Something You Should Know - How, Why and When Doctors Make Mistakes & How Creatures and People Actually Evolve

Episode Date: September 3, 2020

When someone is sick or in the hospital, it is customary to send them flowers. Who doesn’t love flowers? But do flowers actually help sick people heal? This episode begins with a discussion on some interesting research that connects healing with plants and nature. http://askinyourface.com/2012/05/06/the-healing-power-of-flowers/ Everyone makes mistakes, including doctors. But medical errors can have serious consequences. It has been reported that medical errors are the third leading cause of death in America. Could that be true? What is being done to prevent medical errors and what can we as patients do to make sure we are not the recipient of one of those errors. Here to discuss that is Dr. Ofri, Clinical professor of medicine at the New York University School of Medicine and practicing physician at New York’s Bellevue Hospital for more than two decades. She is author of the book When We Do Harm: A Doctor Confronts Medical Error (https://amzn.to/3hVGku9) Have you ever wondered why traffic seems to stop on a highway for no apparent reason and then just starts up again? How does that happen? Listen as I explain the science of phantom traffic jams and what we could all do to stop them if we all worked together. http://www.livescience.com/713-science-traffic-jams.html How does evolution actually happen? How did fish come out of the water and start walking? Where did their lungs and legs and feet come from? How did reptiles transform into birds? How does any creature evolve into another? We have a lot of new evidence that helps explain that says Neil Shubin. Neil is a paleontologist, evolutionary biologist and Professor at the University of Chicago and author of the book Some Assembly Required: Decoding Four Billion Years of Life, from Ancient Fossils to DNA (https://amzn.to/3gzfoii). Listen as he explains the fascinating world of evolution.  Learn more about your ad choices. Visit megaphone.fm/adchoices

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You can now make the first move or not. With opening moves, you simply choose a question to be automatically sent to your matches. Then sit back and let your matches start the chat. Download Bumble and try it for yourself. Today on Something You Should Know, phantom traffic jams. You know when traffic just stops on a highway for no apparent reason? I'll explain why that happens. Then, medical errors.

They seem to happen a lot, but why? So let's say the nurse grabs the wrong IV fluid. So yes, that's an error that could say she did that. But then you can look at, well, what were the systems that made that error possible? Was she being given too many patients to take care of? Was the lighting poor so you can't read the labels? Then, when someone is sick or in the hospital, you send flowers. But do they really help the patient heal? And how does evolution work? There's fascinating new evidence.

And we can now see in great detail how some of these huge events that made our world what it is today, how they happened. How did fish evolve to walk on land? How did birds evolve to fly? How did these great leaps happen? Well, we can now take them apart with fossils and DNA. All this today on Something You Should Know. Since

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Something you should know. Fascinating intel. The world's top experts. And practical advice you can use in your life. Today, Something You Should Know with Mike Carruthers. Hi, welcome to

another all-new episode of Something You Should Know. You know, it is customary when someone is sick or in the hospital that you bring them or send them flowers. And it turns out that get-well flowers actually help people get well. Kansas State University researchers discovered that patients recovering from surgery who had plants in their room had less anxiety, lower blood pressure, and needed less pain medication. Professor of psychology John Davis explains that anybody can benefit from exposure to nature.

A lack of contact with nature may create stress since you're being deprived of the natural human setting. You certainly don't need to be sick to enjoy plants and flowers. Keeping potted plants on your desk, taking lunch outside, and making an effort to be near an abundance of trees from time to time can be a natural dose of tension and stress relief. And that is something you should know.

I know I've heard this statistic, and you've probably heard this too, that medical errors are the third leading cause of death in the United States. And just on the face of it, I mean, if that's true, that's just horrible. How could that be? We supposedly have the best medical care in the world. How could the medical profession be making so many serious mistakes that it's killing more people than everything else but two other things? And then what about all the medical errors that are causing harm but not killing people? Well, that statistic may need a little further examination. And here to do that is Dr. Danielle Ofri. She is a clinical professor of medicine at the New York University School of Medicine.

She's cared for patients at New York's Bellevue Hospital for more than two decades. And she is author of the book, When We Do Harm, A Doctor Confronts Medical Error. Hey, doctor, welcome. Thank you. It's so nice to be here. So how big a problem really are all these medical errors? It's a good question that you ask. Part of the problem is we don't know the answer to that. So a couple of years ago, there was a big article with huge headlines

about medical error being the third leading cause of death in the U.S. It was funny because I work in a very busy urban clinic. I thought, boy, if medical error is the third leading cause of death, I should see it every day, shouldn't I? But I don't, or at least I feel like I don't. So then I wonder, is it there and we miss it, or are the data wrong? And partly we don't know because it's very hard to know necessarily when an error occurs and whether the error is the cause of something bad.

There's no place to check off medical error on a death certificate. So we don't actually know. It's pretty common, though. Where did that number come from then? So this study reanalyzed a couple of older studies. And they were looking at hospitalized patients, which, as you can imagine, are not representative of all people, right? Not everyone's in the hospital, thankfully.

Hospitalized patients tend to be older and sicker with many more moving parts. And one of the problems is that because you're reanalyzing someone else's data, you're relying on their judgment of whether an error occurred and whether the error actually caused the death. Imagine a patient dying of liver cancer and they're given the wrong antibiotic and they die. So there's been an error and there's been a death, but did the error cause the death? It's often very hard to tell. So it's already a judgment call and then you're relying on someone else's judgment call. So any biases will then get

magnified if you then extrapolate to 350 million people. And so we hear the sensational stories about, you know, the doctor cut off the wrong leg or, you know, these horrible medical error stories. I imagine, God, I hope that's the exception, not the rule. Are they very rare or are they, I mean, one is bad enough, but I mean, how bad is that? Well, it depends how widely you cast the net. So catastrophic errors like cutting off the wrong leg or operating the wrong side of the brain, those are rare. It takes a lot. A lot of things have to go wrong for that kind of error to happen.

They do happen, but they're not that common. However, there's lots of errors that are smaller and cause mild amounts of harm. Maybe the patient had to stay in the hospital a day longer, or maybe they had an upset stomach when they didn't need to have that. Things like that, which there may still be an error, but the consequences weren't grave. And then there's a huge category of what we call the near miss. That is, an error has happened, but the patient did okay. Or as I like to think, the patient got lucky that day. And those errors are probably vast. We don't really know the number because who reports near misses? Very few people do. And because the patient isn't harmed, we tend to ignore them. However, that's kind of like the minefield of the future errors waiting to happen. So to me, near misses are just as important, even if there's no harm from those medical errors.

Understanding that you're a physician, a practicing physician, so you're on the team, so I'm sure you have conscious or unconscious biases about this, But still, you've objectively tried to look at this problem, an important problem. So how would you, if you could step back, how would you rate your profession, your colleagues? How well a job do they do as it relates to medical errors? That's also a tough question because there's many levels to that. So one is, what does the individual doctor or nurse do? So let's say the nurse grabs the wrong IV fluid. So that, yes, that's an error that you can say she did that and that was incorrect. But then you can look at, well, what were the reasons, what were the systems that made

that error possible? Was she being given too many patients to take care of because they're short-staffed? Was the lighting poor so you can't read the labels? Do the medications look alike or sound alike? Was she being interrupted every five minutes by people asking for ginger ale and directions to the bathroom? So even though we can rank that nurse as, boy, she was really rotten because she gave the wrong medication, you can also find the systems that made that error more likely. As a whole, as a field, I think we are finally waking up to the sheer volume of errors or care that is less than we want it to be. And that includes not just outright errors, but harms that patients receive that we don't intend for them to

get, even if an error wasn't committed. That's quite a vast issue. So the profession is waking up. We're still going a little slowly and partly because we tend to want to blame the nurse or the doctor for making the mistake as opposed to looking at the system that makes the error or bad outcome more likely to happen. Seems like that would be the case that the system is the problem. And, you know, I've heard the comparison that, you know, the airplane pilot, if he makes a big error and somebody dies, he dies too. So that's why there's far fewer airplane accidents than there are medical problems, because the doctor doesn't harm himself, he only harms the patient. It seems a little harsh, but I see

the logic in that. But I also think there's fundamental differences between the aviation industry, between airplanes and medicine. So for one thing, all the moving parts of airplanes are moving parts. Most of the moving parts in medicine are people. And there's all kinds of people on the team. On an airplane, there's, you know, one pilot, one co-pilot, you know, a fixed maintenance team. And that's really it. And the flight crew.

In medicine, you may have dozens of people involved in care at all different levels. There's many moving parts, and these are human beings, and they don't all necessarily come out the same. They don't show up with vasculitis diagnosis branded on their chest. They come and say, I don't feel good, and we have to figure that out. So it's quite a bit different. But I think going back to your original point about the wrong leg being cut off, why that's rare, most errors and bad outcomes tend to relate to some form of communication error. So it's not like we're just checking the parts of the engine, making sure it works, but are people communicating correctly? Are the doctors and nurses and physical therapists communicating appropriately? Are they communicating with the patient? Are they listening to what the patient's saying?

And all of those areas are why it's so much more difficult to pin down where things go wrong. What about the patient's responsibility in this? What role do they play in preventing medical errors? You know, medicine, it's a team sport. We hear that all the time. We tend to think of the team as the doctors and nurses and then the medical folks, the people in scrubs. But really, the team is also the patient and the patient's family and the close friends who are there with them. We're all on the same team.

And even if we sometimes feel like we have opposing agendas, there's really just one agenda, and that is helping the patient get better. And so the patient and family, they do have responsibilities too. So knowing your own medical history, knowing your allergies, knowing what medications you're on, that's very important. But of course, the patient's also the person who's sick. And so it's not so fair to ask of them, well, while you're suffering a 103 fever and vomiting your guts out, make sure you ask the nurse the name of every single medication that you get. So it depends on the circumstance. I think the more patients and families can be engaged and involved and know what's going on, keep a notebook, ask the questions, write down the answers, that's all for the better. But I think we can't foist it upon the patient who is pretty busy being sick,

or anxious, worried, frightened, all these other things that make them maybe not at their best at that moment, and much more vulnerable than usual. So the onus really is on the healthcare profession for most of it. Although, the more patients can be engaged and involved, the better for everyone. Where likely do things go wrong? Is it medication typically? What is it? Well, again, we don't have a good answer to that question. And one of the reasons is that we don't have any kind of national database for reporting errors. So we have no way of knowing. Reporting errors is voluntary, or you get sued and then it comes to light. The other day, I detected a near-miss error that was related to the electronic medical record.

I thought, well, you know what? Let me file a patient safety report. It's important for them to know. Well, you know, I couldn't even find the page and the link and I had to go through six different pages on the computer. I had to call the help desk, find out where to, you know, find this. Then I had to open an account with a password and a capital letter and a small letter. And at that point, I gave up. So we don't have an easy system for doing that. We don't have a requirement. We don't have a national database. So we do not know. It's a mix of those. Certainly medication errors are big,

procedural errors, and communication errors. Those are, I think, where the big things are. And then overlaying that is the issue of diagnostic errors. That is getting the diagnosis wrong or having a delay in the appropriate diagnosis. But that encompasses things like communication errors, listening errors, and also medication errors, whether it's the medications the patients are on, those we are prescribing. We hear about defensive medicine, that doctors, for fear of being sued, do things, do extra tests, or do or don't do things to basically protect themselves from liability. Does that play into this? Oh, yes. Defensive medicine is an enormous problem, particularly in the United States, which has a more litigious culture than many other countries. And some several billions of dollars are spent on unnecessary tests because, oh, my gosh, the patient's got a headache.

Better do a CAT scan because they might sue me. Whereas in other countries, you might say, hey, listen, I don't think it's anything other than a tension headache. Let's watch it and see how it goes. And so it's not just the cost, though. Every test you do brings in its own room for error, right? You do a CAT scan, maybe you give someone contrast dye and they might have a reaction to that. Or you do additional tests that pull up incidental findings that maybe are meaningless clinically, but then cause you to do more tests. And so

we definitely, we're just adding to the pile of things going on, and certainly the more that's going on, the more chances there is for things to go wrong. Well, plus there's this whole umbrella problem of people interact with doctors because they're sick. Things go wrong because they're sick. It's easy to blame the doctor. You know, people die, but people are going to die. Everybody's going to die. You can't always blame and sue the doctor

because they were in the hospital at the time they died. Yeah, so it points to how limited the malpractice system is for addressing error because you have to actually prove that the error, the issue, caused the death or the bad outcome. That can be very hard to do. You know, again, people are sick. There are many things going on. A mistake might be made.

It's very hard to prove that that mistake actually caused the death or the bad outcome, which is why malpractice only helps a very small sliver of patients. Other countries like Denmark are experimenting with systems that are more akin to our workers' compensation system, where you don't involve lawyers in going to court, but you simply file a claim. And if the adjudicating board sees that this is maybe less than standard of care or you suffered some kind of harm, then you either get a settlement or you don't. And in this way, many more patients can get some kind of compensation, get their issue addressed. The payments are smaller, but they're faster.

They don't take five years. They take a few months. And also, it becomes now a database, a repository for finding out about problems that are going on. So you might see, oh, in one hospital, there are lots of claims for pressure ulcers. Boy, something's probably going on there. So it has double duty for both giving more patients some kind of restitution, but also enabling, you know, researchers to see where things are going wrong. Well, this is clearly a problem with a lot of moving parts that's really hard to nail down. We're talking about medical errors, and my guest is Dr. Danielle Ofri.

She's a clinical professor of medicine at the New York University School of Medicine and author of the book, When We Do Harm, A Doctor Confronts Medical Error. People who listen to Something You Should Know are curious about the world, looking to hear new ideas and perspectives. So I want to tell you about a podcast that is full of new ideas and perspectives, and

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And finally, wrap up your week with Fisting Friday, where we catch up and talk all things pop culture. Listen to Don't Blame Me, But Am I Wrong? on Apple Podcasts, Spotify, or wherever you get your podcasts. New episodes every Monday, Tuesday, Thursday, and Friday. So, Doctor, what about the problem that was portrayed in the podcast and the tv show doctor death so here was this doctor in texas who was grossly incompetent and and perhaps even maliciously trying to do harm to people and he would just move from hospital to hospital he would get fired for his his negligence and his incompetence, and then he'd get hired at another hospital, and he would just move on and do more harm and do more

harm. Yeah, I mean, that's a tragedy, and I would say very rare. A small subset, very small subset of bad outcomes are caused by truly negligent people like that. But it's very small. The overwhelming majority of errors and adverse outcomes result from clinicians who are committed, doctors and nurses who are doing their best under challenging circumstances and maybe temporarily just miss something. But it's certainly not negligence. But there are a few. It's small. Now, the issue, though, of people covering is something else. Because you can imagine, you know, a step back from that kind of, you know, true criminal behavior. Let's say a doctor's getting older or having poor judgment or maybe off their game, not, you know, doing horrific

things, but maybe not as good as they could be. Who turns that doctor and who reports that? That's very hard to do. I mean, many doctors and nurses have depression, substance issues. They're being very overworked, certainly in the wake of COVID. Many, many clinicians are suffering and it can come through in their work. And we would like our colleagues to bring those issues to the surface because we want to help that staff in addition to protecting their patients. aren't very helpful. Maybe they're good technically as a doctor, but they're lousy as a person doctor. Their bedside manner sucks, basically, I guess is what I'm saying.

And I wonder why that is. If you're a doctor, why are you acting like that when you know people are sick, they're relying on you, and you're treating them poorly. That's a great question. I bang my head against the wall all the time. The book I wrote before this one was called What Patients Say, What Doctors Hear, about the issue of communication between doctors and patients and why it's so difficult. Because you often hear, you know, so-and-so, you know, great doctor, but lousy bedside manner. But what I discovered after researching that book is that those things can't exist apart. You can't actually be a great doctor with a lousy, you know, quote, bedside manner, for which we really mean communication skills, because what the patient is saying is the

primary data from which we make all our diagnoses, all our treatment plans. And so listening, it's not just nice, it's critical to be accurate and to make the right diagnosis. Now, why are some doctors really crappy? Well, some people are probably just misanthropes and they probably shouldn't have gone into medicine. Again, that's probably a smaller percentage, but I think a lot of doctors are simply so overworked by the system. I mean, right now, you know this, everyone knows this. You go to your doctor and they're sitting in front of a computer screen, battling with the electronic medical record. You know, you see them hitting the side of the computer and, you know, muttering under their

breath about the help desk. And we've given doctors and nurses more, you know, annoying work to do than they even have the time for. So it's hard to even spend time with the patient if you have 25 minutes worth of box checking to do and 10 minutes to see the patient and do everything. So a lot of doctors and nurses, I wouldn't say burned out because that puts a little bit of onus on them. I think it's more like a moral injury. They're being asked to basically cut corners because there's no way to do it without cutting corners. And that's morally corrosive. And so we use the term more of moral injury. And for many people, that becomes so difficult, it's very hard to maintain the reason you want

to go into medicine, to spend time with patients and be with them. And some people, unfortunately, end up with the phenotype of kind of a grouchy, uncommunicative doctor or nurse, and that's bad for everyone. Is being a doctor getting so difficult that it's really turning a lot of people off? Are we facing a shortage of doctors like we are nurses or not? Well, we do have a shortage of doctors, particularly in the primary care fields. That is general internists, family doctors, pediatricians, and you might see a common theme. These are the professions that are very burdened by paperwork, are relatively lower paid on the spectrum of doctor payment, which is certainly no doctor is starving, but definitely they're lower paid. The hours tend

to be longer. I mean, compare that to some specialties like dermatology, radiology, where hours are fixed and the pay is very high because they're procedure based. So we certainly have a shortage of primary care doctors. Try getting an appointment with an intern. This is pretty tough these days. And I think it's because, you know, partly you accrue a lot of debt as a doctor. So to go into a relatively lower paid field is maybe not so appealing when you have $300,000 worth of debt. But also the paperwork burden of the electronic medical record is really unappealing and people don't want to do that. So I think it's really a concern that we need to think pretty clearly about. Yeah. Well,

but you would think though that if there was a shortage, that those who did go into it would make more money because supply and demand. Well, we wish, but it's really about who sets the reimbursement for insurance companies. So, if I talk to my patient about diabetes and how to take their medications, maybe, you know, Medicare will reimburse my hospital $48. But if I talk to them about how to make brown rice instead of white rice, which is really important for diabetes, and I simultaneously thread a catheter into one of their orifices, and you can pick any orifice you want, that payment goes up like tenfold. So anytime there's a procedure involved, the payments are higher. When it's talking to your patient about how to take your medications, how to work on the lifestyle to affect your illness, that's not reimbursed.

So there's no supply and demand. It's simply who was at the table when the rates were set. And you can bet that the primary care doctors were not at the table. Well, what about the idea of a primary care doctor? Because it seems like now, and I've had this experience because I moved from an HMO to Blue Cross or whatever, that I don't even have a primary care doctor because it's hard to get in to see one when you're sick. Oh, they can see you in three months. Well, I probably won't be sick in three months. And so I just go to the urgent care and if I need a specialist, I call a specialist. I don't even really have a primary care doctor. Yeah, that pains me to hear that. And certainly for someone young and healthy, that may work for the occasional thing that comes up. But as patients get older and have many chronic diseases,

having a primary care doctor is essential. And it's been proved to me more and more during COVID, as patients, you know, were often cut off from their doctors, how much people's care suffered from having the doctor who's known you for five years and knows the complex interplay of your different illnesses. And also knows you well enough to know when something's wrong, when they come in and say, hi, something's off with this patient just by the way they're talking or the way they're walking or the way they sound. And that's so essential. Plus, there's more to health than just taking care of your acute illnesses. There's also the idea of being well in between. So a good primary care doctor, even for a healthy person, is helping them, you know, have a healthy diet, exercise to prevent all these chronic illnesses, make sure your vaccinations are up to date, helping you through a pandemic or what have you.

So it is really crucial. And you're right, we should be having many more primary care doctors. It's kind of a crime that we have more specialists than we have primary care doctors now. Right. Well, if you can't get in, even when you have one, if you can't get in to see them for eight weeks and you're sick today, you wonder why do they take on so many patients that every patient is eight weeks away from an appointment? Well, if the insurance company reimburses $30 for a visit, in order for the company,

the hospital, the practice to keep the lights on, they have to take a lot of patients on for very short visits. So that's the business model, which, as you can see, is crazy. We sort of have this supply and demand model for a field that really doesn't, you know, it's not toasters or microwaves or jeans. It doesn't quite work that way. And so we're trying to fit one model into something else that doesn't quite work. And that's exactly what the problem is now. Well, we started this conversation by talking about that statistic

that medical errors are the third leading cause of death. And I think you've done a pretty good job of explaining that, A, that's pretty hard to determine, and B, there's a lot more to the story than just that statistic. Dr. Danielle Ofri has been my guest. She's a clinical professor of medicine at the New York University School of Medicine, and she has cared for patients at New York's Bellevue Hospital for more than two decades. She has a book out called When We Do Harm, A Doctor Confronts Medical Error,

and you'll find a link to that book in the show notes. Thank you, Danielle. Well, thank you. It's been a pleasure. Do you love Disney? Then you are going to love our hit podcast, Disney Countdown. I'm Megan, the Magical Millennial. And I'm the Dapper Danielle. On every episode of our fun and family-friendly show,

we count down our top 10 lists of all things Disney. There is nothing we don't cover. We are famous for rabbit holes, Disney-themed games, and fun facts you didn't know you needed, but you definitely need in your life. So if you're looking for a healthy dose of Disney magic, check out Disney Countdown wherever you get your podcasts. GZM Shows and the creators of Six Minutes are rolling out their newest audio adventure with the podcast Discovering Dad. A cautious single dad with a secret past and his rebellious kids embark on a thrilling quest complete with hidden treasure, villains, and a family curse. New episodes of Discovering Dad roll out weekly starting June 11th on Apple Podcasts. Follow the show so you never miss an episode or listen early and add

free as a GZM Show subscriber. Go to gzmshows.com to learn more. How did we get here? And by that I mean, how did creatures change and evolve over time to get us humans to where we are today? Did we really start out as fish and at some point fish came out of the water and stood up and started walking? And if so, how does that happen? How did they get lungs and start breathing air? How does this whole process of evolution work? Well, it turns out there is some new research that sheds some light on all of this. And Neil Shubin is right on top of it. Neil is a paleontologist, evolutionary biologist, and professor at the University of Chicago,

and he's author of several books, including Some Assembly Required, Decoding 4 Billion Years of Life from Ancient Fossils to DNA. Hey, Neil. Oh, it's great to be here. Thanks for having me on. So when I think of evolution, I don't think you know cutting edge new science that that's a story that's been told and we kind of know how it all happened. So what's new? Well we've lived in a scientific revolution for the last two decades and that's the revolution of DNA science of genomics and what that new science does

when you know when merged with classical approaches from paleontology, we see evolution in a whole new light. We can now understand the great transitions in the history of life. You know, life has been on this planet for, you know, over 4 billion years. And we can now see in great detail how some of these huge events that made our world what it is today, how they happened. You know, how did fish evolve to walk on land? How did birds evolve to fly? How did these great leaps happen? Well, we can now take them apart with fossils and DNA. And so when we take it apart and look at evolution through this whole new lens, is it a whole new story? Is it contradicting things we had come to believe?

Yeah. So, you know, one of my favorite quotes, which I was actually pulled out when I was writing the book, was by Lillian Hellman. I was reading her autobiography, and she said, about her own life, she said, you know, nothing, of course, begins when you think it does. And in a nutshell, that is exactly what we're finding. Lungs did not come about when creatures evolved to walk on land. Feathers did not come about as creatures began to fly. Many of the features we associate with the great changes in the history of life came about well before. And we can see that written in the actual structures we see in the fossil record, but we also see that when we look at the DNA of living creatures. So it really changes the time scale in many ways. And in fact, when you look at the world that way, it makes some of these huge transitions in evolution much more likely, much more easy to happen. It's pretty remarkable. And so give me some examples of maybe things that we thought we knew and now what the reality is.

If lungs didn't show up when we think they did, well, how do you know and when did they and why did they? Yeah. So let's take that as an example, right? So we know that about 380 to 375 million years ago, that's a long time, fish took their first steps on land. Before that, most life was in water and the oceans and seas. And after that, first steps on land. Before that, most life was in water, in the oceans, on seas, and after that, life was on land. And you think about walking on land involves a whole lot of structures. You need limbs that can move about. You need a body that can support the creature. You need lungs that can breathe air. Well, as we look at this, we find that first, lungs were primitive. Lungs came about in the fossil this, we find that first, lungs were primitive.

Lungs came about in the fossil record, in the evolutionary record, eons before creatures took their first steps on land. The fish living in these ancient streams already had lungs. Indeed, when we look at the fossil record, we find that those fish already had fins with arm bones inside, with shoulders, elbows, even wrists inside their fin bones. And you can ask the question, as you did, you know, what's this doing in fish? It turns out that fish are originally evolved lungs to live in water that had variable oxygen content. And in fact, we see that in fish alive today. That is, they have both lungs and gills. They use the gills when the water has enough oxygen to support them. But then when the oxygen level falls low, which happens during the course of the year, it can be highly variable, they rely on their lungs. So fish evolved lungs as an accessory

sort of breathing organ in addition to gills, well before animals took their first steps on land. Same thing true with appendages. Same thing's true with arms and legs. We find fish with arms and legs in the fossil record before creatures took their first steps on land. What are they doing? They're living in the water. They're walking on the water bottom, likely. They're living in weed choke streams and using their little appendages to maneuver through it. So what we're seeing is the course of evolution doesn't necessarily always involve the origin of new structures or new genes. What you're doing is you're repurposing, reusing, modifying what exists in new ways. And that's the big step. And we see this at the level of DNA as much as we see at the level, you know,

when we look at fossils and anatomical structures and so forth. So the lungs in fish adapted to the oxygen in water, which helped them walk on land. But why did they get out of the water? What made them get up on the land in the first place? Yeah, so that's a question my colleagues and I have been working on for the last few decades. And we lead expeditions to the polar regions where there are rocks of the right age to answer these questions. It turns out when you look at what the world looked like 375 million years ago, in the water, you had all kinds of fish, big fish, little fish, but every single one of them was a carnivore. They were fish-eating fish. If you look at land at that time, there weren't any creatures with backbones, any of our relatives living on land. there were invertebrates, like spider-like things and invertebrate-like things, and there were all kinds of plants.

So compare water to land at this time period. Water is loaded with other fish that'll eat you and compete with you. Land has food sources, but no predators or competitors. So we think that there was sort of a push-pull, that any feature that would allow creatures to get away from the water would get them into a much more hospitable environment where they don't have competitors and predators. And so lungs already existed, appendages already existed, so one group of fish took those first steps. So does any of this explain or change the reason why we see evolutionary changes in people and creatures and things or is all of this consistent with what we've known before? It's quite consistent with sort of Darwinian natural selection and common descent. That is that there is a shared history

of life on earth. What it does is it changes how we, you know, how it's deployed over time. You know, so when you look at this, what you see is evolution takes much more unexpected twists and turns than we had ever expected. One thing we see is that similar biological inventions appear independently in many different species, often at the same time. You know, we see this, by the way, in human technologies as well. That's why patent lawyers can be, you know, well paid. But in evolution, we find it as well, that similar designs come about independently. We see that genes can be shared among creatures. Let me give you one stunning fact. Now that we know our genome, the human genome was published over 20 years ago. We've had since then many other

genome projects of thousands of species. When we look at our own genome, it turns out our genes, that part of the genome that encodes proteins that our cells make, that's only 2% of our genome. The other 98% is not that, it's something else. And when we look at that, we find all kinds of surprises. In fact, 8% of our genome are ancient viruses that attacked our genome and were later knocked out and they sit as like dead corpses of viruses of infections passed inside of our genome. It means we have about four times more viral genetic material inside our own genome than our own genes. Okay. And you can ask the question, how does that affect evolution? Um, scientists at the university of Utah were working on, they weren't studying viruses. They were studying memory

in mice and they found a gene that's active in making memories. And it turns out when they looked at this gene, its structure, and the proteins that it makes, what did they find? They found that this gene is actually a modified virus. And when they traced its evolutionary history using the DNA record, they found that what happened sometime in the distant past, way in the distant past, like millions, hundreds of millions of years ago, is there was a virus that infected the genome of our ancient ancestors and that virus was repurposed to function as a gene involved in memories. So we find these incredible twists and turns to how evolution happens, to the fuel of evolution in ways we could never have predicted.

Nobody would have predicted that, you know, decades ago. Fundamentally, though, does evolution happen because, let's use the fish example, did they need to develop these arms and things to get out of the water, or it's just that the fish that already had them are the ones that survived and the others didn't? There you go. It's the second one. They already had them. So the ones that already had them are the ones that survived and the others didn't. There you go. It's the second one. They already had them. So the ones that already had that stuff were poised for success, if you will. That is when the environment, so they already had those structures, they evolved them for one purpose, living in water. But then when the environment changed or when the time was right, all of a sudden those features became incredibly useful to, you know, get out of the water when they needed to get away from predators or away from competitors and so forth. So it's very much using what exists, not waiting for new

stuff to appear. So this whole idea that we evolve, because I think people have this perception that we develop things to meet our needs, and that's not the way it works. No, it's not the way it happens. I mean, the needs change too. So, you know, the needs at one time, you know, might favor certain features. But those features are really, you know, for that particular time useful. It's only when the environment changes, then those features can find a new utility. Oftentimes, that's what we're seeing. And so in that fish example, the fish that didn't have those developed arms and things that looked like they would be helpful, they just die off. No, they don't die off.

They just, you know, they just evolve in different ways. Well, some of them became bigger fish and better predators. Others of them developed armor. You know, so there are different ways, different strategies. Think of this as in these streams 380 or so million years ago, 375. Think of it as, you know, it's a fish-eat-fish world. Well, if you have that sort of environment, there are different ways you could be successful. You can get big, you know, because big fish eat little fish.

You can get armor because that's obviously protection from being eaten. Or you can get out of the way, you know. And so what we find are fish following these different strategies, our distant ancestors, you know, those fish that took the first steps to walk on land, they're the ones who got away, you know and so what we find are fish following these different strategies our distant ancestors you know those fish that took the first steps to walk on land they're the ones who got away you know but other fish took different strategies to deal with that environment so i understand how the evolution helps species survive but what i don't really get is how do they turn into other species how does a fish eventually become a human and not just a bigger fish? Yeah. So basically what we have is when you follow the course of change, what you'll see is when we're talking over, you know, hundreds of millions of years,

what we can do is I can trace. So let me give you an example. I, my colleagues and I working in the Canadian Arctic designed expeditions to find an early-limbed animal. We ended up finding a fish that was transitional. It was one of the first fish to have arm bones and so forth. But it was a fish with a humerus, an upper arm, a forearm, even parts of a wrist, inside of a fin. Likewise, this fish had a neck. This fish, as I mentioned before, had lungs and gills, things like that. So we can trace the upper arm bone, the humerus, from fish to amphibians, to reptiles, to birds, to mammals.

We can trace the ulna and radius, the forearm bones, from this fish all the way up to people through different species. We can trace the neck. We can trace the wrist. So we can deploy the fossil record to really see these connections and to see how similar features evolve to be used in different purposes from fish to amphibians to reptiles to mammals to birds. Even more, we can look at this at the genetic level. That is, we can ask the question, what are the genes that build in our development, build our hands and feet? Okay. Fish don't have hands and feet. They have fins, right? And so what are the genes that build our hands and feet? So we can look at those and we can, there have been a bunch of experiments

over the last, you know, 15, 20 years that show this, show a set of genes that are involved. Well, we can trace those genes all the way to fish. It turns out fish have those hand and wrist building genes too. And guess what they're doing? They're building the terminal end of their fin. So what we're seeing here is that what you have are similar genetic tools that build, you know, one end of a fin are also building a limb. So that genetic continuity exists as well. So what we see is incredible continuity, you know, among, you know, all life, honestly, but we can trace that all the way from fish to people. And we can do that at the level of fossils and arm bones and head bones and so forth. We can do it at the level of anatomy and we can do it at the level of DNA. And it's really all three of those records which point to the same thing so in school remember that chart where

that showed the the ape and then you know the next guy was a little more human and then the next guy and the next guy and then pretty much this up standing up straight human guy yeah i remember that i don't like that one it's kind of like doesn't really depict evolution as we think about it now you know it shows a much more linear path for evolution. And honestly, what we're seeing now is a path of evolution that has twists and turns and mergers and acquisitions and reversals and independent origins of different things. It's much more chaotic than that similar, that simple, you know, continual ladder of change. But there is a progression of change, because we're told anyway that we are descendants, or apes are our descendants,

that we evolved from that. We're descendants of apes. We're descended from apes. Right. So on that chart, there's these various depictions of man developing along the way, but in terms of fossil records,

it doesn't seem like there's a lot of those middle guys anywhere. There are a ton of middle guys. There are a ton of middle guys. I mean, the argument goes every time you find a middle guy, you create two gaps in the fossil record. We have early hominids that have small brains and are bipedal. Then we can trace the origin of larger brains. Given the fact that the fossil record is notoriously

incomplete, we have amazing connections among species. You know, my colleagues and I designed an expedition to find, you know, a creature transitional between fish and limbed animals and land living animals. And we did it using the tools of evolution and stratigraphy and so forth. It took us six years, but we found just that animal, you know, and people are doing that over and over again with feathered dinosaurs that look a lot like they're bordering on bird anatomy, with whales, with hind legs that show how they arose from other mammals when creatures returned to the seas. We have, you know, hominids, which show, you know, the acquisition of many of our traits. But even more than that, we have the DNA. We can compare our DNA now to the DNA, our entire genome. We can compare from a human of different kinds to chimpanzees.

And we can ask the question at the level of DNA, what are the genes that make us different from chimpanzees? What are the genes that make chimpanzees different from other mammals? And on and on and on. And people are doing that. We now can list out what those genes are and ask the question, what are they doing? How are they involved in brain development and things like that. And so you found this transitional creature that's somewhere in between fish and human. That's correct. And what did it look like?

It's pretty wild. I think it's one of the most beautiful fish around. It's a creature that's about four to eight feet long. So the smallest one's about four feet, the biggest one's about eight. If I was to hold it in front of you, you know, what you'd see, it was a fish with, you'd say, initially you'd say, probably looks like a fish, right? Because it has scales, you know, on its back and its belly. It has fins, and you can see the fin webbing, the fin rays in the fossil. It has fish-like texture in the bones of its skull. The shoulder looks in part fishy. But when you look again, what you'll find is this thing has a flat head like an early land-living animal, almost like a crocodile. It has paired nostrils. It has a neck. No fish has a neck.

When you look in the fin, it has an upper arm, a humerus, forearm, a radius and ulna, even parts of a wrist inside the fin. Some of the bones in its shoulder look like limbed animals, like there's a scapula, which is similar to our distant relatives. It really is a mix. I remember when we found it, we found it in 2004 and published the paper in 2006. And my son was in nursery school close to here. And the teacher asked me to bring a cast of the fossil in after, you know, after the paper appeared. So I brought the cast of the fossil in to my son's class. And I asked the kids, I said, hey, guys, what do you think it is?

And one kid raised his hand and said, oh, I think that's a fish because he has scales and there's a fin there. So fish have that. And another kid corrected him and said, no, no, no, it's like i'm like you're both right you know i was like you know so you sort of see both features in this thing land living and fish and so it is it a it's a transitional creature between fish and human but but it isn't like fish became human it's like didn't then the fish become something else that and then it became apes and then it became human i'm's like, didn't then the fish become something else that, and then it became apes and then it became human. I'm sorry. Yeah. That's so basically over time, that's what

happens. It's not the fish did it. It's descendants did look, you know, we are modified descendants of our parents. Our parents are modified descendants of their parents and on and on and on and on. And I can trace that genealogy with our DNA, right? If I had your DNA and the DNA of other people, I can actually trace your genealogy from the genomic signature that it leaves, right? Well, I can use those same techniques to take our relationships even deeper. I can show how we're related to chimpanzees, use those techniques, gorillas, deeper in the tree and so forth. So think about it as a giant family tree, right, of descendants. Each descendant is modified from its parental, you know, it's either its parents or parental species.

So think about it as descent with modification. I'm a modified descendant of my parents. My parents are a modified descendant of their parents. And just continue that on and on and on to millennia and you can see how you know how evolutionary history works and those modifications from my parents to me are modifications just because of the blend of the parents yeah and also you have unique mutations you acquired and I acquired mutations my DNA is not identical you know there are certain parts of it that when it gets copies, it makes mistakes.

And those mistakes are mutations. And so, yes, it's blended from both parents, male and female. But also we acquire mutations because every time DNA is duplicated, there's some mistakes made. And some of those mistakes are good. Some of those mistakes are not so good. Most are kind of neutral. But that's the case right there. So but, you know, then when we pass our genes on to our kids, the same thing happens, right?

So, you know, they are modified descendants of us and their killed children will be modified descendants on and on and on and on and on. And that's kind of how the tree of life works. And so what does all this mean? What's the big so what here? The big so what to me is kind of profound, actually. That is, in every tissue, in every gene, in every organ of our bodies, we contain artifacts of billions of years of the history of life. And you can ask the question, like, who really cares? Well, who really cares are, you know, if you look at the Nobel prizes in medicine and physiology awarded over

the last decades, who have they gone to? They've gone to people working on corn. They've gone to people working on mice, on flies. In fact, two Nobel prizes awarded to five people in the last, say, 12 years have gone to folks working on a tiny little worm, the size of a comma on a piece of paper. Yet that little worm shares our genetic structure, and it tells us how our genes are turned on and off in health and disease, and how our cells are programmed to die, and what goes wrong in diseases like our own cancers. So I like to think that as we discover cures to everything that ails us, our connection to the rest of life on our planet is something that has profound importance.

And the more we understand about our relationship to other species, and the more we understand about the workings of the genetics of evolution, the more we can sort of leverage that and put it to use for human health and also understanding our place in nature. Well, you know, that chart that was always on the wall in the science classroom of those guys that were standing up not so straight, and then six guys later it's standing up pretty straight. I always suspected that it wasn't that neat and organized, and it turns out, as you've been explaining, it's really chaotic. It's interesting to hear. Neil Shubin has been my guest.

He is a paleontologist, an evolutionary biologist, and professor at the University of Chicago. The name of his book is Some Assembly Required, Decoding 4 Billion Years of Life from Ancient Fossils to DNA. And there's a link to that book in the show notes. Thanks, Neil. Thanks for being here. Thanks, Mike. It's been a pleasure. If you drive much, I'm sure you've wondered about the science of traffic flow. It's really fascinating. It turns out that if we all worked together better, we'd all get where we're going a lot faster.

Phantom traffic jams, for example, they're a real thing that traffic will just slow down for no apparent reason. Why? Well, it turns out that when a car in dense traffic slows down even slightly, that causes the car behind that car to slow down even more. And then the car behind him slows down more, and that action spreads throughout the entire lane of traffic, and it gets worse and worse the farther back it goes. And pretty soon, cars have to stop. According to a study by physicist Craig Davis, selfish driving costs us about $100 billion a year in wasted time and fuel. Here's what would improve traffic flow dramatically and reduce traffic jams. Look past the car in front of you to anticipate what's coming up ahead.

Excessive braking is a big cause of traffic jams. Act altruistically. When people are trying to merge from the on-ramp, slow down and let them in. Don't procrastinate. If highway construction is shut down in lanes up ahead, merge early before the lane closes. All those things will help traffic flow a little better and get you going to where you're going a little faster.

And that is something you should know. I know you know people who would like this podcast and they would appreciate it if you would share it with them. I just know that to be true. So share it. I'm Mike Carruthers. Thanks for listening today to Something You Should Know. Welcome to the small town of Chinook,

where faith runs deep and secrets run deeper. In this new thriller, religion and crime collide when a gruesome murder rocks the isolated Montana community. Everyone is quick to point their fingers at a drug-addicted teenager, but local deputy Ruth Vogel isn't convinced. She suspects connections to a powerful religious group. Enter federal agent V.B. Loro, who has been investigating a local church for possible criminal activity.

The pair form an unlikely partnership to catch the killer, unearthing secrets that leave Ruth torn between her duty to the law, her religious convictions, and her very own family. Hi, this is Rob Benedict. And I am Richard Spate. We were both on a little show you might know called Supernatural. It had a pretty good run, 15 seasons, 327 episodes. And though we have seen, of course, every episode many times, we figured, hey, now that we're wrapped, let's watch it all again.

And we can't do that alone. So we're inviting the cast and crew that made the show along for the ride. We've got writers, producers, composers, directors, and we'll of course have some actors on as well, including some certain guys that played some certain pretty iconic brothers. It was kind of a little bit of a left field choice in the best way possible. The note from Kripke was, he's great, we love him, but we're looking for like a really intelligent Duchovny type.

With 15 seasons to explore, it's going to be the road trip of several lifetimes. So please join us and subscribe to Supernatural then and now.