The Tim Ferriss Show - #153: The Man Who Studied 1,000 Deaths to Learn How to Live

Episode Date: April 13, 2016

At the end of our lives, what do we most wish for? And how can knowing this help you live better lives now? BJ Miller, MD (@zenhospice) knows. BJ is a palliative care physician at Zen Hospice Project in San Francisco, where he thinks deeply about how to create a dignified, graceful end of life for his patients. He is an expert in death, but he’s also learned how we can dramatically improve our own lives, often with very small changes. When you consider that he has guided or been involved with ~1,000 deaths, it’s not surprising that he’s spotted patterns we can all learn from. BJ is also a triple amputee, and his 2015 TED Talk, "Not Whether But How," is a moving reflection on his vision to make empathic end-of-life care available to all, ranked among the top-15 most viewed TED talks of the year. If you want to know what being around death can teach you about living, you'll want to listen to this. I LOVED this conversation, and I hope you do as well. Enjoy. Show notes and links for this episode can be found at www.fourhourworkweek.com/podcast. This podcast is brought to you by Wealthfront. Wealthfront is a massively disruptive (in a good way) set-it-and-forget-it investing service, led by technologists from places like Apple. It has exploded in popularity in the last two years and now has more than $2.5B under management. Why? Because you can get services previously limited to the ultra-wealthy and only pay pennies on the dollar for them, and it’s all through smarter software instead of retail locations and bloated sales teams. Check out wealthfront.com/tim, take their risk assessment quiz, which only takes 2-5 minutes, and they’ll show you—for free–exactly the portfolio they’d put you in. If you want to just take their advice and do it yourself, you can. Well worth a few minutes to explore: wealthfront.com/tim. This podcast is also brought to you by Boll & Branch. There is a lot of nonsense in the bedding business. For instance, did you know thread-count is not a good measurement of quality? It’s a total myth. The “Made in Italy” label? It isn’t something you should necessarily pay extra for because it generally means it’s just finished in Italy and woven in places like China. The general industry mark-up for bedding is 700 to 800 percent at most retailers. Boll & Branch creates incredibly high-quality bedding. They are the same sheets you’ll find at my home in San Francisco. The best part? You can try anything you order at home for 30 days. If you don’t love it, send it back and get a full refund. Go to Boll & Branch and use promo code “TIM” for 20% off your entire order. Whether sheets, towels, blankets, duvet covers, or anything else. Shipping is always free.***If you enjoy the podcast, would you please consider leaving a short review on Apple Podcasts/iTunes? It takes less than 60 seconds, and it really makes a difference in helping to convince hard-to-get guests. I also love reading the reviews!For show notes and past guests, please visit tim.blog/podcast.Sign up for Tim’s email newsletter (“5-Bullet Friday”) at tim.blog/friday.For transcripts of episodes, go to tim.blog/transcripts.Interested in sponsoring the podcast? Visit tim.blog/sponsor and fill out the form.Discover Tim’s books: tim.blog/books.Follow Tim:Twitter: twitter.com/tferriss Instagram: instagram.com/timferrissFacebook: facebook.com/timferriss YouTube: youtube.com/timferrissPast guests on The Tim Ferriss Show include Jerry Seinfeld, Hugh Jackman, Dr. Jane Goodall, LeBron James, Kevin Hart, Doris Kearns Goodwin, Jamie Foxx, Matthew McConaughey, Esther Perel, Elizabeth Gilbert, Terry Crews, Sia, Yuval Noah Harari, Malcolm Gladwell, Madeleine Albright, Cheryl Strayed, Jim Collins, Mary Karr, Maria Popova, Sam Harris, Michael Phelps, Bob Iger, Edward Norton, Arnold Schwarzenegger, Neil Strauss, Ken Burns, Maria Sharapova, Marc Andreessen, Neil Gaiman, Neil de Grasse Tyson, Jocko Willink, Daniel Ek, Kelly Slater, Dr. Peter Attia, Seth Godin, Howard Marks, Dr. Brené Brown, Eric Schmidt, Michael Lewis, Joe Gebbia, Michael Pollan, Dr. Jordan Peterson, Vince Vaughn, Brian Koppelman, Ramit Sethi, Dax Shepard, Tony Robbins, Jim Dethmer, Dan Harris, Ray Dalio, Naval Ravikant, Vitalik Buterin, Elizabeth Lesser, Amanda Palmer, Katie Haun, Sir Richard Branson, Chuck Palahniuk, Arianna Huffington, Reid Hoffman, Bill Burr, Whitney Cummings, Rick Rubin, Dr. Vivek Murthy, Darren Aronofsky, and many more.See Privacy Policy at https://art19.com/privacy and California Privacy Notice at https://art19.com/privacy#do-not-sell-my-info.

optimal minimal at this altitude i can run flat out for a half mile before my hands start shaking can i ask you a personal question now what is the appropriate time i'm a cybernetic organism living tissue over metal endoskeleton this episode is brought to you by ag1, the daily foundational nutritional supplement that supports whole body health. I do get asked a lot what I would take if I could only take one supplement, and the true answer is invariably AG1. It simply covers a ton of bases. I usually drink it in the mornings and frequently take their travel packs with me on the road. So what is AG1? AG1 is a science-driven formulation of vitamins,

probiotics, and whole food sourced nutrients. In a single scoop, AG1 gives you support for the brain, gut, and immune system. So take ownership of your health and try AG1 today. You will get a free one-year supply of vitamin D and five free AG1 travel packs with your first subscription purchase. So learn more, check it

out. Go to drinkag1.com slash Tim. That's drinkag1, the number one, drinkag1.com slash Tim. Last time, drinkag1.com slash Tim. Check it out. This episode is brought to you by Five Bullet Friday, my very own email newsletter. It's become one of the most popular email newsletters in the world with millions of subscribers. And it's super, super simple. It does not clog up your inbox. Every Friday, I send out five bullet points, super short, of the coolest things I've found that week, which sometimes includes apps, books, documentaries, supplements, gadgets, new self-experiments, hacks, tricks, and all sorts of weird stuff that I dig up from around the world. You guys, podcast listeners and book readers, have asked me for something short and action-packed for a very long time. Because

after all, the podcast, the books, they can be quite long. And that's why I created Five Bullet Friday. It's become one of my favorite things I do every week. It's free. It's always going to be free. And you can learn more at Tim.blog forward slash Friday. That's Tim.blog forward slash Friday. I get asked a lot how I meet guests for the podcast, some of the most amazing people I've ever interacted with. And little known fact, I've met probably 25% of them because they first subscribed to Five Bullet Friday.

So you'll be in good company. It's a lot of fun. Five Bullet Friday is only available if you subscribe via email. I do not publish the content on the blog or anywhere else. Also, if I'm doing small in-person meetups, offering early access to startups, beta testing, special deals, or anything else that's very limited, I share it first with Five Bullet Friday subscribers. So check it out, tim.blog forward slash Friday. If you listen to this podcast, it's very likely that you'd dig it a lot and you can, of course, easily subscribe any time. So easy peasy. Again, that's tim.blog forward slash Friday. And thanks for checking it out. If the spirit moves you. Hello, ladies and germs. This is Tim Ferriss and welcome to another episode of the Tim Ferriss

show. This one was such a treat for me and I really hope it is for you as well. This is an interview that I had hoped to set up and tried to set up for close to, I'd say five years. And here's the question I'll pose. the end of our lives. What do we most wish for? And how can knowing this, if we can know it help you to live a better life now? Well, it turns out BJ Miller, MD, Dr. Miller knows exactly this. BJ is a palliative care physician at Zen hospice project in San Francisco, where he thinks deeply about how to create a dignified, graceful end of life for his patients. Now, this is, of course, not one of the usual suspects you would expect to see making the rounds on the podcast. And this is precisely why I wanted him on and why I hope you listen to this podcast. BJ is an expert in death, but important. He's also learned how we

can dramatically improve our own lives, often with very small changes. When you consider that he has guided or been involved with roughly a thousand deaths, it's not surprising that he has spotted patterns we can all learn from. On top of this, BJ has developed incredible empathic abilities. He is a triple amputee and his 2015 Ted talk, not whether, but how, which is a moving reflection on his vision to make empathic end of life care available to all ranked among the top 15 most viewed Ted talks of the year. I absolutely love this conversation. And without further ado, please enjoy the wide ranging dialogue, conversation, rambling exploration between myself and BJ Miller, MD. BJ, welcome to the show. Thank you, Tim. It's nice to be here. I have been wanting to talk to you, or I should say I have wanted to talk to you for years now. And to give a few examples and illustrate that, the first was an article that I came across in the Princeton Alumni Magazine, Princeton Alumni Weekly, about your work. And then the next was a profile in a magazine here in San Francisco.

Following on the tales of that, Adam Ghazali, who is just an incredible neuroscientist at UCSF, who's been on the podcast, reached out to me. And that was related to, I I think it was a senior partner at IDEO who had also reached out to him to suggest that you be on the podcast. So I feel like this was fated to be. And I've been increasingly over the last few years thinking about death and the the value of meditating on death among other things but before we get there and i suppose we'll get there rather quickly when people ask you what do you do how do you how do you answer that well i guess i guess i, you know, generically I'll say, oh, I'm a physician.

And if people seem like they actually really want to talk things out, I'll say, well, I'm a palliative care doc. And then people won't talk out from there. I'll say I work at a remarkable place called the Zen Hospice Project and do some work at UCSF and do increasing amounts of speaking and beating the drum, I like to say. So depending on how interested the person asking the question is, that's what they might hear from me. Let's say they're very interested. I don't know if you drank, but let's say the other person's had two drinks, so pleasantly drunkenly curious.

And they say, what drum are you beating? I'm really interested to hear more. What, what is the, what is the drum? Well, the drum I suppose is really is getting a society to pay attention to the inevitables in life.

Uh, getting, helping, helping each other look at hard stuff, helping each other live with hard truths. I'm trying to get people to pay attention to the fact that we all die and that the way we die could be a lot better than it is in general. So let's dig into that because I really enjoyed, for instance, your TED Talk,

and maybe you've given multiple, but at least the one that I saw. Just one. Yeah. Which is, and one is enough, by the way. No kidding. But let's look at a sample experience. So you have a new patient come into your facility. What does the first meeting look like? And what does that first day look like for them? Well, so let me pre-answer your question because it so depends. So for example, at Zen Hospice Project, by virtue of coming to our place by virtue of enrolling in hospice many corners will have been

turned just to get to that place so when we're meeting folks for the folks for the first time in zan hospice they they for the most part are aware that time is short are aware that they're dying soon are aware that there's really not much more to beat back their disease to be done. So, and there's plenty of work to be done even on the far side of turning that corner. But I think another, you know, a more, I don't know, an interesting, another way of answering your question is really, you know, upstream of hospice. When folks are struggling, gone to war with their disease, engaged in that fight, whether it's chemotherapy or whatever. Now that's the kind of person I'll meet in clinic at UCSF. So I, a part of my job is on faculty at UCSF and I work in a clinic that's the kind of person I'll meet in clinic at UCSF. So a part of my job is on faculty at UCSF, and I work in a clinic that's called the Symptom Management Service.

It's about 10 years old, and that's just basically a euphemism for palliative care. The Cancer Center wanted us to call it the Symptom Management Service because it felt that the palliative care phrase had too much baggage around it. And is palliative care, I'm just going to plead ignorance here, is that synonymous with hospice care or are those different things? They are related but different. And thank you for asking that question, Tim. I mean, this is part of the drumbeat. So hospice is that portion of palliative care that's at the end of the road. And hospice is an insurance designation as much as it is a philosophy of care. So, hospice is by definition end-of-life care.

Palliative care makes no, it doesn't, time is not an issue in palliative care. You just have to be suffering. So, you know, you can see folks in palliative care for many, many years, far in advance of their death. So, yeah, all hospice is palliative care, but not all palliative care is hospice. Got it. All right. So palliative care, just to kind of make it, is basically within the context of dealing with illness, palliative care is the pursuit of quality of life, period. That's it. So the fulcrum in palliative care is suffering.

Are you suffering in some intractable way, struggling more than you need to? And if so, then come see us in palliative care. We'll help. And in palliative care, you can receive our support and continue on with your more aggressive, invasive, life sustaining interventions as well. You don't have to give up one type of care to add palliative care to the mix. Whereas once you're entering hospice because of its insurance details and vagaries, you do have to, in general, you have to give up curative intended care to qualify for hospice. So we, and we could spend a lot of time on this or a lot of wonky details, but does that sort of make sense to you? It totally makes sense. Okay. I mean, the first thing that leapt to mind for me, and that will lead to a lot of tangents, I apologize in advance, but was that the way that you define palliative care would seem to include almost everyone on the planet in some respect suffering more than they need to. And we'll, we'll dig into, uh, the, the learnings and

philosophies and so on that, that you've cultivated. But so let's say they have gone through the paperwork and the process to get to the Zen hospice project. What does their first day look like? So first day at Zen hospice is usually there's always the folks by almost by definition are pretty fragile state. So just the ride getting to the house and into the house is often plenty overwhelming. So very often the resident will just sleep much of the first day. But as soon as they're beyond the logistics of the trip over, the first day is generally our nurses, our volunteers, the kitchen crew sort of swarming around that resident and their family and just getting to know them. That's where all the potency

comes. It's inherently a relationship. So there's some details around medications, et cetera, but most of the early work is just getting to know people and making them feel that this is their home now. They've come to live here. Yeah, they're going to be dying soon, but they're here to live until they die. So it's a very non-medical establishment, and the first day doesn't feel anything like being admitted to a hospital. You know, and pretty soon as you get to know someone within the first day, invariably questions get asked like, you know, tell us what's most important to you now.

You know, you want something to eat. We can whip you up something in the kitchen or we'll tend to the family. It's very casual. It's meant to feel like you're entering a warm embrace of a familiar setting. And what does the, just to highlight also the differences, can you describe upon the patient's death, what happens in Zen Hospice Project versus in a conventional hospital setting? And you can present either first. Yeah, well, so much of, you know, in hospice and palliative care in general,

but certainly places like Zen Hospice Project, in many ways they were created as antidotes to the hospital. So in some ways they're, they're really, you'll feel like opposites and that that's to some degree by design. But a death in a place like Zen hospice project is usually very peaceful because we've gotten to know that person. We've been living with that person.

We know what they want, what their idiosyncrasies are. And we work with local teams of hospice agencies who come in and provide the medical care. So for the most part, people can enjoy and expect a much more comfortable and peaceful death at Zen Hospice Project and places like it. That's what all of the expertise is geared towards. You're not distracted by beeping machines and other things and other agendas happening, research agendas, whatever it is. And to your question, Tim, you know, so when the person dies, invariably the mortuary needs to come and retrieve the body so and we have this

ritual that we offer people which is on their way out the building you know the mortuary guys have picked up the body and if there are family or friends around and certainly staff and nurses and volunteers will gather around and we'll all gather on the porch and we will do this, our flower ceremony, which is basically we gather around and the mortuary guys pause for a moment and we maybe say a few words or sing a song or whatever it is, just reflect on our time and remember the person who is just leaving us. And then we'll sprinkle the body with flower petals. It's just this very simple, gorgeous moment. And then the body bag is zipped up as it has to be by law and the body heads out the door.

But it's this very stunning, poignant, gorgeous, simple moment. And you can feel everyone entering into this sort of grieving phase more fully, especially, of course, the family. And you can watch folks have this little bit of closure, perhaps. But more of the point is you watch them swarmed with warmth and love and easing into the grief process because there's space for it and there's this sweet segue and you can just feel that something's been completed there and then the family now have to live on but can do so with some imagery that's sweet and beautiful to remember rather than traumatic. So, you know, counter that with a typical hospital death. And by the way, Tim, and we can talk about all sorts of things

together. I hope we do, but you know, no knock on hospitals. They're incredible places. They're just not really designed to have a beautiful experience per se and they're not really designed to help you die well um so and you feel that mismatch so i've worked on a lot of work in hospitals as a patient but also as a physician and you know a typical hospital death is is in a more sterile room usually lined with a bunch of machinery um and all the sounds and lights emitted. And it's very cold. I mean, the second the person dies, you can feel the cleaning crew waiting to descend on the room and they need to get the body out of the room because someone invariably is waiting for the room. And there's no ushering in of grief. There's a sort of a snuffing of it. And it's very disorienting for everybody

involved, including the clinicians, because there's no pause moment to reflect on the experience you've just had with this person. It's just kind of on to the next. And it's a stark, stark contrast. How many, since you began your work with palliative care and hospice care, how many deaths have you witnessed or experienced even in the periphery? Not necessarily watching someone die, but under your care or in your periphery, how many deaths have you experienced? My guess now, I mean, I finished my final bits of training, and then there's all the deaths during residency and fellowship, of course, but I've been out of my final training now for 10 years. If it's not 1,000 people, it's approaching 1,000.

I don't know that for sure, but it's certainly many, many hundreds. This is a huge question, so we can certainly find, slice it, and feel free to tackle it any way you like. But what has observing that many deaths and the march towards death taught you about living and specifically your own life? Well, that's the perfect question, man. I mean, you know, there's like a, those of us who work in the field of hospice and palliative care, you know, we can feel like you're sitting on a secret. And, and because I think the assumption is that, oh, wow, that's got to be very morbid. You know, it is. I mean, it's got to be very morbid work or very depressing work. And sure, it is loaded.

I mean, it is emotionally laden work without a doubt. I don't mean to make it sound easy. in the field, you pretty quickly get a real sweet hit that, you know, paying attention to this zone of life is very, it's very nurturing. The sort of secret is that paying attention to the fact that you die can help you live a lot better. So a lot of my colleagues and I are very, you know, are aware of the clock, you know, and I'm sure that can make you anxious as well. But we, you know, we know we're aware of our finitude. And so we're just a little more likely to be kind to ourselves and others. And we're a little less likely to squander that time because we have all these remarkable vicarious deathbed moments with our patients and their families.

You can learn a lot. One of the things I love thinking about, a real organizing theme for me is avoiding regret essentially. We avoid regret by, again, paying attention to our decisions, paying attention to how precious things are, and getting very good at forgiveness and reconciliation. And these are themes that play out in this work all the time. So in a sense, we're exercising these muscles on behalf of others

that all of us need to exercise on behalf of ourselves at some point. We just get pretty well practiced at it. So yeah, so this is where the work gets extremely beautiful and really nurturing and can help you live better. And I guess that's part of the drumbeat. Why do we want to talk about this? Well, there's some systems issues, there's some economic issues, but there's these beautiful civil issues on behalf of kindness, on behalf of justice and equality, the fact that we all die. Well, paying attention to this has all this potential for this to be a bond among human beings. The fact that we die and the fact that we're cognizant that we die, That's part of this drumbeat. And in the case of paying attention to decisions, what would be examples of some specific decisions you've made or habits you've developed that have been impacted by this work? So to one thing, you know, caveat is I'm, I, like anybody else, I'm flawed and I'm a work in progress and I forget all the lessons that I've learned a million. I have to learn them over and

over again. So, you know, I got all sorts of work to do it myself, but I think as we all do. Yeah. Yeah. Amen brother. So, but, but I do think I've gotten a lot better at – I'm pretty good as a hyper-educated person at rationalizing all sorts of things and behaviors. And I can convince myself to stay in relationships or in situations that don't necessarily feed me or that aren't working very well. And I think I've gotten a lot better at calling that for everybody's sake. So I might be – I think I'm a little bit better these days at not squandering my time. And in terms of friendships and relationships, navigating them, not taking them seriously so that we're just not wasting each other's time. So I feel that in my relationships.

I feel these lessons in my relationship to nature. So that's a great salve for me is being out on Mount Tam out here in Marin County or just about anywhere and feeling, letting myself really delight and bask in the crazy grandeur of being alive at all. And I get thrilled that I can feel anything, sometimes even pain. The way I deal with my own pain is I remind myself that I'm glad to be to feel anything at all so my relationships uh I think are impacted my sort of orientation to mother nature's impacted I think I'm a lot lot I've got a lot lot better at forgiveness so not holding grudges you know how we walk around with anger at others and ourselves and it's just unnecessary.

It doesn't help anybody. So I've gotten a lot better, I think, at letting go of certain things. So to drill into that, I apologize for interrupting. Yeah, yeah, no. Because this is a particular Achilles heel of mine and I've improved. I think I'm trending in the right direction over the last few years, but I have always had a lot of difficulty letting go of grudges and those loops that we tend to repeat, or at least I tend to repeat and reinforce like a groove in a record that can just create this bitterness might be a strong word, but it's not totally

out of place when, when you find yourself, when you catch yourself angry with someone or not letting go, what is, what is the internal dialogue? What do you say to yourself? How do you ameliorate that? Well, this is where, uh, you know, meditation, mindfulness, self-awareness, whatever you want to call it can be so helpful because one, one, one thing to, is to self-awareness, whatever you want to call it, can be so helpful. Because one thing is to just get better at realizing you're doing it in the first place. Definitely. Even before you're able to change it at all, there's great potency in just being aware that you're doing it. I used to be much more – I could walk around for months with grudges and chips and bitternesses, et cetera, before I really even realized it.

I would just be really moody or whatever else. So job one, I guess, is just paying attention to yourself and seeing it for what it is. And then the next step is actually – that's the hard part as you watch yourself spinning out then you can kind of call it the silly useless thing that it is and you kind of take the wind out of its sails you know you dis disempower the anger and and for me you know in my life man i the the absurdity, being in touch with absurdity has been very, very helpful. Yeah. So that's my next step. So the awareness and then is sort of watching the silliness of it all.

And then that anger and maybe with some deep breaths or whatever else or a walk to sort of bleed off the physical anxieties of it. But then I can sort of unspool, unwind, and maybe even quickly kind of laugh at myself. And that's great because A, you've let go of the junk. And B, it's an exercise in humility and forgiveness, which is always pretty dang useful. And for those people listening, you might have the same issues. And a lot of us do, of course, uh,

there's a book with, with a very bland title called radical acceptance by Tara Brock that I found very, very particularly helpful to me in this, in this instance, you mentioned mindfulness meditation. Do you have a regular meditation or mindfulness practice? Not really. Well, I guess your whole job in a way

is a mindfulness practice. So that perhaps might be overkill to just add another session on top of everything else you're doing. Thank you for that way out, brother. You're welcome. There is some truth in it, actually. This is another reason why this work is so potent and fun, is your personal and professional lives are deeply entwined, almost necessarily, because so much of this work is just being aware, is listening, is paying attention and bearing witness and coming to terms with all the stuff you can't control, whether it's for my own sake or my patient's sake. So there is some real truth that I kind of feel like doing this job well. And so empathy is job one in this world, in this work. And so I do feel that much of my daily life, the daily grind for me is itself sort of meditative. But I also want to be clear.

I have my own relationship. For me, it's a bike ride or it's time with my dog or it's time sitting in my backyard just looking out at the hills. It feels to me like a meditation. I like movement. It's something ever since I became disabled, I think I'm particularly primed to appreciate movement. I like a walking or a bike ride. It feels like meditation. I feel like I'm doing it a lot in a way but I also want to honor those folks in the audience and elsewhere who truly have a meditation practice and that is really its own discipline uh so I I don't really have that but I got those other things and I think they're all present state mindfulness practices, right?

Yeah. And if you're riding a bike – now, you mentioned something we haven't covered, and I didn't cover it very deliberately, but it makes sense, I think, at this point to rewind the clock. Could you tell us about the dinky? Yeah. I'm sorry. I love the – I just love – speaking of absurdity, the dinky, this, what a, I mean, I lost three limbs to a thing called the dinky. Sorry, I'm laughing, but. It is kind of silly. But anyway, so as you know, fellow tiger, there's this commuter train that runs on the campus of Princeton University. Although I guess it doesn't run on campus anymore.

And it's a commuter train. It's called the Dinky with affection to some. And the Dinky runs from Princeton to Princeton Junction. And commuters can take the trains into Philly or New York or whatever else. So that's what the dinky is. So why it's significant in my life in particular is one night, it was November. It was just after Thanksgiving vacation, sophomore year. So it was November 27th, 1990.

A couple of friends of mine and I were out just hanging out, having fun. Not a crazy night, but we were walking. Will you remember the Wawa Market, Tim? I do. I was at Forbes. So I walked by the Dinky and the Wawa every single day multiple times. Right. So a late night visit to the Wawa market was pretty common. And so we were heading over to get a sandwich or whatever. And we were just walking by the dinky.

And it was just parked there. It was not operating hours. And it has a ladder on the back. And we just walked by it and just decided to climb it you know like you would climb a tree or whatever it didn't we really did not think we were doing anything that daring or put it this way we've done a lot more like a lot stupider things besides that at least we thought so um but i just happened to be the first one up on the up on top of the train.

And those trains run like the buses in San Francisco, wires that run overhead. And then there's this metal thing called the pantograph, I think, is what it's called. And that connects the train itself to the power source. And it's this big metal pole. And so when I stood up on top of the train, I had a metal watch on. And I happened to be close enough to the power source and the electricity arced to the watch. And, yeah, entered my arm and then blew down the feet.

That was that. So what happened at that point? So, well, I should say I don't really, I actually don't remember anything about that night. But my friends were with me, pieced it back together. But there was a big explosion and I was thrown some distance. And one friend came up on top of the train while the other friend ran and called 911. And you can imagine, I mean, both of my friends were freaking out and extremely right into action mode. And, you know, getting up on top of the train that had just in ways they couldn't have possibly understood and just electrified their friend.

And yet they got up on top of the train to help me. I mean, just ever a daily shout out to my friends, Jonathan and Pete and Tommy too, for all they did for me that night. And oh God, and so many nights. But yeah, so Pete held me down because I guess at some point I came to and I was just thrashing about. And you have – electricity enters your body and so you've got all this heat you burn from the inside out. And apparently it's very common that people wake with extreme energy.

I mean you are electrified. So I mean I'm just flailing, punching him through. I'm just a wild tear, apparently. So Pete, who was a very particularly large, strong, and sturdy, heroic friend of mine, held me down. So I didn't roll off the top of the train and make things worse. And then the ambulance came. And I don't blame them one bit, but the ambulance drivers refused to get on top of the train, as they should have. But between my friends and a Princeton police officer by the name of Officer Dawson, I believe his name was, who went on to become – who was promoted, I think, after that to Sergeant Dawson.

But anyway, Sergeant Dawson got up on the train with Pete and together with Jonathan, they got me into the stretcher and handed me down to the ambulance guys. And the ambulance whisked me off to the local hospital. And the local hospital did these things where they basically just slice open the skin to allow the heat out. It's called the fasciotomy so that you stop burning yourself essentially and uh and then i was uh flown to the uh burn unit at saint barnabas hospital in livingston new jersey which is new jersey's one and only burn unit at least it was at the time and that was that and uh flash Flash forward to when you became fully cognizant of what had happened. What, you open your eyes, what does the scene look like?

Well, you know, so it's interesting. It's like, it's, it's, I was conscious. I was awake throughout the ordeal. And it's just more the sleepiness of memory. So there really was not it was not like coming out of a coma where I was asleep and then awake. So there was not a sort of a singular moment. Right. memory, which I actually, some freakish reason I love this story. I don't know why, but I'll tell it to you anyway. I do like the story, so I will tell it to you anyway. So your blood pressure is unstable. You're just a hot mess. So surgery can't happen until you're more stable if it can be avoided. And so it's common to wait several days before the surgical amputation of the dead tissue. And also in part because it's not totally clear what tissue is viable and what tissue is not.

So anyway, it was maybe day five or day six before the first amputations, and I woke up the night before. I remember this very, very well. You know that feeling where you wake up from a dream, and it's been a bad dream, and there's a moment of sort of panic, and then you sort of orient yourself. You look around, you orient yourself, and you realize thank god you know that was that was just a dream you know that sensation and it's an incredible somatic you know it's a beautiful feeling of relief that washes over you so anyway i somehow i looked around a burn unit which is a particular environment it's not like our guest house that i was just describing a moment ago at Zen Hospice. It's a very technical, sterile, intense environment. And somehow in my stupor, I looked around and saw all these machines and still managed to think, oh, thank God,

that was just a dream. And so I had the sensation I had to use the bathroom and so i got i said oh i don't want to get out of bed and go to the bathroom and uh so in this state i x i was intubated on a ventilator i i extubated myself jesus not not easy to do by any stretch so i I extubate myself. I pull out, I have all these lines running into my jugular veins in my neck. I pull those out. I just decouple myself from all these machines and get out of bed on my crispy little feet and start heading for the door to go to the bathroom. You know, I just obviously out of it. But in my mind, very clear, everything's fine. And then the, you know what a Foley catheter is, Tim? I don't know what a Foley catheter is, but a catheter I would understand as something that's probably in your urethra.

There you go, pal. You got it. So, yeah, that's right. And the way it stays in there is there's a little balloon on the tip of it so the tip is fed through your urethra into your bladder uh and the catheter just is there to spontaneously drain your bladder but the way that thing stays in there is they there's a little balloon that gets inflated once it's in your bladder so that it doesn't slip out of your bladder so there's this you know small ping pong ball at the end of it that's now inflated. So I'm walking to the door, and they usually clip the catheter in the bag onto the side of it.

So you know where this is going. So anyways, I'm walking to the door, and the thing runs out of slack. And it yanks the dang catheter, of course, and it comes not all the way out, but like partially out. Sorry to you and all your listeners. Oh, this is like a – wait. Are we talking like a small python that ate a golf ball kind of situation? No offense. I mean large python that ate a golf ball.

No, no. Small python. Yeah, so no, that's right, man. So I mean this is hot. Oh, man. So, I mean, this is hot. And the total reverse, that total warm bath of relief that you experienced thinking it was a dream. So that just goes totally in reverse. And in a millisecond, I realized that all of this was not a dream. I fall down to the floor because all of a sudden I really can't walk either.

I just fall to the floor and I'm screaming and I'm pulling on the – I'm trying to break the rubber tubing of the catheter which is no way i could um and to somehow relieve the pain and anyway finally a nurse comes running in uh and gets me back in bed and that was that but so anyway that's my first real memory oh my god I can see why it's vivid. Oh yeah. I'm sort of bent over as I'm talking to you. Oh god. So let's contrast that with one that I've heard you tell but I don't recall the details.

And this is Snowball. Am I getting this right? Uh-huh. Could you tell the Snow snowball story? So, yeah. So, you know, so a burn unit, uh, is like I said earlier, a particular place, uh, they're gruesome places. Uh, they're very difficult environments. The pain that the patients are going through is gut wrenching. And so working in a burn unit is, is, is very difficult. Uh, people often don't last in a burn unit very long as a clinician.

It's incredibly difficult work. And we learn from wars over time, is my understanding of certain medical history, that the way burns often kill people is indirectly through infection. So once you've disrupted the integrity of your skin, you're much more vulnerable to infection, right? And so the thing that often kills burn victims after they've survived the initial trauma is infection. So burn units are incredibly sterile environments. So everyone's gowned up, masked, gloved.

For the first maybe several weeks, I could only have one person in my room at a time. You know, it's just like you're in a bubble, in other words. And therefore, you're cut off from everything. There's no day, night runs together. There was no window in my room. There's no, you know, you're in a little cell. And even when people are at your bedside there there's all this garb in between you and them so there's no you have no relationship to the natural world you can touch nothing and also you're in a fair amount of pain of course which does not necessarily reward your paying attention to anything so it's, it's not fun.

But so this was November at some point in December, maybe it was early January. And honestly, I can't remember who brought me the dang snowball. I can't remember. There were two nurses in particular that I was felt very close to. And it may have been one of them. And I think it was, it may have been, her name was Joy Varkardapone. And it may have been one of them uh i think it was it may have been her name was joy varcardapone and it may have been joy but anyway it was snowing outside and i didn't know that i didn't know it was night or day and uh and she had the uh bright idea of just smuggling in a snowball to me so i could hold so i could feel snow and man it was so was so, I mean, it was just stunning. You know, what a simple little thing, right? But to put it in my hand and just feeling the contrast of that cold snow on my sort of crisp, like, you know, the burnt skin, the obnoxious inflamed skin, and and also watching it melt and watching the snow become water and just the

simple miracle of it uh was just a stunner for me and and it really made it so palpable that we as human beings as long as we're in this body we are feeling machines and if we're cut off we can't if we can't take if our senses are choked off, we are choked off. And it was the most therapeutic moment I can imagine. And I would never have guessed this, but just holding that snowball, first of all, the sensation, but also the implied inherent perspective that it helped me make, right? That everything changes. Snow becomes water. It's beautiful because it changes. Things are fleeting. And it just felt so beautiful to be part of this weird world in that moment. I just felt part of the world again rather than removed from it. And it was potent.

BJ, what did you study undergrad or what were you planning on studying or studying at the time? I always forget when people make decisions in undergrad, even though I went through it myself. Yeah. Well, like you, I mean, I started out,

you know, 10, I started, I was at Princeton 89 and 93 and I started out, I went there really high on the idea of learning things that, that were foreign to me, you know, totally seeing a different worldview and really delighting in the liberal arts education.

And so with that, Tiananmen Square had just happened before freshman year, and I was, so China was on my mind. And so I was, I started studying Chinese language and was heading for a major in East Asian studies. But when I was out with this injury, art, which I'd always been interested in, especially music, I became much more interested in art, not just listening to it or looking at it, but the idea of art. So I, I switched my major, uh, to art history and that's what I ended up studying. What do you mean by the idea of art? So why the hell do people, what is this art stuff, right? I mean, why do humans,

we seem to be unique as a species that we reflect on our lives, we reflect on our mortality, we reflect on our experiences, and we, one way or another we reproduce them we use them as creative grist so either in our sort of daily lives or those of us who make art um you know we use it to make art we we it's it's this and you know what's the purpose of making art art is inherently kind of useless and that seems to be part of its charm um so so i that seemed to me the fact that we as a species make art and care about it seemed to me really important because i was trying to figure out well who am i now like what what am i my less human because i have less fewer body parts?

Is that the measure of what it means to be a human being? No, but I couldn't really answer the question, what was my humanity? What did it mean to be a human being? Why was I happy to be still alive? Those are the kinds of questions I was trying to kind of wade through, like essentially questions of identity so so studying art the hunch was well well this seems to be a peculiar the situation i'm in was a sort of peculiar to being a human being that one could survive injuries like that and go back out into the world in this damaged way and make their way again and return ostensibly to some sense of wholeness in themselves and it seemed to me

rightly placed to focus on uh something like art as as a as a guide to help me get creative with the reality i was now facing you know in a way it was the thing i was trying to learn how to do was make perspective. And that's what art really helps you exercise that muscle. It helps you learn how to see, how to listen. And that was really empowering because there's so much I would have loved to change about what I was seeing. When I looked at my body, I would have loved to have changed so much about it. But I couldn't, but I could change with this knowledge. I could change my perspective. I could change how I saw myself and there's, so that's, that's what art helped me learn and where I focus my energies. And it really paid off. I have to say it was very helpful. I'd love to explore that some more because I've been

in the last few months in particular asking myself over and over again, why do humans care about music, create music like a compulsion and dance? Every group of humans on the planet,

and it just seems so peculiar, yet unsurprising if you look at, say, bird song and animal mating calls and mating dances and all this, that and the other thing. But there seems to be many layers. There seem to be many layers to it. So what did you find, how did it pay off? I mean, you gave one example already in terms of changing perspective, but were there any particular classes, teachers, books, pieces of art that really influenced you? So, boy, let's see here, man. So let me, yeah yeah so really so much of i mean art history the way the curriculum was set at the time it really didn't actually dig in so much around why humans make art it just presupposed that we do and that that's interesting and were and went from there

which was cool i mean it just put me in basically put me in front of a lot of art and helped me tweak my eye and my ear. And that was great. But on the sort of identity, sort of philosophical front, like the existential, like why do we do this? What's the meaning of this? That was actually kind of left up to me as an individual and in my relationships and there was one of my dearest friends a guy named justin burke who is he is a philosopher in art history i mean that's what he studied through and through his to his doctorate and frankly a lot of stuff we're talking about right now tim and the and the benefits i reaped from it was really in from conversations with

justin fed in the backdrop by this this pounds of artwork that I got to spend time with. But working through this philosophical stuff was really with my buddy Justin. So that's one point. And there was no particular work of art. Again, it was more the idea of art than it was any particular piece of art that was so potent for me. And even to this day, I love going to museums, but I just like being around art. Sometimes I don't even look at it. I just like that it exists and I like to reward places to help it exist. So anyway, there's no one work I can point to. Although I would say

probably the painting of Mark Rothko has proven to be very poignant and potent for me. Any chance I get to stand in front of a Rothko, I will do. How do you spell that last name? I'm an ignoramus when it comes to this type of thing. Oh, Rothko, R-O-T-H-K-O, Mark Rothko, abstract expressionist, mid-20th century guy, made these big, beautiful color form paintings paintings non-representational yeah quick random anecdote that might be entertaining so i grew up on eastern long island where jackson pollock basically turned himself into one of his paintings by driving a car into a tree and uh he actually used to show up at one of my relatives' homes

completely shit-faced drunk all the time. And he would bring his poor dogs in the car, and he'd show up at like 9 o'clock. And this man and his wife would say to themselves, oh, no, it's fucking Jackson again. And they would pretend to be going out to dinner, no matter what time it was. And they'd go, oh, we're so sorry, we can't stay, we're just on our way to dinner.

Because what would happen is he would stay, the dogs, he would forget about the dogs, they would shit all over the car, he would take the dogs home, leaving the shit intact in the car, and then blame it on my relatives to his wife, who then had to contend with the whole mess. So anyway, related but totally unrelated. But if we're talking about abstract, if you were – this is an awkward transition, but here we go. That's kind of my MO. You were brought in as a physician slash, let's just say, mentor, guide to someone who had just suffered nearly identical injuries to yourself, 20-some years old. What would your conversation be like with them, or what resources or reading or otherwise would you point them to? You know, so I, I find myself every once in a while, I'll get called

by friends in the hospital, come visit with someone who is in similar shoes, you know, and actually I wish I remembered his name, but someone did that for me when I was in the burn unit. He'd had a similar accident. I think he lost two legs below the knee. I should say both legs. And I learned a lot from how I gained from his visits to me. I have just sort of reproduced, which is basically walking in these rooms with almost no agenda, almost no plan to advise in any way. The potency, especially early on, was just seeing someone in similar shoes. My early questions when I was in the bed was like, what am I going to look like? What's it going to feel like to walk on prostheses?

And that's kind of what, you know, it was that nuts and bolts kind of stuff. Will I ever have a, will anyone want to date me again? You know, I mean, I don't know. It was on that level. And so when this guy would come visit me, it was just seeing him, just seeing him upright, just knowing that by virtue of the fact that he'd entered my room he came from somewhere else he was out in the world knowing he was a functioning human being out in the world and just seeing him look me in the eye uh with some kinship that was the therapy of it um i think i've gotten in trouble when i've tried to uh come in with some uh predetermined idea of advice giving. Oftentimes that's not really what's needed.

It's more just the camaraderie and the bearing witness. And so to answer your question, when I do go into folks' room, I'm there and I'll avail myself to any questions they have. But I think most of the power of visit is just visiting, just being together and sharing this awkward body. From what I've heard and read of yours, one of the recurring themes appears to be, and please correct me if I'm getting this off at all, is how powerful simple things can be, or maybe are, and that our tendency is to perhaps undervalue the things that are not expensive or difficult to obtain. The snowball.

Could you talk about the things you've noticed that most help people in hospice care. And the reason I ask is specifically related to cookies, which maybe you could talk about, but I'd be curious to hear sort of what really brings the most peace to these people. Well, so you're right i mean i think one of the joys about the one of the upshots or silver linings about the end of life is that if you want it to if you let it you can let a lot of the rules that govern our daily lives fly out the window

because you realize that we're walking around in systems and society and much of what consumes most of our days is not something that you know it's not some natural order we're all navigating some superstructure that we humans created that is the work day the work week whatever it is you know it's it's not and if i think part of the trick is if when you're dealing with serious illness or some natural trauma or facing the end of your life, oftentimes that becomes crystal clear. Where you've been hanging out and spending so much of your time and energy and worry is like living in someone else's dream. Sure, society and what we've structured there's a lot of importance to it i don't mean to dismiss it but we inherit that we don't spend a lot of time creating our realities in a cop you know most of us don't in a sort of in a clear

intentional way and so when you have this excuse to forget all that, it can be really liberating. A little bit scary, too, because a lot of people then invariably realize that they feel like they've been wasting so much of their time on things that actually weren't that important. Right. And that's part of the trick of checking yourself over time. In a daily way, am I doing things that I really care about, et cetera? So back to your question. you know over time you know in a daily way am i doing things that i really care about etc so back to your question so you know to this point about simple things i mean the simple things uh the small things ain't so small you know actually um the like i say about the snowball

just the joy of feeling anything of having a body at, of being capable of movement at all, that is so profound. It's so potent. And yet, I don't know how many of us take that. I think most of us take that for granted. So anyway, as a clinician and as a person, I love looking for moments where the rules get to go out the window. I love having residents at the guest house at Zen Hospice who smoke, frankly, or anything that just kind of reorients us and puts things in proper proportion in relationship to the natural world and rejiggers our priorities. I love that. I love that reorienting feeling.

And, and, and again, it does seem to be one of the silver linings for folks in this zone. So, you know, like, I don't know how many of us,

like I think about this most, most nights, like every night, depending on where you are, of course, but you can look up and usually find a star. I mean, I feel like, you know, when, when any of find a star i mean i feel like you know when

when any of us are struggling with just about anything you know look up just ponder the night sky for a minute and and just to realize that we're all on the same planet at the same time you know and that and as far as we can tell there we're the only planet with life like ours on it anywhere nearby. And then you start looking at the stars and you realize that the lights that are hitting your eye is ancient and that the stars that you're seeing may no longer exist by the time the light gets to you. sort of mulling the bare naked facts of the cosmos for me is enough to just thrill me, awe me, freak me out, and kind of put all my neurotic anxieties in their proper place. You know? Right. So, yeah.

And a lot of people, when you're standing at your horizon on death's door, you can be much more in tune with that cosmos than you are with what the body is doing in a day-to-day kind of way. Does that make sense, Tim? Can you imagine? No, it makes perfect sense. So just because I brought it up and I don't want people to be harassing me about it on the internet, the cookies. Can you mention? Yeah. Yeah. Well, you know, I mean, the smell of fresh bread or for most of us, the smell of a chocolate chip cookie does

magical things. You know, it's first of all, food is primal, you know, our sense of smell. I mean, the shortest, I mean, it is, it is one of our oldest senses. It is primal. You know, you can walk by someone who may be wearing a cologne or perfume of someone you knew 30 years ago. It's been maybe a few years, but there's a perfume that I would smell that my babysitter wore when I lived in St. Louis when I was in preschool. And it would throw me back there instantaneously. And so the sense of smell is potent. And food is primal and potent. I mean, it's nourishment, it's nutrition, it's how we live in some ways, right? So there's all this symbolic stuff happening too. But there's also just the basic joy of smelling a cookie. It smells frigging great. And it's like the snowball. Like in that moment, I am rewarded for being alive and in the moment.

Smelling the cookie is not on behalf of some future state. It's great in the moment by itself on behalf of nothing. This is another thing back to art, art for its own sake. Art, as part of its poignancy in music and in dance, is its purposelessness and just delighting in the wacky fact of, of, um, perhaps a meaningless universe and how remarkable that is. Uh, you know,

that's the, that's kind of what I'm shooting for. And that's a way for all of us to live until we're really dead until we're actually dead, uh, is to prize those, those little moments. And the,

you guys, I might be fabricating this, but make cookies at the Zen Hospice Center for this precise reason, right? And so you mentioned absurdity a few times. This is something I've been thinking about a lot, and for reasons that may inferentially become super clear in a second. But just the being able to try to laugh at the cosmic joke so to speak i

mean like the the meaninglessness if there if it is in fact meaningless uh of things uh as opposed to taking all things so damn seriously which in a way prevents you from doing a lot of the serious work you'd like to do. But the question I was going to ask is to get your opinion on a modality, we'll call it, or a tool. And I'm going to explain this vis-a-vis a friend I'll keep anonymous. So this is a female, young woman, who used to work in hospice care. And she found, just as you alluded to earlier, that she felt like she was sitting on a secret. It gave her incredible joy and presence to do that work. She really loved the work. At some point, became very frustrated with the

insurance policies and vagaries of our healthcare system and now does something that is illegal, but I think should not be, which is guided work with psilocybin. And she said, now I get to experience people dying

every weekend. The only difference is they come back to life. And many people listening to this will have read or should read an article that was titled The Trip Treatment by Michael Pollan in the New Yorker about the use of, I believe, specifically psilocybin, for those people not familiar, which is extracted or the psychoactive compound in magic mushrooms, for end-of-life care in terminal cancer patients. So I'd just love to hear your opinion on the use of compounds such as those in end-of-life care or otherwise. Yeah, well, I'm so glad you're asking this question. So there's all sorts of stuff coming out of the closet these days, and it's really wonderful.

And, you know, there's a movement afoot to revisit psychedelics from a therapeutic perspective. And I don't pretend to know the full history of how psychedelics went from considered therapeutic to considered, you know, you know, toxic and the devil's work. But here we are. There's a, there's a revisiting happening with fresh eyes and serious eyes. So it's not folks who are just with a wink trying to justify their own recreational use of these.

Oh, it's UCSF, UCLA, Johns Hopkins. Johns Hopkins. You got it right. NYU. Friends at the River Styx Foundation have been funding some of this work. They do beautiful – the people I know who are involved in this work are deeply thoughtful, caring, loving people. So anyway, that's sort of a preamble.

But to get to your question, I am thrilled for this for a number of reasons. One is just the counterculture fun kind of things coming out of the closet. Another is a whole generation, i.e. the baby boomers who are now the focus of so much of our efforts in healthcare and the aging population. How do we cater to this population? Well, a lot of folks of that generation have experience with these compounds and now they get to sort of be above board potentially. So anyway, I love the subject for many reasons, but as a clinician, I'm particularly excited because we're pretty good at treating nausea, treating pain as a rule. And where things get very difficult, and in palliative care, we talk about this. We call it existential distress.

And basically, existential distress is a crisis of meaning in some way or another. So it's particularly potent at the end of life when people don't have much time left to make meaning and they realize they haven't been living a very meaningful life or haven't thought much about it. It can be really traumatizing to realize, oh gosh, to take all of a sudden to take that seriously and then realize you don't have much time to do much with it. So anyway, this idea of existential distress is huge in medicine and palliative care. It's very nascent. I mean, the way we treat it now is, well, if someone comes to us and they're miserable, well, we rule out and or treat pain, nausea, other anxiety, depression. We look for a diagnosis that we can treat and then we treat it. And if folks after all that are still miserable and shut down, then we'll sort of invoke this phrase existential suffering or existential distress.

And this is what we call medicine, a diagnosis of exclusion. So no one knows what the hell to do about this. Diagnosis of exclusion. Yeah. So you just rule out everything else that you understand, and then whatever you're left with, you just call it this bucket term. And in this case, that bucket term is existential suffering. Not particularly inspired, right?

But this is where it also gets thrilling. This is my favorite thing about my field, which is palliative care, first of all, organizing around the human condition and suffering and what it means to suffer, this highly subjective state that we all have some experience with in our lives. So it's total ubiquity, absolutely unesoteric field, absolutely relevant. No one I know has not suffered. It seems to be elemental to being a human being. And this is our fulcrum in palliative care. And what's more, we have named this thing existential suffering, which is so mysterious, right? And there's so much, it's so ripe to invite the arts into this mix, philosophy into this mix. We've already talked a little bit. So this is my favorite strategic zone to upload into healthcare

all these otherwise non-medical issues. So there's a ton of reasons why I love this space. And I'm getting around to an answer to your question, which is – so we have named – I'm not in any rush, man. This is a long podcast. It always is. Good, good named- I'm not in any rush, man. This is a long podcast. It always is. Good, good.

Because I love this subject. So we have the leverage, now that palliative care is accepted and part of healthcare and has called out the nature of suffering and has called out this thing, existential suffering, we have this portal to upload all these other fields and interests and to keep them, to make them relevant. So this is where it gets thrilling. Meaning you have a channel because you've wedged your foot in the door with palliative care through which you can insert other things that wouldn't otherwise have an easy gateway. Exactly. You got it.

Right. So now enter the relevance of the arts, philosophy, design, you name it. I mean, what field isn't relevant in some way or another to the human condition, right? So all of a sudden, there's this huge invitation, or at least possible invitation, to the rest of the world besides the sort of narrow medical sciences, per se. All right? So that's really exciting so now so back to psychedelics well so we can call out this existential suffering but to date as clinicians we don't really have much to offer it um we're aware that we've talked as we've

like bearing witness and and non-abandonment, accompanying people in their struggles is itself a great salve, and that's beautiful work. But what else can we do? Well, I often find myself prescribing people for their existential suffering to remember what it is that they love, to keep an eye out for aesthetic moments in their days where they feel something, anything, whether it's that snowball or sun on your skin, some just to note when you feel happy to be alive. And there's our little toehold to work from. So there's a lot to build around this. But what we haven't had is we certainly haven't had any chemicals to offer people to help in this way and it seems the data to date seem really robust that it may be that uh compounds like mdma psilocybin and other things may be radically helpful in fostering um a meaning making moment for someone of fostering a sense of belonging in this sort

of cosmic way. And so in other words, we have potentially with these compounds a way to respond to this wacky thing called existential suffering. So this is just thrilling for all those reasons. Yeah, I couldn't agree more. And for people who want to dig into this, and I would encourage So this is just thrilling for all those reasons. and PhDs called the Hefter Research Institute, H-E-F-F-T-E-R. It's just hefter.org. And they do some incredible work with not only patient-focused studies, but also research studies using things like fMRIs and different types of neuroimaging to look at the specific effects of different types of psychedelics, whether you call them entheogens or psychoactive, psychotropics, whatever it might be. So it's a very, very, a lot of interesting work.

And you can learn a lot about how these compounds function just by looking at, for instance, some of these studies and examining sort of the methodology, right, the protocols that they use. So if we look at... And by the way, Tim, the protocols that they use. So if we look at – And by the way, Tim, can I just interrupt? Absolutely. I've also had some really fascinating conversations with other folks in this space. And another organization to point your listeners to is a group called Compass.

Compass. I think they're – Compass. And they are beginning to also support research in this vein and also starting to try to align healthcare systems and other institutions to participate in this work one way or another and to sort of pull this stuff again out of the closet. I'm not sure where they are in their development, but it's another group to be aware of. And I think their website is compasspathways.org. So just another group in this space that's doing cool stuff. Cool.

And you know, I'll throw one more in there. Uh, maps, uh, which is, uh, which is doing a lot of, uh,

investigation, interesting work related to policy and the legal side of things as well. Uh, and that that's worth checking out. And for, for people wondering, these will all be links to all these things will be in the show notes at, um, four hour work week.com forward slash podcast, all checking out. And for people wondering, links to all these things will be in the show notes at 4hourworkweek.com forward slash podcast, all spelled out. But coming back to your story and your life, I mean, I really have so much I would love to ask.

And we'll dig into some of them, but we're not going to have time for all of them, which is fine. Uh, the, the question that I'd love to ask next is what you feel you do on a daily or weekly basis that is different from most people, routine wise, thinking wise, self-talk wise, anything different from other physicians or just people in general? People in general, because I don't want to make it exclusively professional. This is because I'm looking for what I'm fishing for are practices that you've adopted or developed habits, whatever it might be, that people listening might be able to test drive for themselves? Well, let's see here, my friend. I have two answers to that question. So the one is, you know, we've touched on a little bit, but I find myself increasingly interested

in the aesthetic domain. And by aesthetic, I mean just the life of the senses, not just beauty, but just the felt environment at all. That is the world of the aesthetic domain. And one of the reasons I'm particularly interested in the aesthetic domain, besides just delighting and having a body to feel anything like we've talked is is it's how it prizes purposelessness so so i am all for meaning i i see human beings as meaning making machines and we talked about this a little bit like whether there's some grander meaning in the universe i i don't really know and frankly i'm fine not knowing. I enjoy the mystery of it. And I'm okay if there's meaning on a grand scale or not, frankly.

But meanwhile, I am aware of our talent as a species to make meaning for ourselves and to string together narratives and stories and to make sense of our lives. And I think it's a profound impulse and a lot of good comes from it. And I also just increasingly want to carve out a space for meaninglessness, purposelessness. So, again, like the snowball or anything that makes us feel in our bones, feel happy to be alive in that moment on behalf of nothing else but that moment. And that is, I think, we could all benefit from letting ourselves delight in things that don't necessarily have any meaning, but just feel good and don't hurt anybody else. But just give ourselves a space to delight in purposelessness. That to me is a huge deal. And I see its therapeutic relevance for my patients very often who are beyond their life of purpose. They can no longer do that job they loved or their role in their family has changed. And they're so crestfallen because they don't have that reason to get out of bed. So let's find new reasons to get out of bed.

Let's repurpose ourselves. Yes, yes, yes. And let's get really good at honoring just the joy of smelling a cookie. And that can be enough. Watching a ball game, that can be enough. It doesn't have to be big. It doesn't have to be a means to an end. So anyway, I think that's one answer to your question. I don't know how many of us are out there pri might be a strange connection, but it made me think of Kurt Vonnegut, the writer, who I actually consider a fantastic philosopher in a lot of ways if you read his fiction. But one of his quotes that I've always loved is, I tell you, we are here on earth to fart around, and don't let anyone tell you different. And there's a story, I think it's actually in a dialogue with another writer at some type of event,

and I'm sure someone will be able to find it. I'll try to put it in the show notes, but it might be tricky to find, where he talks about this long walk that he takes to mail something at the post office and his wife doesn't scold him but just laughs and asks him why he wasted so much time. And he's like, no, no, no, no, no. You don't get it. I didn't waste time because – and he runs through all of these seemingly meaningless, seemingly trivial but to him very important kind of absurd interactions with multiple people along the way. And it's just a very good meditative exercise because I feel like it's extremely easy to think that the big overarching abstract things are the important things and the small tangible things with sensory

inputs are the unimportant things and i am not convinced at all that that is the case in fact it might be quite the opposite and if you had a patient come in, they are finally getting comfortable at Zen Hospice Project, very introverted. And they say to you, you know, I'm going to want to talk to everybody and get to know them, but I'm not quite ready. I just want to read. What one to three books would you suggest I read? So funny because I mean, I'm laughing because I am probably the least well read person you will ever meet. And especially one with like degrees, uh,

uh, college and stuff. I, I, uh, if I, I am, all right,

if they said, give me one to three things that I can watch, do, absorb, look at, et cetera, without human interaction, what would your answer be? Thank you. That's better. For me. I mean, hey, I'm all for books too. Those apparently are cool. But for me, you know, I love film.

I love music. I love film. I love music. I love art. I love doing nothing. I love being outside. So that's for me the litany. But I would put big picture books in front of people. I mentioned Mark Rothko. Staring at Mark Rothko work is just a gorgeous splendor, but it, you know, suit your

taste. So for me, I guess I put some, a picture book of Mark Rothko paintings in front of them. I would put probably any music from Beethoven into their ears. And I probably would reserve that third thing for staring into space. Before they stared into space, if they wanted to watch a movie, what would you put in front of them? Man, there's so many good ones. Ratatouille. No.

I think I have a real soft spot for Waiting for Guffman not that it has this great meaning per se but speaking of absurdity I just think it's hilarious Waiting for Guffman, I've never even heard of it You've never heard of Waiting for Guffman? No, just a string of ignorance on my part in this conversation although you don't read books so i feel that evens us out so oh yeah and you but this is good news because man you have so much to look forward to i mean so this this movie is by christopher guest and company the guys who

did spinal tap and oh wow uh you know best in show sure sir how do you say guuffman? I think it's G-U-F-F-M-A-N. Okay, got it. It's frigging hilarious. So that is just always a long-term favorite. I mean, as a kid growing up, Kentucky Fried Movie. Oh, my God. I haven't thought about that in decades. Yeah. Wow.

That was like really an important movie in my childhood. We watched it probably, I don't know, a hundred times. I mean, every day. I mean, that and GrooveTube. I mean,. And, you know, one that leaps to mind, I don't, I don't know if you'd really even consider it a documentary, but I guess it is. It's, you know, the movie Grizzly Man. Oh, man. Oh, man. Yeah, I consider that a documentary. Yeah, sure. It's called a documentary. So yeah, of course it is. I mean, it is, I – any piece of art where I simultaneously – or I'm not sure whether to sob or laugh hysterically. I love that feeling where you just can go either direction. You're not even sure which is the correct emotion. You're simultaneously attracted and repulsed to something.

That was my experience watching that film. I think it's an amazing piece of filmmaking. And I also particularly like its poignancy around our humans' silly dance around nature and how we humans think of ourselves as somehow opposed to nature. And yet when we try to reinsert ourselves into the wild, it doesn't necessarily go very well. And how we romanticize how Mother Nature can coddle us. And I spend a lot of time in the desert in southern Utah, as much time as I can. I just love that landscape.

And speaking of perspective making, thinking on geologic time and making myself feel very, very small and inconsequential is really deeply therapeutic for me. And when I go out in Utah, and I've gotten lost twice walking around this particular area, and it's the same feeling I had watching Grizzly Man, which is Mother Nature, as far as I can tell, is pretty indifferent to us. Yeah, I would say so. So anyway, there's my answer for you. So that brings to mind two things. The first is you mentioned that feeling, which is two sides of the same coin almost, that

of being simultaneously repulsed but wanting to laugh and unsure of which way to go, that seems to me to be a very primal emotion, like a singular emotion in a way. When, for instance, I've watched nature footage of chimpanzee troops when one of them is torn to pieces by a jaguar or some such on the ground, and the response tends to be breaking out into what would be considered by primatologists, hysterical laughter. And this seems to be something very, very hardwired. So returning to that in some way and it being therapeutic doesn't surprise me. The second is just to tie together a few things you've said related to sort of the meaninglessness, which may be too loaded a term for some people. It might come off as very negative, but

seeming inconsequential or small and meditating on that, or not even meditating on it, experiencing it in a very visceral way by being in the desert or looking up at the sky, I think is very compatible with something that struck me, which was told to me by Tony Robbins, who's also been on the podcast. And he said that, and I'm paraphrasing, but that most geological timeline, which puts our shitty week into a just hilariously diminutive perspective, makes a lot of sense. This is unrelated, but what do you think of or who do you think of when you hear the word successful? I think, well, you just pointed to something. The relationship of self and the silliness of self and the power of the self. And I think we do ourselves disservices by playing into polemics around selfishness or selflessness. So there's a lot to say about that. But to

segue to your question about success, on one hand, I sort of think of it in terms, I guess, I think of it as a sort of a self-actualization. Someone who has realized, has played themselves all the way out. And that might be seen and appreciated by practically no one, and therefore not make the measure of some external success. delighted in themselves including their quirks and awkwardness uh and and played that self out uh and you know insisted on itself all the way to the end to me that may be a version of success right so that's a so i guess one part of my answer your question is i i think of it as really an internal process um but then beyond that too i guess i'm a little torn here because i i agree that that what i just said sort of focuses us back to focuses us and success back into the self and i suppose

the second half of the question really has to do with orienting oneself to the other, to everyone but oneself, and to the relational dynamics between the self and the other. And so I think probably success may be, or the second half of it has to do with, in a way, maybe seeing yourself in others and others in yourself and realizing the unseen connections between us all. And this is another reason I love our mortality. It has the potential to be this equalizing, uniting force. So anyway, so success may be this sort of self-actualized piece, but part of that self-actualizing is exploding the sense of self and feeling part of everything around you and vice versa. That consonance with the world around you,

that seems like a great success. Is there anyone who embodies that for you or comes closest? Hmm, man. Man, well, yeah, gosh. Hmm. Well, I recently had the joy of sitting with Oprah Winfrey and watching her make use of her life and now point and also point her energies to promoting and helping others is a very, I mean, a remarkable life's work. And it's just a name we all know and wow but you know i'm also interested in all the gazillion successful people we walk by every day and don't even know it you know this kind of happiness this kind of success doesn't necessarily brag about itself and i i love the uns i love presuming it when i don't

when i when i'm unaware of it and assuming it exists in others that I walk by on the street. And in a way, you find yourself kind of imbuing others with an idea of success and it changes how you look at them and how you treat them. And that's sort of a sweet favorite daily exercise of mine. So no, it's hard for me to say a single person that I would point to as embodying all this. So let's, let's, you, you actually touched on a much more interesting, uh, answer or point than my question deserved, which is your morning practice. So could you elaborate on that please? When do you do it? How do you do it? So you're walking just to take us through this morning exercise. How I get up in the day to start the day? No, what you just talked about, sort of assuming the presence of this type of success. You said it's a morning exercise of yours.

I'd love to just hear you elaborate on that. Oh, I don't know. I didn't remember saying morning. That's what tripped me up. Ah, sorry about that. Sort of a daily exercise perhaps. Ah, there we go. Yeah, I could have made up the morning part.

Who knows, but sure. But it's sort of any time of perhaps. There you go. Yeah, I could have made up the morning part. Who knows? But sure. But it's sort of any time of day or night. This is useful. It's kind of like just the power of meaning well, of wanting well of others. And when there's a choice in the matter to choose to see good. And if you can't know, assume good. And this kind of builds an argument for your day of gratitude and happiness and some amount of comfort. So I'll catch myself being bitter or I get kind of road ragey.

I'm very aggressive on my motorcycle and car. And actually just today, I was really annoying someone by falling in too close and whatever. I get in my bullshit zone pretty quickly. But when I'll catch myself and then, so when I walk by, you know, particularly here in the Bay area, the homeless epidemic is enormous. And it's just, I'm particularly, uh, acutely aware of this exercise when walking by someone who otherwise the world would assume, uh, in a sense that they are failures in one way or another. I like to invert that whenever possible. So I'll just fill in the blanks whenever I see a homeless person that I'll assume that whatever they're going through is vital to them and that maybe, however, whatever junk we project onto them, that inside maybe they're all right with who they are.

Maybe they're way more all right with who they are maybe they're way more all right with who they are than a lot of people i see striving and otherwise looking successful uh so it's really it's just simply that i actually learned this my mother took me to a deepak chopra conference when i was pretty young it was a long long time ago and the one thing i heard that stuck it was really interesting to me was it was getting in the habit of saying you know and when anyone when you hear anyone sneeze either say it out louder to yourself say bless you it's just a it's like a nerve like a neural loop of goodness and it just means in that quick second you meant well towards somebody and even if you don't say it out loud even if you don't share it

say it to yourself and i gotta believe that that resonates and registers somewhere, you know, that that lands somewhere, that that lends itself to a vibe. So that's the kind of stuff you walk around and you see people and you just project well-wishing onto them. Now, I hate to focus on something maybe superficial, but you said riding your motorcycle. Now, I apologize if this sounds like a weird question, but you have three limbs that have been damaged. How do you ride a motorcycle? So, yeah. So, you know, this was a long dream that recently came true. Congratulations.

I mean, it's awesome. I'm just so curious about the logistics. Thank you. Well, it's interesting you ask because right now there's the man who helped make this dream come true, Randy. Randy, he ended up being my patient and our resident at Zen Hospice Project not long after he converted my motorcycle. So there's a lot to this story, my friend. So cheers to Randy and his family and his wife and his mother, Melanie, who I'll be seeing next week, actually. So that's one piece of this story.

But the other is I love two wheels. I love gyroscopic lifestyle. I love the feeling of it. I've always loved riding bicycles. I'd always wanted to get on a motorcycle, but I kept going to shops. People would look at me, and no one got into it. I could never find a mechanic who was willing to take it on and try to help make it happen. A fellow named Mert Lawill, who's an old motorcycle racer champion, sort of legendary in that world.

He happens to live around here. He lives in Tiburon. And he built a prosthetic component. I don't know what the story that inspired Mert to do this, but he's a machinist himself and a handy fellow. And in his retirement, he got into this business of building this prosthetic component that lends itself very well to mounting an arm onto a bicycle or a motorcycle. So the first piece of this puzzle was discovering Mert's invention and getting a hold of it myself, which allowed me to get my prosthetic arm attached to a handlebar in a very functional way. Now, does that connection, so you have throttle, rear brake, and then typically front brake on the left. Do you have, how are those controls modified?

So, okay, so Randy, what he figured out, so first was to get the arm piece. And then what Randy figured out was, and then, well, then Aprilia, and I know Honda had made a version of this as well. But Aprilia makes a model, the Mana, M-A-N-A, that is clutchless. So that was a huge piece to get out of the way. So this is essentially an automatic transmission. So that do away with the clutch and gear changes. So that's a huge piece of the puzzle out of the way. And then Randy figured out a way to splice the brakes, front and rear, in a certain ratio into a single lever.

So I'm doing nothing with my prosthetic feet except to hold on to the bike I'm doing nothing with my prosthetic arm except for holding on the bike so all the actions in my right hand what breaks into one lever then Randy built this box and moved all the controls the turn signals horn and all that stuff over to the right size of the bike and in good distance for my thumb to reach them. So I have throttle, brake lever, and then the turn signal box all going with one hand. That's so awesome. That's it. That's away you go.

Okay. I just have to pause here for a second and just ask everyone listening, what bullshit excuses do you have for not going after whatever it is that you want? Like, please, write in, tell us on social media why these are real excuses with hashtag bullshit afterwards. Oh, my God, man. That's such a great story. I'm so glad I asked about it. What a really fantastic workaround. Man, congrats. That's awesome. Thank you and thanks, Randy, and thanks to the folks at Scuderia, the bike shop in the city. I mean, a lot of people helped me make this come true, and it took a long, long time of trying to find the right folks to make it happen. So amen.

Amen to that. So just a few more questions. I want to be respectful of your time, but I'm having a blast here. What $100 or less purchase has most positively impacted your life in recent memory? I'm guessing not the motorcycle. No, that was a little more than $100. Holy cow, man. Wow.

You know, I would probably point us to a beautiful Pinot Noir from Joseph Swan up in Sonoma County. It's like the artwork of Andy Goldsworthy or anyone who delights in anything ephemeral. The charm in a bottle of wine, the craft, all the work that goes into it, and actually delighting in the fact that it's perishable and goes away, I find really helpful. So I've gotten a lot of miles out of a beautiful bottle of wine, not just for the taste and the buzz, but the symbolism of delighting in something that goes away. Hear, hear.

And I have a practice that some folks might enjoy, which I didn't come up with. I'm pretty sure I borrowed it from some past girlfriend, but I have a small glass jar and I keep the corks from bottles that I finished with friends at home. And I have each of them write something on the cork. So I have this collection. The bottles are gone. The wine is long gone. But there's this vestige.

Is that the right word? Maybe that's not the right word. I'm trying to GRE to sound intelligent. But the corks in this sit, I'm looking at it right now. It's on this floating shelf on the wall, and so I see it as I walk by it. So no matter how sort of lonely I might feel at times, I think we all do at moments. It's sort of a reminder of how close by,

how within reach sort of friends and that type of experience are. If you could put one billboard anywhere with anything on it, what would it say? Oh boy, that's a doozy. Let's see here, man. Well, you know, it makes me think of his biggest billboards are, you cannot, you can only put so much on them. And it makes me think of the, my favorite bumper sticker. And I guess, and it seems like such a potent, I just love, I love it. And so I would love to see it on a billboard,

which, and the basic bumper sticker, I'm sure you've seen it, is, Don't believe everything you think. I've actually never seen that. That's a really good one. Oh, it's so good. It's such a sweet, hilarious, true reminder to not take ourselves so dang seriously. So anyway, that's probably my choice. Don't believe everything you think.

Don't believe everything you think. I was really waiting for what this was going to be i was i was really wondering uh i saw one this is i'm really going to lose any shred of respect that people have for me by saying this but i saw one recently that was a it was not a bumper sticker it was surrounding the license plate uh i'm not sure what the license plate casing, I guess it said, if you're on my ass, you better be pulling my hair. I thought that was pretty clever, but it shows you where my level of emotional maturity is. In any case, don't you're, I, you know, I thought I might, I might lose you with that one. That's okay. I'll try to really, really back in with the next few questions.

So yeah, don't believe everything you think. That's awesome. I'm astonished I've never seen that. What advice would you give your 30-year-old self? And if you could place us with where you were, what you were doing, that'd be helpful also. Wow, that was a particularly poignant time for me, actually. So it was a lot going on. I was deep in med school. It was my last year of med school. Boy, I had a really sort of experimental tour of my 20s. And I was sort of settling into a new rhythm. I was, I had finally let go of a fair amount of,

of guilt around my own accident and the effect on my friends. And, uh, I was, you know, I was, I was, uh,

pretty neurotic at that time. And my sister had just died. So it's, uh, this may not be the intention of your question but 30 happened to be a really sort of heady heavy time for me so but i'll still roll with the question and i think i guess i would have helped myself get uh you know i this sounds way too tidy but i might have said something like hey hey, man, don't believe everything you think.

Don't – let it go. Don't take it all – I do mean to take life very seriously, but I would have somehow encouraged myself to let go a little bit more and hang in there. And don't pretend to know where this is all going. And you don't need to know where it's all going. Yeah. Yeah, you don't need to know where it's all going. And you can't. And you can't. What have you changed your mind, in the last several years, allowed myself to feel that I have a true vocation

in this work around palliative care and helping us as a species deal with our, and dance with our mortality. I had convinced myself that, hey, man, I had gotten very loose and I was whatever. I didn't feel the need to accomplish so much per se. But in these last few years, I've let myself – I think in a way, man, I think I've let myself get more ambitious in a way and to take my work even extra seriously uh more seriously than perhaps i i had been and letting myself feel like this could all work and letting myself feel like actually the

health care system could be fixed and so in other words i guess in a word is to reacquaint myself with something I had talked myself out of, which was ambition. I still think of that word in negative with negative connotations. I see bad behavior on behalf of ambition a lot. And I'm sure you have too in around where we live and places like Princeton and people stepping all over each other to get ahead. And that's not what I'm talking about.

Maybe it's aspiration. Yeah, yeah. Yeah, I think that's right. Well, on that point, do you have any last requests, asks, suggestions, or otherwise for the people listening. Oh, thanks, man. That's such a great invitation. I mean, one is, uh, folks, Hey, everyone, everyone, I hope we could start seeing the remarkable amount that we all have in common, uh, by virtue of being the same species on the same planet, et cetera, and mortal beings at that. And I guess I would ask that we start looking to make that all real. I would ask that we prize kindness.

I would ask that we learn to forgive in a daily way. But more strategic, I would ask you guys um if you're so moved to get involved uh reifying and supporting hospice and palliative care if if you're in and around the bay area or just so moved we would love your support at zen hospice project these places uh rely heavily on philanthropy um so if you're moved please come check us out at zenhospice.org. And otherwise, think about what's going on in your own geography. Support hospice and palliative care. It's work that needs to be developed and built. Yeah, I'll leave it at that. That's plenty. And I've been so excited to chat with you for so long, and I've had so much fun in part because it's exciting to me to think that in studying and refining how to die, we can study and refine how to live. foot in the door, the wedge that is palliative care, you have the ability in this laboratory

called Zen Hospice Project to do a lot of experimentation that could actually translate much more broadly to life, not just at the end of life, but throughout life. And I find that very, very inspiring and exciting. So I think it's a real tremendous opportunity and a potential point of leverage that you have. And so people can find you at zenhospice.org, Z-E-N-H-O-S, zenhospice.org, zenhospice.org. Facebook is Zen Hospice Project. Twitter, at Zen Hospice.org, Zen hospice.org. Uh, Facebook is Zen hospice project, uh,

Twitter at Zen hospice. And I'll put all of this in the show notes, of course, for everybody listening. Can I also, on that note, Tim, can I just give a shout out to the work?

That's also the great work that's being done at UCSF. Absolutely. Of course. The symptom management service in the UCSF cancer center, the outpatient palliative care program there, Mike Rabo and all the work going on around there is, is gorgeous. And that's another thing to consider supporting,

but that's another place to find my work too. Definitely. Yeah. UCSF is just spectacular. And I've, I've done, I've, I've also been involved with,

well, the Gazali lab and other folks at UCSF. I'm just continually impressed. BJ, hopefully we'll get to do a round two, maybe with some wine sometime. But I really appreciate, number one, first and foremost, the work that you're doing and how you've dedicated your life. It's tremendously important and tremendously impactful. And also on a smaller level, of course, the time that you carved out today for this. It's such a pleasure, Tim. And that went really fast, man. And thank you so much for having me on the show. It's such a joy. And to everyone listening, you can find the show notes,

links to everything we discussed at fourhourworkweek.com forward slash podcast, all spelled out, or just search Tim Ferriss and podcast. And as always, and until next time, thank you for listening. Hey guys, this is Tim again. Just a few more things before you take off. Number one, this is Five Bullet Friday. Do you want to get a short email from me? Would you enjoy getting a short email from me every Friday that provides a little morsel of fun before the weekend? And Five Bullet Friday is a very short email where I share the coolest things I've found or that I've been pondering over the week. That could include

favorite new albums that I've discovered. It could include gizmos and gadgets and all sorts of weird shit that I've somehow dug up in the world of the esoteric as I do. It could include favorite articles that I've read and that I've shared with my close friends, for instance. And it's very short. It's just a little tiny bite of goodness before you head off for the weekend. So if you want to receive that, check it out. Just go to fourhourworkweek.com. That's fourhourworkweek.com all spelled out

and just drop in your email and you will get the very next one. And if you sign up, I hope you enjoy it.