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The new power move, everybody. Welcome to another episode of Conversations with Tom. I'm here with Nicholas Christakis. Before start rolling, you're speaking Greek.
It is so rare for me to get a chance to speak Greek. So thank you for being kind and fighting through my deep American accent. You did have an American accent, but your sentences were grammatical, so that was good. All right.
It's a step in the right direction. It's interesting. My wife is actually Cypriot, so. So already I'm trying to sort of fake a Greek accent and not sound like a Cypriot, which my wife.
So this is coming from a Cypriot, says they're sort of the country people and already they themselves have an accent. So, yes, it is not easy to be understood. It's really rare here in Los Angeles to find people who speak Greek. It's a little bit easier in New York, but without getting too lost on that tangent, so one thing that I find just really fascinating in life is the notion of how much of us is born and how much of us is made.
And you sit at that intersection. The book blueprint that you wrote about the evolution of culture, which I'm not sure you'd explain it that simply, but I'll round it to that, just to get us started. What drew you to that notion of how much culture itself evolves in Saxon itself? Well, that's certainly one motivation for the book.
In fact, as you mentioned, I try to explain what are the evolutionary origins of our capacity for culture. I mean, why. Why are we culturally animal at all? I mean, so this thing that allows us to be so variable from person to person, from place to place, this capacity for variation which we take as so important is actually, how to put this exactly, is actually fixed.
So there's this kind of irony that the very capacity we have to be so different from place to place is actually a capacity that unifies us, that all human beings share this capacity for culture. And so one of the ways. Look, I could just set back even from that, just a moment. It's.
It's. Every animal, almost every animal can learn from its environment. So an animal, you know, little fish in the sea, can learn that if it swims up the light, it will find food there. And that's independent learning, where an animal on its own can learn.
Some animals learn socially. So, for example, I see you put your hand in the fire, and I learn, you know, you burn yourself, so you learned independently, like the fish swimming. You put your hand in the fire, you learn to burn. But I can watch you put your hand in fire.
And now I get almost as much knowledge. Fire burns, but I pay none of the price. My hand isn't burnt, or I can watch you eat red berries and you die. And I'm like, oh, my God, I'm not gonna eat red berries.
And so that's an incredibly efficient form of learning, social learning, imitation, observation of other members. Some animals learn socially. We do it. Chimpanzees do it.
Certain other animal species do it. Can learn socially from watching each other, but we do something even more extraordinary is we teach each other things we set out to affirmatively teach. Let me show you how to build a fire that is exceedingly rare. We do it again.
Certain other primate species do it, elephants do it, which is kind of interesting and in certain ways not quite like we do. And there's some thinking that certain dolphins species do it as well. Anyway, that capacity for teaching and learning and for accumulating knowledge and spreading it across time and place is what gives us the capacity for culture. So it's one of the tensions and ironies in the book.
And because, as your listeners may know, there's like, people think of, like, evolutionary biologists explaining human behavior, evolutionary psychologists explaining it, and anthropologists and other people who are interested in culture as, like, fighting with each other. Like, and this group is interested in universals and what all humans have in common. And this group is interested in variation and how every group is different. But actually, you can unify those ideas if you realize that we evolved to have a capacity to be different.
Now, what is it? So you're a super smart dude, you write, you said, basically, a book every 10 years. Why are you so drawn to this particular thing? I become obsessed with it because I grew up feeling that I was not as smart as the people around me, that I was making a struggle to do things I wanted to do in life.
And that a couple life instances led me to really feel like I was never gonna go anywhere with my life. And so that had me slightly towards depression. And it was beginning to read about brain science and realizing, actually, hold on, a single brain plasticity. Actually, when I first started reading about it, it was hotly debated.
And I just chose to believe that that was gonna prove out to be true and so really leaned into that. And my life has changed radically as a result of me putting time and energy into skill acquisition. What has made this such an important obsession for you? Is it something in the way you were raised?
Was it something you came across? Well, first of all, I became obsessed with the topic of this book for other reasons. One was to try to make an extended argument about our common humanity and the fact that human beings around the world are. There's more that unites us than divides us.
Because you saw it going in a problematic direction. Yeah, because I thought for too long scientists and people on the street had been obsessed with the bad part of our nature and the evolution of selfishness and violence and cruelty and mendacity and warfare. But equally, we evolved to be good. We didn't just evolve to have these awful qualities.
We evolved to have the capacity for love and friendship and cooperation and teaching, which we already discussed, and all these wonderful qualities. And in fact, these wonderful qualities, I would argue, are more powerful than the negative qualities they had to be, otherwise we wouldn't be living socially in the first place. In other words, if every time I came near you, you were violent to me, or you filled me with false information about the environment, you lied to me or you killed me, I would be better off not approaching you. We would all be better off living as animistic, independent individuals.
But that's not what we do. We live socially. So the question is, how and why did we do that? And what forces counteract these negative forces?
But I actually want to come back to the other thing you said about struggling with one's fate. But we can go back to that if you want. We can keep going. I love that topic.
But one thing I want to ask you about. So I think most people watching this, if they have any name recognition with you, they will certainly know about the whole thing happened at Yale. You were sort of the famous guy at the center of that, what I will call a sense of hysteria. And were you already researching this book?
Like, here's a guy who is really intrigued by this notion. People talking way too much about the negativity, what pulls his party starts and our differences. Everyone's interested. People seem to think that what's important about us is our sexual identity or our ethnicity or our immigration status or our racial background or our socioeconomic class or all these differences between people, which I don't negate, that.
It's to say I recognize that these differences exist, but to me, that's not what's interesting about human beings, what's interesting is what we all have in common. And in fact, it's the fact that we all have these things in common, the fact that we are united, in my view, by our common humanity that allows us to bridge these divides. In other words, if you think that your life experience is dictated by your membership in groups, whether you're an Eagles fan, for example, or whether you're in the army or the Navy, or all of these distinctions that we make, if you think that your identity in life or your feelings, your thoughts are specified by your membership in groups, then why on earth do you communicate or talk to me at all? In other words, you must believe, as I do.
I hope people believe this, that we can talk across these divides, that we are united by our common humanity. So that's a philosophical principle, but it's also, as I discuss in the book, a scientifically grounded set of ideas. And yes, I started this book in 2009, and the events, the Halloween costume events of 2015 reinforced, although they were unpleasant, very unpleasant events, and I think many people lost their minds, it didn't degrade my fascination and admiration for our species and affection for our species. And so.
So I rushed to finish the book, actually. Yeah, that. That is. That brings up a few interesting things.
So, one, when I think about what I'm trying to do with my life, so I'm trying to basically build the next Disney, which most people don't see that side, what we're doing, because it is so much harder and takes so much more time. And I was literally today asking myself, like, why am I spending so much time energy on this is so stressful. It is. It asks a lot of me both in terms of my time and energy, but my finances, like, everything.
This is a huge undertaking. And the answer that I always come back to is it's the only way that I think I personally meet somebody. You can influence culture. Like, when I think about what are the things that really are going to determine the way that somebody thinks?
So my core thesis is, right now, your zip code determines. It is more predictable of your future success than your iq. I find that, like, really troubling. So what are the things that make your zip code so powerful?
It's going to be obviously the way that the culture around you thinks that becomes the most problematic thing to put a female in. So I thought, okay, what ways is I can influence that? I can't change who your parents are, I can't change your friends are, but I can change the way. Or I can change the ideas that get embedded in pop culture.
And because my background is storytelling, went to film school, that was my obsession, learning language of story. I just thought, okay, I have a passion for this. I love it, I understand it. Could it really have a meaningful impact on that?
Is that part of why you wanted to get this book out is to change the conversation that's going on? Yes, yes, in part. I wanted to get people focused on, again, what we have in common. Two aspects of that.
First of all, our common humanity, in the sense that what we share in common. But second, when you hear the term our common humanity, you typically think about good things. There's also bad parts of our common humanity, but we think about good things. And I want people to be thinking that way.
I want, you know, like everyone, most adults have had this experience of traveling to another place, could be another town or another state or another country. And when you first go, especially if you go to a faraway place, when you first get there, you think, oh, my goodness, this is so different. People are dressed differently, and they worship different gods and they smell differently, and they eat different foods. And their cities, their language is different.
And, you know, everything is so different, you think, and then you spend some time there and you see, oh, my goodness, these people are just like me. They laugh at jokes. They spend time with their families. They have friends which they derive satisfaction from.
They cooperate with each other to achieve collective objectives. They're all these fundamentally human things that we do as an animal because ironically, ironically, these most human things of us, about us, actually, we can identify them in part because they're so animalistic, because they evolved in our biology. One of the arguments, for instance, I make in the book is that if we can share the capacity for friendship with elephants, because elephants also have friends, they evolved independently from us to have friendships. And elephant social networks look just like our social networks, even though the last common ancestor we had with elephants about 9 million years ago didn't have social networks.
So the elephants, independently, by something known as convergent evolution, just like those famous examples of the. Of the armadillos and the pangolins, you know, that independently come to look similar, you know, but completely independently, they evolve these capacities. So, but you can evolve not just physical traits to look similar. You can evolve behavior.
So elephants, and we independently evolve friendship. And so one of the ironies is if we look at elephants and say, my goodness, elephants have friends, too. If we share this trait in common with elephants, then we can share it with each other. Did you see that video of the elephant that I think pretty recent.
An elephant was friends with a dog, the dog died. The elephant carried the dog back a mile and a half after being attacked by coyotes to lay it down outside the house and, like, show signs of continual mourning over the loss of that dog. That's fascinating. I have not seen that video.
But the ability of elephants to feel grief, which I also discussed in the book Blueprint, has been long known by indigenous people in Africa and long observed by scientists as well as. And it's a very. It's a very interesting property. And we know that elephants can express something that looks just like grief in us.
And so why did elephants apparently independently evolve this capacity for grief? Well, the capacity for grief is the flip side of the capacity to be attached to individual people. So you might be sad if you see that a stranger has died, but you won't grieve the death of that stranger. If a person, you know, an identifiable, unique individual, dies, you feel grief.
And so this capacity for grief evolved, I believe, and I argue in the book, in parallel with the capacity to express individual identity. So what do I mean by that? Why, for instance, I'll back up the fact that why do all of our faces look different? I mean, why don't we all just have a face that looks the same?
For your kidneys to do their job, all human kidneys to do their job properly should work the same. Physiologically, they should be the same, but for faces to do their job, they should look different. And what is the job of your face? The job of your face is to communicate.
This is me, not someone else. You're trying to communicate your individual identity. And not only that, not only. And this genetics of this has recently been worked out or partially worked out, like how our faces come all of our faces to be different.
We don't only have the capacity to signal our uniqueness, we also have the capacity to recognize our uniqueness. A large part of our brain is devoted to being able to look out at a crowd of people and uniquely identify every one of them. Even we can look out at people we've never met before and say, these two are siblings. So we can discern a connection between them by looking at their faces.
Do elephants have that same kind of ability? Yes. Yes, yes, yes. So elephants have identity, and incidentally, so do dolphins and, of course, many primates.
So they are unique individuals. Now, the reason for the evolution of this capacity to signal and detect individual identity is that, paradoxically, it's because we live socially. If you're gonna live socially, you need to have a way of tracking who have you had sex with, who have you cooperated with. No, seriously, who is your offspring?
Like you want to feed your child, not someone else's child. So you need to be able to tell the difference among all these other people. Who do you owe a favor to? Who can you call on for support if you are in a battle?
So all of these qualities rely on the. These social qualities rely on our capacity to signal our individual identity. And then comes with that, the capacity for grief. So you mourn when, when Susie or Tommy dies.
You don't mourn when some unnamed person dies because they are unique to you and you have a connection to them. So, so this is grief. Anyways, I'm not surprised at all about that. And also elephants, another fascinating trait is they seem to hate animals that eat carrion.
So they shoo away if they find a dead animal on the savannah and their vultures there, they will run at the vultures or the hyenas and they will chase them away. They really don't like those kinds of animals. They apparently think they're awful. And they have been known to help humans in distress.
So they can tell the difference. An elephant can tell the difference between a human that is sick and a human that is not. And help a human that is sick. Incidentally, dolphins, if you don't do this, you know too, they're famous stories going back thousands of years.
Many, many documented in modern times. Some of this is discussed in the book too where dolphins will rescue drowning sailors and take them a long distance to shore. Did you ever watch a show Flipper? Yeah, a little bit.
Yeah. I used to love that surprise, that whole notion of it, you know, the dolphin being there to help people out like that is how I grew up thinking about dolphins is that they had very human like traits. The ability to understand distress, the willingness to rescue somebody. It's pretty interesting.
I didn't know that about elephants, especially when they're so notorious for. I would assume if they detect that you are a threat, that they are so devastatingly vicious is the word I would use before you said that, that they can. They'll go on the attack with humans. Aren't they one of the number one killers of humans in terms of animals.
And secondly, there was no conflict between before we developed serious weapons. There were group hunts for Macedon and elephant predecessors a long time ago. So we occasionally would hunt large groups to people. This is dangerous for us to go hunted elephants was not an easy thing.
But There was no like intrinsic conflict between our ancestors. And given the ivory trade and given the conversion of land to agriculture, the elephants and humans come into conflict. And an unarmed human, of course is nothing against an elephant. And you see occasionally in India, you know, people go running when they see an elephant.
I mean it's not a joke, but they're peaceful. I mean they don't intrinsically attack us, not at all. The people who win, they're not smarter, they just absorb more ideas faster. There are thousands of books right now on business psychology, leadership, books that have already changed how the best operators think.
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But it's sometimes engaging copyrighting. But this goes back to our discussion of culture. So elephants will teach each other how to raid human crops. And they know, for example, to do the raid on nights Winners and New Moon.
And they. And they. And they. Yes, and they.
And they have special knowledge about which crops are appealing and where they are located, which they remember and transmit. So they'll form parties to go, like hunting parties to go on a dark night and then to get, you know, the desired food. Of course humans will like this so. Because elephants will trash the whole field.
But no, it's quite remarkable what they can do anyway, that's discussed in the book too. One of the things that I want to go deeper into is grief, man. Like grief is. That is a crazy part of the human experience.
And when you see footage of somebody throwing themselves on a casket and wailing and you know so intimately that sense of just devastating loss, like, I'm never going to be able to go on from this. Even having the concept of dying from a broken heart is pretty intense. That, that whole thing, man, about humans is. Is crazy.
And what we will do to avoid it, how far we will go when we're in the grips of it. It's pretty intense. If you've never. Yeah.
If you've never had grief. First of all, I was a hospice doctor for many years. I took care of people who were dying. And I've personally experienced grief.
My mother died when I was 25. She'd been sick my whole childhood. Is that part why you became hospice doctor? Yeah, of course.
Yeah, of course. It's another whole long story. We go about that tangent, if you want. I remember two tangents ago.
Eventually I might circle back to you, but. But no, I think that feeling, it's a very physical feeling, like your chest aches and you want to hurt yourself, pull out your hair. Why the fuck is that? That's so true.
I have literally never put that into a thought for why on earth do we do that? We don't know that. Self injury, covering yourself with ash, not eating, it's a very complicated thing. And the thing is, typically human beings don't experience grief very often.
That's why it's so distinctive. It's not like just bad sadness. It's a different feeling. And while most people are familiar with sadness and anger and depression and human beings have these feelings, grief is a rare emotion in part, again because it's tied to particular people and also to permanent.
So for example, right now, during the coronavirus pandemic, incidentally, I'm writing another book about this called Apollo 0 that's coming out in October, but that's fast enough for you? I'm impressed. Yes, I very unexpectedly decided to do it. But there's a lot of grief related to this, not just because people have lost their lives.
And when you and I are speaking about 100,000Americans have lost their lives, that means probably about a million Americans know that those people and are grieving. And probably 10 million Americans are aware of someone who has died. But as the pandemic claims, more and more lives, more and more people will either know someone who died and be grieving that person, or be aware that they say no personally, not. In other words, how many can switch between your intimate with someone, your family member or close friend vs oh, I know this person, oh my goodness, they died.
So that's going to change in our society over the coming year or two as the pandemic becomes continues and grief is going to be part of it. But we don't just have grief for the loss of life, we also have grief for the loss of our way of life. Right. There's a sense in which some things have been permanently lost.
People who graduated from high school and college this spring did not have commencements. People lost their jobs, people lost their careers. They've lost opportunities to get a wedding. You know, like they want to plan a wedding.
And these are non trivial losses. And sometimes you can think of these as Eliciting grief. Because one of the qualities of grief is that it's focused on something distinctive and something that is basically permanently gone. Right?
Like, that's why you feel grief, that it'll never come back. And so I think there's gonna be a lot of grief as part of this pandemic as well. Man, I'd love to know if you have insights into. When I think about grief, the wailing, the chest pounding, the hair pulling there.
When I literally sit here and think about what that feels like, there's this need to move, to do something, to. I don't know, like, if there's some association between movements or aggression. The. The.
It feels like. So your notion of permanence. It feels like I. I so cannot deal with the fact that this is permanent, that I need to.
To change the state of something else. I need to change my own state. Like the. The notion.
There's this book I read in high school, the Breaker or something like that was about people who wanted to destroy and tear things down. And I remember reading it going, I fucking get this. Like, I get the impulse to break something, to. But I don't know that it's.
It. I didn't resonate with it in the sense of I want to watch it burn. I resonated with it in the sense of, like, changing its state. Like, just dramatically getting your hands in it, breaking it.
There is something freakishly cathartic about that. And I don't know if there's, you know, back to my central obsession with you. And your work is 50%, you're born with, and 50 is changeable. And it feels like that collision of something in your subconscious is like coughing up into your conscious mind.
And the only way to deal with it is through movement, which obviously, as a species, we've been. I mean, some say that we have a brain specifically for movement. Well, first of all, generally in grief, it's not a period of movement. So usually people, when they grieve, stay home, they might stay in bed, their emotions become slowed.
Do you think that we pass through, though, a more violent phase of that in the beginning? That certainly is my experience. No, it's possible. So, yes.
So there's a rage component too, often at the imminent loss. So often people, for example, if their loved one is sick and dying, they will feel a kind of rage about that. And you also see that a lot when people. You know, when people engage in mass killings in our society, it's often because they feel hopeless and they want to burn it all, you know, which is a kind of, you know, extreme manifestation of what we're discussing.
But generally after the death of the person, most people do not. But not to say everyone but most people, in my experience, grieving is a kind of period of subdued expenditure of effort. And then religions, of course, for example, Judaism, you sit shiva, for instance. In Islam, there's a lot of traditions about how you wash the body and rituals, funeral rituals and so forth.
Christianity, of course, the same. So there are many. Hinduism, Buddhism, there are all these religions have rituals that also partly are directed at supporting the person who's suffering and grieving, but also reconnecting them to the broader society because, you know, a tie has been cut. So there's a lot of visitation and attention.
For example, chimpanzees, when one chimpanzee's loved one dies, other chimpanzees will come and groom the grieving chimp more, and there'll be more social engagement in an attempt to reconnect the person to their. And incidentally, there've been some bits of observations in chimps about body washing, like. Like mothers of chimps that babies that die will tenderly prepare the body of their baby. The same thing has been seen in killer whales, where mother killer whales will try to carry the body of their dead offspring for a long time and move it to the surface to breathe and so forth.
So many of blackfish. Yes, I did. Oh, good Lord. The part where they.
The guy is recounting and he seems like a tough nut, the tough nut, grizzled guy, talking about, you know, back in the 70s or whatever when they captured him and they were showing the footage and just breaks down crying, talking about how the whales were screaming and they wouldn't leave as they were harvesting the young. I was like, oh, God. Like, that is horrendous. Yes, that's an excellent example.
That's exactly right. And old whalers would do awful things. I mean, they were whalers. But, you know, in the intervening centuries, we've come progressively to be more humane about animals, which I think is terrific.
And it's really more humane about each other too. As many people have argued over the last couple hundred years, generally speaking, the moral sphere has widened. You know, it used to be just us, and now more and more groups count as being important, which is good. Eventually, including animals.
The whalers would do things like. Like kill the young calves or injure the young calves so that it would draw other animals together. And there's one awful story I can't remember if I put the book and I don't remember where I got it, but these orcas are very smart and they were being predated. There was a pod of orcas and they were being predated by humans with harpoons in a boat, like modern humans, not Inuit hunters.
And, and the orcas seem to form a plan where the, the females and the children went down one branch of a river and the males tried to draw the humans away from their, their women folk, you know, and young. Unbelievable. Like they clearly know, you know. So yeah, I mean it's, it's, it's, you know, these are these other animals, these sentient, social, intelligent, long lived, all those qualities go together.
Animals are very similar to us in these same fundamental ways ironically that define our common humanity. I don't know, we got me to some grief and I forgot how we got down this tangent. Well, even before we leave that one thing I, I would love to understand. Why did you stop being a hospice doctor which I could not have doing for even a day.
So you are a better than me? Well, I am for many reasons. Some personal, some administrative or practical or professional. So I practiced as a home hospice physician in Chicago from 1995.
I finished my medical training in 1995 when I was about 33. And then I started at the University of Chicago and then I worked as a home hospice physician taking care of people on the south side of Chicago. Home based hospice. On Saturday afternoons I would go to people's homes of people who were dying and take care of them and their families as best I could.
I was part of a Hospital Horizon office in Chicago even though I was at the University of Chicago Medical Center. And then in 2001 I moved to Harvard and then I worked there as a palliative medicine physician, initially on the Paleo Medicine service, hospice service, Mass General Hospital, then I moved to Mount Arvin Hospital. And about 10 years ago now. So it would have been.
When was it exactly? It was maybe 2010 or something like that. I finally stopped seeing patients. I did for a couple of reasons.
First of all, I had taken on some additional responsibilities at Harvard. In fact I was the so called master of just like at Yale, Halloween instant at Harvard with greater success. I had been the so called master of one of the houses, so called it at Harvard for four years or so. And that was important and heavy duty.
And so I didn't have time to continue my clinical practice. My laboratory was taking off. They were doing a lot more science in my lab and it needed my attention. And then I had some logistic Issues like traveling around the city.
Just was spending so much of my time going from place to place. So that's one of the reasons I gave it up. Another reason was that this will take a minute to explain. So when I.
So when I first started practicing hospice medicine in 1995, there wasn't even a specialty aboard certification yet in hospice care. And the care of Americans then as now, was abysmal. So you may, your listeners may not know this, but something like half of Americans die in pain. We're the richest nation on earth, and half of Americans die in pain.
Between 40 and 70% then and still. And we have other awful things. So most of us want to die at home. Many of us, most of us cannot.
You know, many of us have extended hospitalizations before we die, which is unnecessary, or other kinds of suffering before we die. And so I was very angry about this and very concerned about this. And my initial part of my career, I did a lot of research about how to improve end of life care in our society, but I was also practicing hospice physician. But in 1995, the main patients I was asked to see were patients, let's say, in their 60s and 70s and 80s, who were dying of solid tumors like colon cancer or breast cancer, prostate cancer or lung cancer that was metastatic.
And you need to understand that most of the time, 95% of the pain that we feel is what's called somatic pain. When a tissue in our body is affected and the nerves detect the pain and tell our brain, this part hurts. There's a different kind of pain called neuropathic pain. That's when the nerve itself is affected and the nerve is screwed up.
Not the tissue that the nerve is detecting, but the nerve itself, let's say, is being invaded by a tumor. It's called neuropathic pain. So the patients I was taking care of in my 30s were older than me. They were dying of somatic pain, which you can easily treat with morphine.
And I could help the families and the patients easily and enormously. So I could go to a patient's bedside. Things were a mess. No one had talked to them about the fact they were dying.
No one had prepared the family. The patient was in pain. I could give them morphine and just sit there and give it intravenously. It's unbelievable.
You just unbelievable. The patient's in agony. They want to die because there's so much pain and you lose their pants. And you feel so powerful and so physicianly, you feel like you're doing some good in the world using this very simple drug.
Of course there were complicated tricks up your sleeve because often pain is very easy to treat. But there are other symptoms, believe it or not, like constipation or dyspnea. Shortness of breath is awful at the end of life, or itching, which is very hard to treat, can really affect people a lot. And they're miserable from these symptoms and those are harder to treat.
But anyway, so typically I would take care of someone much older than me with a somatic pain and with a family situation that required me to prepare them from like, let's say, a natural end to a decently long life. Okay, 1995. That's my practice. Let's talk about the most powerful force in wealth building.
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Love the way. Well, what happened in the intervening 10 years or 15 years is progressively a lot of these principles got filtered back to other doctors in the hospital. So other doctors became better at using morphine. Prior to 1995, doctors were afraid to use it.
They didn't highly use it. They thought they gave the patient a milligram or 200. They would die, which is wrong. You know, they didn't know.
They were afraid to talk to patients about death and dying. So they would call us to do it because we were the experts. So we would just go and Basically sit and listen, which was, you know, the skill that's required. So but eventually those skills moved correctly and wonderfully moved to the rest of the medical system.
Pain became a fifth vital sign. Up until that point we had heart rate, temperature, respiratory rate and blood pressure with the four vital signs. It was a big move in the 1990s, got a fifth one, pain. So at the foot of your bed, the nurses recording five vital signs.
How much pain are you in? And the idea there was if you ask the patient every day, every day in pain, they can't tell you it's an 8 out of 10, three days in a row, you don't do anything about it, you have to address it. So all of that stuff filters out. So what happened as a result is my personal practice changed and I got older.
So I went from being 35 to being 45. And now I was being asked to see a 32 year old woman younger than me, dying of metastatic ovarian cancer. Metastatic to her sacral plexus, the nerves at the base of your spine, having neuropathic pain, which I couldn't easily treat, and three small children at home. So how can I tell her, help her to accept death, you know, so the caseload became much, much, much harder, honestly.
And do you talk to somebody like that about death? And that, that is. When I heard that you were a hospice doctor, I thought, dude, you were meeting people at the worst period in their life, obviously the family's worst period. I mean, this is like, it would be hard to go home and laugh.
Yes, yes. Well, many, many professions have that, you know, police, firemen, nurses, oncology nurses, burn, burn unit nurses, you know, people who, coroners, you know, there are many professions in our life, in our society which involve contact with, with sadness and pain and, and challenging, you know, very challenging situations. Soldiers, for goodness sakes, you know, who return from battle can have PTSD and so on. So, so it is difficult.
But of course you're a man and you're entitled. It's your job, you know, and this is what you signed up for and you then are entitled also go home and have a normal day and be pissed off while you wait while I at the post office can anyone else or be happy because you're hugging your kids like anyone else. So yes, you can't compartmentalize and most people do. People do burn out in all the professions I mentioned and many others.
And then they switch professions, you know, it's too much for them after a while. So you said, listening, go ahead Yeah, I was gonna say that listening was a key part of talking to somebody about that. Is it just that? Is there a universal thing people want to talk about?
Is it they just need to be heard to be with somebody, or are there actual things you need to impart? No. Many people want to tell their life story near the end of life. This is a very common experience, and they want to talk to their families about it, and they.
Sometimes they want to talk to their healthcare providers about it, and sometimes it's an interesting. I mean, there's some lore among hospice nurses. I don't know, maybe. I don't know how it reaches it.
How many hospice nurses are listening to this? But if. When they hear this, they're all gonna nod their heads and that. You know, that often it's a bad prognostic sign.
The patients will be not doing so well, and then they'll perk up and they'll be very chatty, and they'll tell you about their life story, and then the next day they die. And, you know, I've never seen any formal scientific study of this phenomenon, but I certainly experienced it myself. And it's certainly a lore in hospices that often when the person engages in that kind of life review, especially if they were failing, and then they kind of perk up to do it, it's like a sign of death coming. So, no, I think people.
First of all, people generally like to be heard. I mean, you know, I don't know if we're talking earlier about your Cypriot wife, you know, oftentimes, or if you've seen that viral video about. It's a nail, you know, like the nail in the woman's head, and the guy's just trying to say it's a nail, and she just wants to be. She just wants to be heard, right?
Yes. And, I mean, that story is very gendered, but men are very similar. You know, you. You just want your partner to listen to you.
You know, it's My wife, and I will literally start conversations by saying either I just want to be heard right now, or I actually want you to stop, because we kind of. You don't set that out right at the beginning. You're in for a rule of her. Yes, yes.
And a good marriage will live all this capacity either explicitly or implicitly. And that's exactly right. And oftentimes, just five minutes of listening is all your partner needs. You know, they just want to share with you the problem.
They had a shitty day at work, and they just want to tell you about their day. And it was awful. There's nothing you could do to fix it. They don't want you to fix it.
They just want you to know they had a shitty day at work. And you listen to them and then. And that's such a simple thing to do anyway. It's a very valuable skill.
I learned this, the importance of listening from a magnificent doctor at the Mount Arbor Hospital when I was in medical school by the name of Matthew Carnety. Just an extraordinary human being, a magnificent clinician, a master clinician. So when I was still in medical school, Matthew, Dr. Carney taught me about how to do this.
Yeah, that the ability to listen, I think, is already pretty extraordinary. And I would imagine that part of being good at that is also being able to give people straight, honest talk. There's somebody in my life right now is dying of pancreatic cancer very rapidly talking about from diagnosis. He's, I would say, nearing end of life at this point, is no longer pursuing treatment.
And I think he was diagnosed like two or three months ago. It was post the kickoff of COVID And the. Just the rapid bodily changes, the dramatic loss of weight is. It's really shocking.
And to know, like, to try to run the experiments, which is where this has been interesting in my own life, to try running the experiment when I'm doing something, to think, what will I think about this at, you know, the end of my life? Is this something that I'm going to regret? Is not something that I'm going to regret. And you can realize there really are.
Like, you. You might think that that won't apply to me, but there's so many things that just seem universal. Whether it's, you know, wanting to be heard out or whether it's needing to sort of come to terms with things you regret. It is.
It's interesting, but you need that straight talk to understand what is happening so that you can begin that process. Like, is that something that doctors struggle with? Is that an important part of the process to just let people know what they can expect? Well, my first book was on this topic.
It was called Death Foretold Prophecy and Prognosis in Medical Care. It was a whole book about prognostication and the formulation of prognosis, which is the first problem. Can the doctors formulate an accurate and reliable prognosis? Forget about whether they tell anybody.
And the second, are the chances of communication. Can you. Are they willing and able to communicate a prognosis? And of course, many doctors misrepresent the truth.
They either sugarcoat it and they say everything is fine when it's not. Or sometimes they do the opposite. They do something called hanging crepe. They will say the situation is more dire than they think it is because then the patient does well, the patient will think, oh my God, I'm a great doctor.
You know, I'm living longer than the doctor predicted. Which is this has been discussed for thousands of years in the practice of medicine. So what's the right approach? Because I actually get why you.
Well, what I would do, I mean, I know the right approach. First of all, you just ask. When I was seeing patients, I would ask them, I would say something like this and I wouldn't say it as fast or as callously. So ordinarily I would say it in a very slower.
I would sit down at the patient's bedside and I would indicate my body language. I was there for the duration until they were, they were done with me. Would you touch them? Oh yes, I would hold her hands, of course.
So interesting. Oh goodness, yes. And I, I, I had of course a particular physician who examined patients all the time and but we're getting weird societally about touch men. I am way worried about touching people that I don't know very, very well.
Yeah, that's a whole other topic. But in a professional situation, you know, where of course you would sit down to bedside and it's very normal in human to hold her hand or you often have to be my patients. I would examine them or whatever. But so you communicate with your body language that you're there for the duration and, and then I would say something like it, I wouldn't say quite as rapidly or as directly, but the gypsum, it would be something like people vary in their desire for information about what's likely to happen to them.
Some people want a lot of information and some people don't want very much information at all. What kind of patient do you think you are? And they might say, you actually doc, I don't know anything. You know, do more people want to know or more people.
Most people in our society say yes. But it also varies. It's ethically stratified. So there are many, many people, for example of Hispanic descent or, or Asian descent who say, talk to my children.
You know, I don't want to discuss that. So, so there's a lot of variation. There's some variation. Most people do want to know.
And then you also have to recognize it's not a one off thing. You know, if you've developed a relationship with the patient, you're gonna see it again and their ideas about what they want to know will change and their clinical circumstances will change. So you can discuss this with them at some future point anyway. And then the question is, how do you communicate the bad news?
And there's a magnificent book by John Hopkins University Press. It's called how to break Bad News by Buckman is the guy's last name. Can't remember his first name is Robert or Richard right now. Anyway, it's an incredible book and it's actually good in life in general.
It's intended for physicians and nurses on how to break bad news, but actually just good in life in general. If you want your teenager, your father or mother crashed the car. How do you break bad news? There's like good tips in there on how to do this and there are a number of principles.
One, for example, is firing a warning shot. So you say, you know, I'd like to talk to you about some serious matters or you know, I'm afraid I have some unfortunate news. So you fire a warning shot. You know, you'll just deliver bad news.
You allocate time. Like I said earlier, you also. It's crucial in hospice care and caring for patients. A very important thing is a commitment to non abandonment.
So both doctors and patients especially, but doctors too, one of the reasons they don't have these conversations is they're afraid that the doctor, the patient, the doctor will abandon the patient if the patient is dying. Let's say they're worried that the doctor will just give up on them. So I was always very careful to say, you know, I have this bad news and I'm delivered the bad news. And then I would say, but I promise I will not abandon you.
And there's much that we can do to address her condition even if we cannot stop its course. So you communicate to the patient. Not abandonment, support are things you can do. Empathy, sympathy, interest.
Right. There's lots that's humanly available, you know, even at the end of life. So anyway, we're off on multiple chances. This is old work I used to do a long time ago.
Yeah. I came across death were told when I was doing research on you and I just, I find that part of your story so interesting and so raw human. And one thing I'm always trying to do when I research somebody is to actually understand them, to understand their worldview and just the, the hospice thing which is an act of service so grand like I don't know that that can be overstated. I know you may not see that why she actually did it.
But from the outside, like that seems patently true. And then when I go into what you're doing from the looking at culture, but more importantly, having ended up writing that book as a way to try to get us to, as a society to focus on the good and not the bad. Good is even the title of the evolution of a Good Society. I can feel you trying to help and be useful, which I find particularly.
Very, very kind of you to say that. Honestly. It's a very kind thing you just said to me. Thank you.
It is. I think it seems accurate. Look, we've never met before now, but it just seems to hold true. And everything that I've watched and read about you leads me to that out, which I'm interesting.
What motivates people to do they do and to try as hard at the things they try. And this seems like a really interesting period in time for somebody who focuses on the things you focus on. When I think about colonizing Mars, Right. You write extensively about shipwrecks, which that may be one of your intentional communities, but y' all talk about communes.
So, you know, looking at what's gonna happen in Marsink, what's going on in AI Robotics. Yeah, I do some of the robotics work in my lab too, but. But we do some work on social robotics and, and what we call dumb artificial intelligence. But the Mars stuff, when I was.
I. I'm 58, and I thought I would live long enough to see a human on Mars. You know, when I was a boy, I thought I would live to see that. It was so important to me.
And I. I don't think I'm gonna live to see it. And I'm so sad about it because it's clear we're gonna colonize Mars. And I suspect in 100 years, 200 years, when we have sort of colonies going, it'll be a replaying of the new and old world.
The colonists won't like having to send resources back to the, you know, to Earth. And they want independent government. And all that stuff, I'm convinced will play itself out. I think we will eventually terraform Mars.
I think it's inevitable. There is. I mean, there's technology to do it, you know, take time and it's expensive now, but we'll get better and better at this. And initially we'll live in, in the bubbles that we construct there.
And anyway, that's all gonna happen eventually. But I would love to at least live long enough for people to. To, you know, to witness a human being get Getting to Mars and I saw the Martian. I've watched it a half dozen times.
It's Matt Damon and you know, it's just. It's so deeply moving that movie and imagining him on that surface as the first person he goes everywhere I go I'm the first person ever to have been here, you know. Anyway, I thought that movie and the book was magnificent. It is a very fascinating thing the whole idea of humans striking out to have that adventure spirits.
You want to do that but then understanding being able to colonies. Yeah. So in fact I had it in the book. I took it out.
NASA has for years looked at shipwrecks as models for what would happen in an isolated colony. And in fact in other experiments like for example, I discuss in the book the scientists that winter over on the South Pole. Small communities, about 30 scientists every year that winter over there. So you know, how do these people get along?
And so I discussed the shipwrecker extensively blueprint and I had a whole section on the colonization of space but I cut it out because the book was already too long. Maybe I'll publish it one day. Oh man, that would be really interesting and I'd love to know of talking about things like pick Karen and where I'll say that was a. The.
Everything has to do with the exact people that go for sure. And your breakdown, Shackleton. I've read the book Endurance. It's phenomenal.
Talking about how he. They were gone for like two years or some crazy amount of time. He was an extraordinary leader and the men were. Had an extraordinary spirit and they were able to survive.
No one died. It's unbelievable. Unbelievable. Like people when you read the book you're like there's no way like when you.
Because you're reading it, you know, in a relatively short amount of time. So you don't think about the fact that two years a long time to be wet and cold like wet cold and not know if you're about to die. Yes. And my favorite, my favorite story in the book which I stumbled on is the story of the graphene and the indigo on the south auckland Island in 1864.
So it was almost a perfect natural experiment. Two shipwrecks on the same time on the same island never encounter each other. Totally different outcomes. On the southern part of the island, the grafted wrecks, five men wash ashore, they survive for a couple of years and all make it off alive.
On the Inverco, 19 men wash ashore, all but three of them die. And they're very different stories. And what they did. How they did it, you know, was wonderful for me to read.
I was even tempted to write a whole book about just that contrast. But I, you know, I decided to just tell a brief version of their stories, which are amazing. Even the brief version was really fascinating in terms of. So from my own memory of reading Shackleton or Endurance, how one he was trying to.
And you talk about this in the book, he was giving people an opportunity to teach each other so that one be high one minute, low the next, and so created what you refer to as, oh, God, mild hierarchy. The notion we need a hierarchy, but if it gets too crazy, then people end up revolting, and then the other guy was all about every man for himself and became cannibalistic and pretty crazy. Yes. Yeah.
Shackleton did lots of things that were very interesting, and his men did it. Wasn't just him, he was an extraordinary leader, but the men, too, were, you know, very good with each other. And this notion of setting up school. So a lot of the shipwrecks that did well were ones in which they set up a school where they taught each other things.