose, higher variability is going to have higher insulin, all things equal.

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. So what you can eat to achieve that varies tremendously by individual. You know, there are some people who just dispose of glucose remarkably. So that blood test we're going to do in you next week is going to be our best test at measuring that. And so glucose disposal is mostly a function of the insulin sensitivity of the muscle,

because the muscle is where we dispose of the majority of glucose. But it's a little more complicated than that, right? Sleep impacts that, right? So sleep deprivation makes us more insulin resistant. So this has been experimentally demonstrated, even with two weeks of sleep deprivation. So it's a small but very well-controlled experiment that was done out of the University of Chicago,

probably six years ago. They took a very small number of subjects, like I said, about eight subjects, and for two weeks, let them only sleep four hours a night. And they did a very invasive test called a euglycemic insulin clamp at the beginning and at the end of the experiment. And their insulin sensitivity, their glucose disposal, deteriorated by 50 percent. And with no change in what they were eating. So it's highly variable, right? So that's theoretically the answer.

On a practical level, I would say the answer is this, right? If it comes in a package, you're probably better off not eating it, right? If your ancestors couldn't have eaten this even 200 years ago, it's probably not worth eating. So if you just followed that advice, think about how many things you'd eliminate from your diet, right? If you just took packaged foods away from your diet. And again, notice, I'm agnostic. You want to be a vegan? Knock yourself out.

You want to be the paleo man of the century? Go for it. I don't give a shit. I couldn't care less, right? But if you can largely adhere to those principles, you're kind of going to be fine. You're going to get 70% of the way there. You want to get 80, 90, 100% of the way there? Well, then there's no simple answer.

Now at that point, you've got to dial in and you've got to go full immersion into how do you tweak to your biochemistry. How much protein? What's the timing of the meals? When do we fast? I mean, all of the stuff that is my world and maybe soon to be your world, that's the stuff for which you cannot provide, you know, systemic advice. But at the societal level or at just the most basic level, yeah, I mean, think about that advice. Like, you don't eat sugar anymore. You won't eat refined carbohydrates anymore.

You're not going to eat, you know, processed crappy foods anymore. What are you going to eat? You're going to eat fruits. You're going to eat vegetables. You're going to eat meat. You're going to eat grain. You know, what kind of grains are you going to eat? Well, you know, you're not going to really eat these sort of refined, crappy grains that people eat.

You're going to, you know, your starches, I'm sorry, not grains. Your starches are probably going to be in the form of potatoes and rice. So, again, a lot of people, you know, again, I just, I sort of, I think the reason I like talking about nutrition anymore is I don't find it to be an intellectually honest discussion anymore. I find it to be just a discussion of dogma, right? So if you're a low carb camp, you're a low carb camp. If you're in the, you know, whatever, the vegan camp, you're in the vegan camp. Like there's, you can't even have a discussion about this stuff. And at least not with most people.

Yeah. So I just, you know. You ever read the book called Diet Colts? I know. So does it get into this nonsense? Yeah. That's the whole book. Really so interesting, fond to read too.

So good. All right. We'll have to check that out. Diet Colts. Now I kind of open with this and since we're, since we're a lot of, a little over two hours right now. Come on. I said that you're probably the most responsible individual for this podcast.

And because you originally, through Kirk, sent me up to do a podcast with Tim Ferriss, which sent me up to do a podcast with Joe Rogan, which was just all awesome. And both those guys told me I should do my own podcast. So anyone that's listening to this podcast, say thanks to Peter for that. Actually, they should thank Kirk, right?

Yeah, Kirk was the man. You know, I mean, Kirk is, I don't need to tell you, but Kirk's one of those guys where, like, he doesn't have to justify and ask, right? So when he introduced me to you, he didn't have to explain. He was just like, I want you to meet Jaco, Jocko's my friend.

I was like, that's good enough. And so, you know, to me, like, that's the measure of when life is good. And because I feel that way with all of my friends. Like, if Tim introduces me to somebody, Tim's introduced me to like a dozen people. A dozen amazing relationships have come out of that, right? And so, you know, really it was just very easy for me to sort of take Kirk on his word that like, if Chaco's a great guy, then that's all I need to know.

I knew you're going to be a great guy. And then similarly, like, I could tell Tim like, hey, you got to meet Chaco. And, you know, Tim gets quote unquote pitched all day long. Yeah, it does. 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 be really interesting and going to be. to benefit his listeners, not just, you know, whatever agenda that person might have. Yeah, yeah. No, it was awesome. And that really did. I mean, the way Tim, the way Tim advised the way he was going to release the podcast in order to support the book. I mean, he just nailed it.

It was kind of ridiculous the way he understands that stuff and how helpful it was to, you know, getting our book out there and getting it sold and all that and getting all these people on board. and then, you know, that turned into this podcast, which, you know, he definitely has promoted the podcast in a fantastic way, along with Joe. So that's both been awesome. But again, started with Kirk connecting me with you and then you connecting me with Tim. So I appreciate that. And speaking of this podcast, my almost silent partner over here, Echo Charles, if somebody wants to support the podcast, How would you recommend they go ahead and do that?

You always have a question. Oh, oh. How'd you hurt your back originally? You know, I don't think we ever really have a diagnosis. There was certainly nothing on that day that I did. That day I'm riding my bike to the gym. I think about the sins of my youth. You know, I was really into martial arts in addition to boxing.

And I used to spend a ton of time. I was really obsessed with spinning back kicks. Now, I don't know if that could have done it or not. But I used to practice 75 spinning back kicks with each leg every single day for probably about six years, seven years. It's possible, even though in theory a spinning back kick, if done correctly, should really not put any torque on the lower back. It's much more in your hips.

And technically, the flexibilities in the thoracic spine, not the lumbar spine. But, you know, God knows, maybe I just wasn't doing those things correctly. I did squat and deadlift really heavy growing up. I did powerlifting as sort of a side sport. But, you know, certainly never hurt myself doing that. I rode crew for a year. And so I always, I've always wondered if that was the most destructive thing I did because in an eight-man boat, you're asymmetric, right?

So when you skull, you're symmetric. When you sweep, you're not. And so I was like, I was a sweeper. And so I almost wonder if, like, that's the most destructive thing I ever did. Yeah. And then you figure if you're asymmetric like that, your everyday life is asymmetric, really, because you have a little bit of overdevelopment on one side. Dang, that might have been.

So I guess I've never really known, but I take it really seriously today. In fact, you know, Jocko, you'll dig this. Two weeks ago, I did a video in New York with a friend of mine named Jesse Schwartzman. And he's like, I call him the savant of movement. This guy's like, just like the kinesthetic man. and I wanted to put a video together of how do you train to train? How do you prepare your body to train? So it's basically three sections.

It's what what's the sort of dynamic, well, the sort of tissue preparation, the static prep, and the dynamic prep. It took us eight, maybe six hours to shoot this video. It'll be edited down into probably three, ten minute videos. And as soon as they're done editing, I'm just going to throw them up on YouTube and my blog. so I'll make sure you've got a copy. Awesome. I mean, Jesse's just, you know, he walks me through all the exercises. But I get the sense like if I had done that stuff all the way in my life, I probably never would have been hurt.

And luckily, knock on wood to this day, I mean, I never thought I'd be able to squat and deadlift again after going through that year of my life. But amazingly, I'm totally fine. And it was a herniated disc that popped off. Yeah, so it was an L5S1 really big herniation, but then a four or five centimeter. fragment broke off and then floats down the canal and that was sitting on the nerve route and then I developed a few other problems after so I developed this thing called a facet arthropathy which resulted in the feeling of having my testicles torn out from the inside I'm not even joking that's just so it's just unbearable yeah I would imagine

that's unbearable I don't recommend that no all right well that being said I guess we can talk about um so you can talk about on it i was talking with greg and terry and i was showing them about uh i was showing them the warrior bars right these are these are dope and then then he was like oh yeah like what else is there there some good stuff on it has good stuff so i brought out that that new pre-workout one which is good by the way ever report on that so that one comes out and then the krill oil comes out oh yeah this is good for this so we're talking about this this big table of like all the sub. It's not a lot. It's like four things. The worry bar, the krill oil and the pre-workout. And three things. And we're like, yeah, this does this and this does this.

And then I kind of step back and I'm like, yeah, we're those guys with all our supplements, talking about supplements, talking about supplements, right? Which I've never done. And Greg goes, yeah, if we weren't such nice guys, this would be a real dushy conversation. So the kind of the irony there is him saying, that he's the one having the douche conversation, but he is the nice guy. You get it? I guess so.

Anyway. The point there, or actually the second point there is on it is good supplement. So if you do talk about them while you're taking them, you're not having a douche conversation. And this is why. I heard Joe Rogan talking the other day about like how hard it is when you're a stand-up comedian and you tell a joke and it's just flat.

Yeah. I think we just got a little. Yeah, but that one. Here's the thing. That hurt me over here. There were. I was giving you a mercy laugh.

But I didn't do it because I'm not a merciful person. That had joking elements, but this is true, and this is part of a bigger point that I'm making. I hope so. I don't expect you to laugh at everything I say, even though you pretty much do. Anyway, the reason that it's not a dushy conversation, here's the point, is because on its supplements, acrylic oil, all that stuff, is actually good quality. It's not like, hey, I'm going to meet it, I'm going to get buff and all this stuff. It actually helps your performance. anyway so in the event of you wanting on it stuff and supporting this podcast while at the same

time supporting yourself go to on it.com slash jaco 10% off second way to support amazon click through christmas is over but we still need stuff duct tape whatever nice etc if you want to support this podcast just go to the website jaco podcast dot com click through the on the um amazon banner link before you do your shopping you can support that way it's a good way to support oh yeah you're into chemistry right sodium when you put a little piece of sodium in the water right it makes this big commotion so that's what kind of what the amazon click through does it seems like this small little thing but applied properly it makes a big impact in the podcast support wise anyway but you get that can we verify that doctor i will have to go and look at the amazon click through

I tell Jockey He typically doesn't really understand Because he doesn't know what sodium does No Might have been potassium Or both actually So now this whole thing's been a lie Or it's at least unsure

No no no I'm pretty sure I'm actually fairly certain Pretty sure goes along where With that go I guess Yeah Anyway You can subscribe to the podcast on iTunes Which seems obvious

Because typically the podcast you listen to you subscribe to but sometimes you don't so subscribe if you have not already and you want to support this podcast Google play Stitcher also in the game yeah and iTunes yeah yeah it's kind of unfair that I don't think about that as much you know when you have an iPhone like you kind of forget all this other stuff I'm over here to help out yeah man good thing you're you're here yeah on this podcast um YouTube of course we're working on putting more videos on there aside from the whole podcast. So some of those videos, and I have gotten like messages saying like those shorter clips

are helpful. They are helpful. Rather than listening to the whole podcast. And there's been people that have been submitting to you on Twitter. Yeah. Which excerpts. Yeah. Are in high demand out there in the world.

Yeah. Yeah. I've been following now. And in fact, I have them all like it's a process. But yeah, we're working on that. So subscribe to YouTube. We are working on. on that we are yeah collectively just so you guys know I'm not working on any of that but

echo apparently is which is cool well technically you saying hey echo put this one up okay boom you did you on yeah man exactly um and then in the event of you wearing like what like a t-shirt or something or a hoodie jaco has a store it's called jaco store the URL is jocco store is that a calculator watch you have i was going to get to that so you mentioned see now we got to change subject real quick, which I like, by the way. Remember you were talking about you're into watches. Yeah. Right.

I was going to show, I didn't want to interrupt what you're saying, but. That is. You appreciate that. That is ridiculous. I just reincorporated this one back because. What is it, a calculator watch? Yeah. Actually, one of the first pictures I posted on Twitter was up before the enemy and it was

like, you know, Jack was always like, yeah, 4.30 a.m. Which one is that the Cassio? Yeah, Cassio. Oh, cool. Dude, circa 1988, 84, 85. That watch when I was a kid, dude, like, I would have killed someone for that. Only the cool kids had the calculator one. Usually, if you had a watch, it was just the regular Casio.

And the cool kids had the calculator. I had the first Iron Man. Did you? Yeah. It was black with like a little red trim on it. I asked for it for Christmas. My parents got it for me, but I knew where they hid presents. So every day after school I would go into their room

And I would take it out of the box And I would set the time I would wear it I would just hang out there And then before I go to bed I'd like sneak back Put it in and so like on Christmas day It was like I'd been wearing the watch for a month Right, that was your watcher Actually I think you got

I'm into watches too Yeah Yeah Well I got one I got quite a few of these You should have your own brand of watches Yeah We'll see how all that turns out

nonetheless yeah i am very proud of this calculator watch back to the store though jocco store no watches but yet yeah are yet yeah not yet but there are some cool shirts in my opinion i think they're cool discipline equals freedom all these things jocco's head good written in backwards various layers to these shirts not just like oh a picture that's it so if you like any of that stuff I'm not even saying go buy this stuff I'm not saying that just go to the jocco store.com see if you like it if you like it you want one then you buy one

and that supports the podcast you know it's a systemic thing good there you go patches on there as well rash guards you know what you didn't mention that you should have mentioned because apparently it's been pretty cool out there in the world laid on me psychological warfare

yeah I didn't mention it this time but I mentioned it last time and in my everyday life and I use it so there you go psychological warfare you use it I use it every day when needed here's the thing you can't use it every day no you can actually you can't I'm not gonna say you can't use it every day but the reason the whole reason that I was like hey Jocko what do you say you know

when you're oh because you don't need it every day I don't need it every day okay but it varies you know from season to season so like you know so if you are coming up against moments of weakness. Yep. We have a little method to get you over those humps. Yeah. It's kind of like coaching a little bit.

Psychopathic coaching. Yeah. Psychop for sure. Because it kind of at the same thing. I played one of them for my seven-year-old daughter the other day because she was about to eat some candy or something. I was like, come here for a minute. Yeah.

So I played her that one, you know, the snack time one. Yeah. Sugar-coated lies. Yeah, sugar-coated lies. she was she was pretty impressed but what impressed me was later in the evening she was kind of saying it yeah see and that's what i was going to say where you explain it's like cool it's jocco telling me to do this so yes i'll do it or not do it whatever but you explain some some some good stuff like to remember you know like that is sugar-coated lies yeah and that's kind of catchy too so it sticks in your

mind poison so you can buy that on iTunes yes it's somewhere else else too right Google play if you want it and also everyone that asks for an alarm tone to wake up that's it that's it it's there now you don't have to ask anymore you can just go to iTunes and get that psychological clear it with your wife though or whoever you sleep with yeah we've gotten some serious feedback on that one yeah because what happens is the alarm goes off if you have it set then it's going to be my voice and it's going to be weird because it sounds like there's some strange man in your room at 430 in the morning which is kind Weird.

Yeah. There's the alarm only work at 4.30 a.m. Like, no, it's just a, it's just a, it's an album. It's an album of tracks.

And each track talks about some moment of week, generally a moment of weakness that you have. Like there's ones to wake up in the morning. There's ones to, you know what? You don't feel like going to the gym? Go to the gym. There's ones you feel like eating a donut.

Don't eat the donut. There's one. Oh, I'm going to put this off for a while. I'm going to procrastinate? No, you're not going to procrastinate. So all the little moments of weakness that we all have as humans can be countered using psychological warfare factually. Yeah, there's actually two on there.

There's one called, like, I think it's called like, no more. It's basically like, I'm not doing this anymore. Yeah, yeah. No more is a good one. That one's good because it puts into words exactly like what you want to think, like, because you always feel that. Like, you know how like, you're gaining some weight or, I mean, a lot of times you know why you're gaining weight.

And so it's a little bit different. But you're like, you know what? I'm not doing, drinking is one where you wake up kind of hung over and you're like, I'm not drinking anymore. You know, like that thing. But you never really execute. Yeah, you know, man, it's perfect because it sticks with you. You're like no more. And then the other one was when you're talking about every day.

It's called every day. Every day. Every day is a Monday. That one. That one's dope. Yeah. So you can get after that. Also, if you want to get some tea, if you're tea,

or if you're not a tea drinker, you can get some jocco white tea, you can get it on Amazon. It's fully in stock. Y'all those days of being out of stock, I think we've got them under control for now. And I won't make any promises, because last time I made a promise, you guys went psycho, so I'm not gonna make a promise,

but you can get the jocco white tea. I figured out, again, it doesn't taste like tea, really, it doesn't taste like coffee, and for a long time I was at a loss for words to describe what it tasted like, and I figured it out, I was really, responding to someone and I figured it out what it tastes like. And it's pretty simple.

The jocco white tea tastes like victory. So if you need to and we need to trade I need to trademark that one stat. The fact that jacca white tea tastes like victory. Boom. So get some of that.

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 hoped for you can drink it from a jaco mug says get after it on it that's good oversized by the way yeah it's big it's big it's not somebody somebody made the comment that it's not comically big right it's not a joke yeah it's not like clown shoes no it's not but it's big enough to you know it's big like a pair of work boots as big as a pair of work boots it will kick you in the ass right yeah so it's that big

if you haven't got the book Extreme Ownership, you can pick that up there. It's about leadership. It's about combat leadership. I'm going to give my friend Peter Atia about three copies of it just to make sure he reads it. So if he has to deal with any C players, he's going to step up his game a little bit hopefully. I read a pre-publication.

That's right. But I clearly missed that chapter. Wait, what's the pre-public? What does that mean? Meaning before the book came out, hey, here's what the book is. Okay. But it's still, that's it. That's it.

Yeah, it's not like, you have the pretty flat. It's a paperback. Yeah, yeah. It was like, yeah. You got the VIP screening. Yeah. Yeah. Hey, speaking of extreme ownership, we're having another muster.

If you don't know what it is, check out the website, Extreme Ownership.com. It's going to be in New York City. So everyone can come because if you're on the East Coast, no matter where you're on the world, it's easy to get to New York. And May 4th and 5th, if you're a leader or you want to be a leader. leader come and get it there's every level of leaders there CEOs mid-level managers every industry you can think of too people that manufacturing and finance and construction and health and pharmaceutical

and there's police there and fire and military and oil industry and entities to everybody all working on leadership talking about leadership so and i've said it's going to sell out we're moving in that direction quickly and echo hasn't even released his videos yet because he's on Hawaiian time. No, no. Oh, you're not? No, I'm working diligently and I'm going for quality. Not, you know.

You're not going to put out any scrub material. Right, right. Once those videos come out, my feeling is going to sell very quickly. So get there now, sign up for it. If you need a police or a fire discount or a military discount, or if you're going to bring a group of people, I think the biggest group we had at the last room from one company was around 16 people from one company or 12 people. But there's some pretty big numbers of companies that are showing up there.

come and get it. Echo, you got any closing comments? My pleasure. No other closing comments, thank you. Other than it was your pleasure. Peter, any closing comments? I would only echo, Echo's comment. And that didn't even get planned until it came out.

Perfect. And if you want to continue these conversations with Peter, on Twitter, you're Peter Attia MD. What are you on Facebook? I don't know. Probably. Do you still have Eating Academy? Yeah, yeah.

Okay. Is that the place to look? I don't do a lot. So Twitter's your most prominent? And I've been berated into doing something on Instagram. I just can't cope at the moment. Yeah. There's a way to connect the two.

I've tried it. I don't like it. I do them separately. Yeah, you don't really connect Twitter to the Instagram. I think it's the other way. Well, there's a way to connect some of them somehow. Yeah. I just don't have enough pictures to show.

Right. Yeah. I don't have anything to. Don't you have a bunch of watches? Yeah. See, I'm showing a watch, the same watch every day. I show that ring how you were explaining it. That's true.

That ass ring. You could do like 12 pictures just on the ring. What if my whole Instagram schick became this? Like my blood glucose at every moment. That'd be pretty cool. And you kind of indicate what you ate or something like this. You could just save. that screen and post it up there.

It's just so much work. It's work. It's hard labor to save that thing and press submit to it. It actually has a little switch so you can just make it go. It's not that much work. All right. I'll think about it. For somebody that's swimming 18 miles in the ocean, talk about too much work to post an Instagram picture.

You got issues, son. All right, Echo and I, we are also present and accounted for on the interwebs. on Twitter, on Instagram, and also if you're going to be looking around that face, boqui boja, we're going to be there. Echo is at Echo Charles, and I am at Jocka Willink.

And again, I would like to thank you, Peter, for coming on. And more important for everything you've done for me, which really, the way it's connected all together, getting me through Kirk to Tim Ferriss, which was the book, and get me on Joe Rogan, which led to this podcast. It's been awesome. So to you and to Doc Kirk Parsley for introducing us,

but thank you and him for what you guys have done for me. The men and women in uniform out there holding the line. Thanks for your service and your sacrifice to the police on the corner. Fighting crime. The firemen fighting fires. Thanks for keeping us safe to the medical people in the medical professions like Peter, doctors, nurses, physicians, assistants, EMTs, all of you working to save lives. Thank you for your commitment to service. And it's obviously a massive commitment when you hear about the hours and the emotional trauma that it takes to go into any one of those industries.

and services and to everybody else us listening thank you it's your communications your questions your participation your feedback and your spreading of the word that makes this possible and it's what makes this worthwhile so thank all of you for all of that that and finally thanks to all of you for getting out there and getting after it so until next time this is dr peter attia and echo and jaco out