We have two tubes that are right next to each other in the throat.
One is for food, drink, saliva, mucus, snot, whatever you're going to swallow.
All of that stuff must go down the esophagus, the food tube, and end up in the stomach.
And right next to the esophagus, millimeters away is the windpipe or the trachea,
which goes down to the lungs.
Throat, heart, feces, genitals.
Every organ from moment to moment keeps us alive and ensures our survival.
The genitals are, in a way, the opposite.
How would you improve the penis and the vagina?
The following is a conversation with Jonathan Reisman, a physician and writer of The Unseen Body,
a doctor's journey through the hidden wonders of human anatomy.
He has practiced medicine in some of the world's most remote places,
including the Alaskan and Russian Arctic, Antarctica, and the Himalayan mountains of Nepal.
This is the Lex Friedman podcast.
To support it, please check out our sponsors in the description.
And now, dear friends, here's Jonathan Reisman.
You wrote a book called Unseen Body, all about the human body, the messy, the weird, the beautiful,
and the fascinating details.
So, from an evolutionary perspective, are most parts of the human body a feature or a bug?
Is it like the optimal solution or just a duct tape solution?
Great question.
I think that most of the time, the way the body works is the best solution.
I haven't seen many alternatives, so it's hard to compare.
But I think there's some parts of the body that make more sense than others.
The way our hands work, for instance, the muscles are up in the forearm
and then the tendons kind of come down like strings on a puppet.
And just the dexterity it gives our hands is just really amazing.
And it's hard to imagine a better tool than the human hand to do everything from hold things,
to play piano, and do a million other daily activities that we do.
One thing I talk about in the book, there's some other body parts that seem to be lacking
that kind of brilliant design, such as the throat, where the food, drink are swallowed
and air is inhaled and those two paths come within millimeters of each other.
And you slip up once, you laugh while eating, or you speak while trying to swallow
and you die from choking.
So it seems less than optimal, though I'm not sure it could be better
from the way we're kind of formed in the womb as a beginning as this tiny little tube.
I don't think it could have been done any better or there's any other way to do it,
but it is an unfortunate thing that, you know, does lead to some problems.
So the hand, if I could just link on that for a second.
You talk about the wisdom of a design in the book, what are the important things about the hand?
It seems like very useful for many things and it seems to be quite effective.
A lot of people think the thumb is foundational to the human civilization.
Is there any truth to that?
I think that is true.
Actually, one of the ways in which the importance of individual fingers comes
to attention is when people have severe injuries to their fingers, for instance.
I have a story in the book about a guy whose thumb is nearly ripped off by his dog's leash.
And, you know, when plastic surgeons who are often the ones to repair that,
sometimes it's orthopedic surgeons, they will debate, you know,
how important is it to save this finger or how important is it to save, you know,
let's say the kind of tip, the one third, the tip one third of one of your fingers,
you know, depends on the length that you lose, it depends on which finger.
And so the thumb really is the most crucial just, you know, for your occupation in most cases
to just daily life and your ability to get around and take care of yourself and others.
So, you know, they'll be more, they're willing to go further, do more surgeries,
more aggressive therapy to save a thumb, let's say, than, you know, the tip of your pinky finger.
So in that way, I do think the thumb, you know, does seem like the most important in many ways.
It's nice that there's backups.
I wonder if that's part of the feature or is it just the symmetry that nature produces?
You think the two hands is like, is it about the symmetry or is it about backup?
We'd be much less formidable hunters, gatherers, survivors in any way if we only had one hand.
So I think that is important to have too, so we can, you know,
even everything from kind of spearing an animal to firing a bow and arrow to butchering an animal.
You really need two hands to do it very effectively.
But can you do a better job with three?
Great question.
And we'll never know, perhaps.
Um, you tweeted, now I'm going to analyze your tweets like it's Shakespeare sometimes.
You tweeted that quote, millions of years of sex and death designed the human body.
It's like poetry.
Are those two basic activities basically summarize everything that resulted in humans on earth?
So like, is that a good summary of the evolutionary process that led to this conscious intelligent
being is death and sex?
In a way, yeah.
So sex is how more of us get made, obviously.
And death is how we get weeded out or the gene pool gets weeded out
and certain genes survive and others don't.
And, you know, the age at which we die, whether it's before we've, you know,
had sex and reproduced ourselves is a big factor and who survives,
who doesn't, who passes on their genes and what the future of the body looks like.
You know, who lived and who died before they were able to be at reproductive age a million
years ago was pretty important in what we look like now.
And perhaps how we have sex and die now will determine what we're shaped like unless technology
has an even bigger role in that, you know, a million years from now.
So do you think that's fundamental to like, if there's alien civilizations out there that have
the same order of magnitude of intelligence or greater, do you think that we will see something
like sex and something like death?
So the reproducing and this selection process plus the weeding out of the old to make room for the new,
is that kind of foundational to life?
I would think so.
I mean, it sure seems to be on earth, you know, perhaps in some distant future when
medicine is nearing, you know, perfection and people can live a really long time.
Maybe we won't even need to reproduce as much or something like that.
You know, it's hard to even know what life will be like in the distant future.
But I would guess that any alien civilization will have the same dependence on who has sex and who dies.
Well, that's the problem with immortality.
How are we going to clear out the old to make room for the new?
Which is kind of a, it's like a framework of adaptability to changing environments.
So as long as the environment is changing and it seems to always be,
because this is the entirety of the earth system is a complex system,
it seems like you have to adapt and to adapt, you have to kill off the stubborn old ideas.
And unless there's a way to like not become stubborn and old, but it feels like the nature of wisdom
is stubborn and old.
Like that's, that's what wisdom is.
It's like the lessons of life, the lessons of experience solidified.
And the solidification is the thing that actually prevents you from reinventing yourself
to adapt to the new changing conditions.
But then again, why not have that both of those modes?
Like I have two minds in one person, one immortal person that like in the morning,
they act like a teenager and the evening they act like an old wise man.
That's possible.
So you can imagine within one mind, both modes, but those are required.
You have to have, you have to have the ability to completely reinvent yourself,
which is what death does in an ugly way or a beautiful way, depending on your perspective,
depending whether you take the human perspective or the human, the nature's perspective,
and then you have to have the selection.
So competition, so sexual selection.
It's an interesting, interesting little planet we got.
What's the weirdest part function concept idea about the human body to you?
We'll talk about fascinating details, but what's you,
you, I should say, for people that should read your book, they will come face to face
with the fact that you do not shy away from the weird and the wonderful of the human body.
It's like, it's fun, but it's honest.
So given that, sorry to make you pick one of your children, but what's the weirdest one,
would you say?
The weirdest body part or concept or function.
So the chapters, you divide it up kind of into parts, but there could be a thread that connects
all of them, the weirdness, maybe, or maybe the texture of the substance could be the liquids,
the solids, I don't know.
Definitely every body part and bodily fluid has their own kind of both gross and fascinating
aspects, that's probably why I'm a generalist as a doctor and couldn't just, as you said,
pick one of my children, become a specialist because I like them all.
I feel like one of the strangest concepts about the human body is that kind of the
aspects of it that are the most universal that we all do are the most taboo socially.
I wouldn't have expected that if I had, you know, just looked from the outside,
like what we do in the bathroom, what we do in the bedroom, what we do to our own genitals,
what we do to our, you know, quote unquote, private parts, they're private, even though it's
sort of the thing that we all have in common, is the most we try to hide from other people
and don't talk about in polite company.
I mean, it makes sense as a human living in the society, but from the outside,
it sort of might be surprising.
How do you make sense of that if you put on your Sigmund Freud hat?
The thing we all do, why do we make that a taboo thing?
Is it because we like taboos?
Maybe we get off, or maybe our kinks as humans is to have taboos,
and it's kind of efficient to have taboos about the things that everybody does.
Like you can make walking taboo or something.
I don't know, but just maybe that's what we love.
That's what's exciting to us is the forbidden.
I think, yes, society loves rules for sure.
They love some societies more than others.
You know, they love controlling how you think and what you do in public versus in private.
You know, there's a lot of societies where, for instance, parents have sex in front of children.
Not, you know, for instance, like in a traditional Inupia Eskimo
societies that was sort of normal.
I mean, but what are you going to do?
Go outside in the middle of the winter in the Arctic and do it out there?
Of course not.
So, you know, there's different taboos in different societies.
Some taboos make perfect sense.
Some taboos are even public health measures.
You know, like as I talk in the book about in India where they, you know,
the hands are symmetric, as you said, but in Indian culture, and the left hand is taboo.
And the right hand is what you use for shaking hands, for eating, for other things.
And the left hand is the dirty hand that you use for wiping your own bottom.
You know, that's the toilet paper is your left hand.
So, while the body is anatomically symmetric, the taboo creates this pretty intense asymmetry.
But for a good reason, you know, yet you probably shouldn't be shaking hands with other people
with the same hand that you use to kind of clean your bottom.
So, in that sense, it makes sense.
Yeah, maybe the roots of it makes sense, but the way propagates, especially as the times change,
might not, because you can wash your hands, but the taboo remains.
Right. Society is very slow to change.
What is the most fascinating part function or concept in the human body?
So, you know, something that fills you with awe.
I guess the most obvious one is the brain, partly because it's so, you know, sort of
poorly understood, though we understand more than we ever have in the past.
There's still so much that we don't understand about how the lump of matter in our skulls kind
of creates this subjective experience that we all kind of understand quite viscerally.
That's an easy one. I would say the kidneys are an underappreciated organ.
They, the way they tinker with the bloodstream, raise levels of this, lower levels of that,
kind of our entire lives from inside the womb until we die is just really incredible.
And when you look at how much energy different organs consume, the brain and the kidneys are
two of the biggest ones because the brain obviously in us is always active and controlling
parts of the body, but the kidneys are just consuming a ton of energy to do what they do.
They're kind of the unsung hero of the body relegated to the back of the abdomen, like
some forgotten organ, but they're, they are great. I did consider being a nephrologist,
which is a kidney specialist because I was so taken with the kidneys, but, you know,
decided I like all the organs, so couldn't pick just one.
So your book is ordered in a particular way. It's throat, heart, feces, genitals, liver,
pineal gland, brain, skin, urine, fat, lungs, eyes, mucus, fingers and toes, and blood.
All right. First of all, great, great chapter titles.
Is there a reason for this ordering or is it all madness?
There's a few different reasons that went into it. I did want to start with the throat for
the reason that it kind of presents the topic of death, which is sort of obviously very important
in the training of a physician in the career of a physician. It's a big part of what I deal with.
You know, in the first day of medical school, we started the dissection of a cadaver in the
class called Anatomy Lab. And so in a way, we were kind of thrown right in there in the beginning.
Like, this is the end of the human story, you know, understand this, and then we sort of backed
up to the beginning with embryology and reproduction and stuff. So it's kind of like, we got,
and I got thrown into that right away, right in the beginning, kind of like, here's a dead body.
Now, start cutting it apart and learn the name and function of absolutely every bit of flesh.
How did that change you, that first experience with the cold honesty of human biology?
Right. That's exactly what it was. It's cold honesty about the kind of the story of each
individual human body. It has an end, and that's it. I think that, well, actually before the end
of that first day, so what we did on that first day was study the superficial muscles of the back,
like the lats or latissimus dorsi and some other muscles. You know, we cut through the skin of
the back. My cadaver was lying face down on this metal gurney. We pulled back the kind of plastic
sheets that would keep him moist for the next four months as we dissected him, cut through the skin
on his back, and then started dissecting through the superficial muscles of the back. And that was
really all we saw that first day. We didn't get any deeper, didn't enter the abdominal or chest
cavity to see internal organs. But I was so fascinated with this sort of behind the scenes
look at how things work in the body, how you move your arms, how you arch your back. You know,
these are the muscles that do it, that I decided I wanted to donate my own body for the same purpose.
So I made that decision literally before the end of that first day of class, and I'm still sticking
to it. So someday there'll be a medical student that can watch and listen to this podcast while
dissecting your body. It could happen. They might not know that that person they're listening to on
the podcast will be the carcass in front of them, but like we don't, we never learned it. The universe
will know. The universe will know. And they will acknowledge the irony or the humor, the absurdity
of that. The universe will chuckle, but the medical student won't know, because they never, as I did
not learn any, you know, personal information about the person, only what I could glean from
looking inside him, which actually tells you quite a bit. I knew he was a smoker. I knew he had
coronary artery disease, you know, you get a window into, I knew he was overweight, you get a window
into people's lives just by looking in their bodies after death. Other cadavers in the lab,
not my own, or I shared one with three other students, but other cadavers. Some had, you know,
metal joints, like a knee replacement. Some had a kidney missing. So they probably, and we could
tell it was surgically removed, not that he was born with one. And we could tell that he probably
had a kidney tumor or cancer that was removed. So you do get an insight into people's lives from,
you know, picking them apart after they're dead, but you don't know their name or what podcast
they've been on. So the, as the book title says, unseen body. So it tells some kind of story of
your life. So it does capture the decisions you've made in your life, the things you've done,
that might be kind of secret to that person and maybe to a few others that knew him or her well.
It's so fascinating. So what kind of things can it reveal? Like what kind of choices in terms of
the injuries, the, the, the catastrophic events, the lifestyle choices of smoking and diet and all
those kinds of things. What, what, what can you see? What kind of history can you see about the
human before you? So all those things you mentioned are things you can see. You can, you know, take
the skin, for example, right? Most things that happen to us leave a mark, you know, as I say,
kind of a story written in the language of scar, where it tells you injuries you've had. And same
thing with animals, you know, I've, I've seen deer hides that have marks that look like they're
made by maybe a barbed wire fence, something like that. You can tell, you know, you sometimes it's
conjecture, but you can sort of imagine what might have happened to cause that perhaps, you know,
two bucks were fighting and one got injured with an antler. And the same with humans, you know,
I have scars on my body. And when I notice them, I remember what happened. You know, I got a big
cut on my hand when I was 13. And it's still there. And I remember what happened, you know,
every time I look at it. And so in that way, only I might know that story, but other people, you
know, when they dissect me and notice the same scars, they can kind of, it can fire their imagination
as my cadaver, you know, did for me. They know that there is a story there. That's such an interesting
way that the skin does tell a story. Both tattoos and scars. Right. And some of the fun you've had
and some of the damage you've done. Right. And even when I, when I evaluate a patient, I can use
scars to help me make medical decisions. So for instance, someone that comes in with abdominal
pain into the emergency room, you can see scars on their abdomen that tell you about, you know,
the past kind of activities of a surgeon, perhaps. I know, I recognize the scars that are left when
someone has their gallbladder removed, the scars when someone has their appendix removed, when maybe
when someone's had a hysterectomy. And that can tell you what it might be or what it isn't. You
know, if someone doesn't have an appendix, their abdominal pain is not appendicitis, end of story.
So in that way, I'm sort of looking at these, the tracks of the footprints of past surgeries to
tell me what might and might not be the cause of this patient's abdominal pain, which is kind of
my main job in the ER, is figuring out what's causing it and to help them. Is there ways to
get more data about the human body as we look into the future of medicine biology that will be
helpful to fill in some of the gaps of the story? So, you know, you have, you have companies,
you have research that looks at, you know, a collection of blood over long periods of time to
see sort of, you know, paint a picture of what's happening in your body, mostly to help with lifestyle
decisions, but also just, you know, to anticipate things that can go wrong and all that kind of
stuff. Is there, can you just speak to a greater digital world that we're stepping in, how that
can help tell a richer story? I certainly think that we have more data than we know what to do
with right now, especially with kind of direct-to-consumer medical devices, you know, smartwatches,
etc., that are just collecting these reams of data. I have not seen them put to, I think, the
eventual use that they will. I think that the potential is sort of just, you know, unimaginable,
and I hope we're heading into a new age where, you know, you can determine, for instance, is a
person going to have more of the dangerous side effects to a drug based on their genetics, or are
they going to tolerate one drug better than the other, you know, based on their genetics. And
we are slowly moving into that age, and especially the age of kind of completely synthesizing drugs
in the lab, you know, much like, for instance, some of the COVID vaccines, actually, like Moderna
never had the virus in their lab. They made that vaccine completely without ever having the virus
themselves, just by having the genome, which is sort of astounding. And there's a lot of potential
going forward, you know, based on that technology and some others.
Well, I didn't know that. So they basically, it's all in the computer. It's computational.
Right. You have the genetic code. You have tremendous power, even if you don't have the
organism itself. What do you make of Elizabeth Holmes and efforts like that? First of all,
I'm a curious, I'm drawn to the darkness in human nature, because that somehow reveals
the full spectrum of what humans could be. So there's a lot of sort of controversial thoughts
about who she is and her efforts and so on. I think you may have even tweeted about it,
but I've read a lot of your tweets, so I'm now forgetting. But what do you make of her and
both those efforts and the charlatans that sort of snake oil salesmen that promise those efforts
to do more than they currently can? I think that her, you know, that goal that she had,
that she created Theranos to try to achieve, to use less blood in tests is a very worthy
goal and a huge frontier that we have not achieved and that I hope we will achieve.
So I understand why, you know, someone describes what a huge step forward that would be,
and it would be indeed, I understand why people put a ton of money behind it.
Can you describe what was the promise? What, what are we even talking about? What's Theranos?
What just for people who don't know?
So Theranos is a company that was basically started to revolutionize the way medical blood
tests are done, both to use a whole lot less blood in doing it. You know, if anyone's ever been to
the doctor and had five to ten tubes of blood removed from them, it can be quite surprising
how much they take out. And, and it's, you know, that's the limitation of our technology that we
need those volumes of blood to run all the tests that we want to. And so the promise of Theranos
was that perhaps with a single drop of blood, we would be able to know as much about the persons,
the condition of their, their body without drawing all that blood. And, and thereby, you know,
there would be these devices she was going to create that would sort of do it. You put a drop
of blood in and spits out everything you ever wanted to know about what's in your bloodstream.
And in a way that would make it so much easier, you know, could be, you could have one in your
home, theoretically, and you, I don't know why you'd wonder what your potassium level is on any
given day, but you could check if you wanted to. And so that, that goal is very worthy. You know,
I put that goal up there with the frontier of making painkillers that are as good as opioids
without the addictive quality. You know, that would be such a huge revolution if we did have that
in medicine. But particularly for me, because I trained in both pediatrics and internal medicine,
so I learned to care for both children and adults. In children, we do draw much less blood. They have
a much lower blood volume. And we use these tiny little tubes to draw their blood. And we seemingly
get equivalent information out of the larger tubes we draw from adults. And I'm still unclear,
to be honest, why we can't draw that little amount of blood from adults. It seems technically
possible. I don't know what the barriers are. I'm sure there are or else we'd be doing it.
But I do think that that is a very important goal. And if Theranos had done it, they would have
really revolutionized the practice of medicine. So to return to that cadaver, that first day
when you got to meet with a dead, with a human body that's no longer living. So how quickly
did it take for you to get used to sort of, you said, looking at the surface muscles of the back?
I mean, that can be overwhelming as a thought. And people listening to this that have never
dissected anything might be overwhelmed by that thought. So how quickly were you able to get
used to the brutal honesty of the biology before you?
For me, it did not take long at all. I guess I've never been a squeamish person. So for me,
it was kind of riveting and fascinating right from the first moment. But I do know some of my
fellow classmates did have some trouble with it. Some of them I heard had nightmares in the first
few weeks of anatomy lab. But then everyone, as far as I know, got used to it. And that was also
actually a big lesson for me, that it's pretty amazing what people can get used to in their
daily lives. And I kind of extrapolated that to people living through war and through just
terrible situations and living under oppressive regimes. And it really is amazing what people
can get used to, almost anything. But in war, people often come back and they
have nightmares. They suffer through it. There's PTSD. There's a lot of complicated feelings
with that. Are echoes of those same complicated feelings possible in the case of training to be
and becoming a doctor? It's a good point. Yeah, I think sometimes just as a barbed wire fence can
leave a scar on your skin, emotional psychological experiences can leave a mark on your brain or
your memory. And I think that that definitely could be a problem in medical training. You do
see a lot of things that are very shocking, very repulsive things that you'd never forget. I know
one of those students that had nightmares initially went on to be a surgeon. So I imagine she's not
having the PTSD of kind of seeing inside her first dead body because she sees inside them
all day every day now. But I'm sure it could. We go on to see so many kind of grosser or more
shocking things in medical training through medical school and then by working with actual
living patients, not just dead and embalmed bodies. So I do think that things can leave a mark,
but I don't think that initial cadaver would be the most traumatic.
Yeah, but maybe some of that trauma, the demons make you a better surgeon,
just like some of your own psychological trauma might make you a better psychiatrist.
Returning to the ordering. Is it order or is it chaos to the ordering of the chapters
from throat and heart and feces and genitals all the way to fingers and toes and blood?
So I did mention that throat was the first one because I kind of wanted to throw the reader
right into the brutal honesty of death. And I followed it up with feces as the third chapter
and in a way partly to also throw them right into the deep end of how I like discussing parts of
the body and revealing their gross and fascinating aspects. So I didn't want to hide anything. You
know, when you train to be a doctor, everything is on the table literally in the cadaver lab,
but also just, you know, you deal with blood and piss and vomit and feces. And that's kind of
the medium of your craft. And yes, the medium of the craft. That's right.
Right. Like if you're a painter, this is the paint that you wear.
Exactly. And then you have to create a masterpiece with it. Like almost like a dance because there's
multiple painters. One of the painters is the biology. So let's return to throat. You mentioned
it's a weird one. So first of all, a friend of mine said, I just see humans as like a bunch of
holes that just walk around. Not untrue. It's a funny way to look at humans. So we have ears,
we have nose, we have mouth, we have the sexual holes, vagina, penis. And then, you know, what's
the medical term for your asshole? Anus. Anus. Thank you. This is a very technical discussion.
The rectum's further in. Don't confuse the two.
Oh, that's very important. What is the difference between throat and mouth?
By the way, so when you say throat, are we talking about when that hole actually becomes tubular?
The throat, I would count as just sort of the very back of the, you know, the back of the mouth,
where the nose also comes down and meets it, where the tonsils are and the uvula.
But you're right that, you know, we are a bunch of holes, but more accurately, we're a tube,
right? We start in the womb as kind of this microscopic little disc, almost like a,
you know, a flatbread. And then we roll almost like a burrito into this tube. And we're a simple
microscopic tube. And from there, we grow into this bigger and bigger tube, and we become more
complicated. And each end of the tube does split into various holes. So all the holes you mentioned
at the front end of the tube, the front end of our body, right? It splits into the nose,
the mouth, the ears, the sinuses, the tube to the lungs, which is the windpipe, the tube down to
the stomach, which is the esophagus. And then the other end of the tube splits as well. You know,
men end up with two holes, and women end up with three holes. You know, the urethra, the vagina,
and the anus, and men just, you know, the urethra and kind of the reproductive system,
they share a hole. So I'm learning a lot today. It really is incredible that you start
from sperm and an egg, and you have some DNA information. And from that, the building project
begins. And then what that leads to is like a, like a pizza dough, and then you roll it
into a tube. And that tube then eventually sort of becomes more and more complicated and gets
eyes and a brain and then can create a Twitter account. So from, it's really incredible that
we're just a fancy tube. Right. We are. And we sprout eyes and a brain and a sense of smell and
taste pretty much to regulate what comes in the front of the tube. You know, we don't want to
eat anything dangerous or poisonous. You know, we want to choose what we eat, even choose who we
kiss. Well, we seem to be motivated by what comes out of the tube as well, in part. That's not just
output. It's a feedback mechanism, seemingly. Like we're also monitoring the functioning of the
output. We're not just obsessed about the input. We're very obsessed with the output. You're
absolutely right about that. People, you know, have medical complaints about their output very
often that are, you know, I'm never, I never cease to be surprised by a new kind of complaint
or observation about the output. I think people have gone to wars over the output and maybe
sometimes the lack of the output or the desire for output for the particular other humans
that you fancy the brain and the eyes that sprouted somehow convinced the rest of the body
that this one particular other tube is fanciful. So you're going to go to major wars and lead
global suffering because because of the fancy and the desire for additional output with the other
tube. Okay. So that's, so on the throat, that part of the tube. Is it, you said the design is
not, you could have thought of maybe a little bit better options because it's too multifunctional.
Is that, can you sort of elaborate on the multifunctional nature of this part? Are a
lot of parts of the human body multifunctional or do you find that it's more specialization is going
to get the job done better? There is a lot of organs, for instance, do have multiple functions,
you know, the pancreas has two, is like two organs in one, one, you know, secretes hormones
like insulin into the bloodstream and the other aspect of it secretes digestive enzymes into
the gut to help you digest and absorb food. The liver is like 15 organs in one. It's just amazing
how many different things it does. But the throat, you know, so basically the problem with the throat
is, as I said, we have two tubes that are right next to each other in the throat. One is for food,
drink, saliva, mucus, snot, whatever you're going to swallow. All of that stuff must go down the
esophagus, the food tube and end up in the stomach. And right next to the esophagus, millimeters away
is the windpipe or the trachea, which goes down to the lungs. And your, your throat does these
daily gymnastics to keep everything but air out of the windpipe because, you know, you slip up once
and you can die. You can choke, you know, you laugh or speak while eating and its curtains,
unfortunately. So it seems like, you know, every aspect of the body when I was learning about it
in med school seems so brilliant and so perfectly designed by evolution or whoever you might think
designed it to, you know, favor survival to enhance life. But the throat seemed the opposite. It seemed
set up almost for failure. And, you know, we developed all these mechanisms as a compensation,
right? We have the gag reflex whenever food or something is headed towards your airpipe,
your windpipe or down to your lungs, your throat has this sort of like rejection of it. It pushes
it away in a gag reflex. At the same time, we have a cough, which is something our body does
when something inappropriate does get down the windpipe. You know, when we get a little food
down the wrong pipe, we end up coughing and the coughing does usually flush it out and get rid of
it. We even have something called the mucus elevator in our lungs, which is this constant
flow of mucus up the airways, up to the trachea, dragging with it all kinds of particulates that
we've inhaled and perhaps some food that went down the wrong pipe and drags it up into the throat
and we swallow it kind of unconsciously all day every day is the truth. Even the mechanism of
swallowing is super complicated. You know, it uses a number of cranial nerves. It uses over
15 different muscles. It's this coordinated act to keep food out of the airway. You know,
you can see someone's Adam's apple in their neck kind of jump upward when they swallow,
you know, which helps lift the airway up against the epiglottis, which plugs it closed and allows
food or swallow drink to kind of skirt just past it. But every time we swallow, those things do
come within millimeters of going down the wrong pipe. And it's just thanks to these kind of
compensations, these adaptations we have to the danger of the throat that keeps us alive.
As I actually took a sip of water, it makes you appreciate the wonderful machinery of it all.
By the way, we have pulled up your Instagram that people should follow. You have a post
about the throat and just showing so many different components from the tongue to the trachea,
the esophagus, just the entire machinery of it all, the teeth for the chewing.
It's so interesting. And so a lot of the structure of this, the anatomy and the physiology,
does it echo other mammals? Are we just basically borrowing a lot of stuff from evolution and maybe
making small adjustments? Maybe due to the fact that we're not using our mouth to murder things
as other predators might. We use our thumbs. Exactly. We have hands. We don't need to bite them.
Yeah, there's a lot of overlap between different animals, which I find very comforting and
fascinating. Someone asked me, is there any animal in which the throat is better designed?
And my first thought was whales, because the blow holes kind of up on the top of their heads.
So I was thinking, oh, maybe they are more separate. But when I looked into it, actually,
no, the paths do come very close just like in us. And I saw a paper about some new
discovered organ that actually helps keep food and drink out of the airway in whales that they
hadn't ever noticed before. So it's a different mechanism, but the same kind of basic problem is
that we're tubes and the air tube and food tube are right next to each other.
How well do we understand, so just even lingering this little part, is there still mysteries about
the complexity of the system? Because you mentioned just even for swallowing all these parts in the
brain that are responsible and all the different things that have to, like an orchestra, play
together. Do we have a good sense from both a medical perspective and a biology perspective,
or is there still mysteries? There's definitely still mysteries. We understand a lot about,
for instance, how the swallowing mechanism is coordinated in the brainstem, sometimes using
some higher levels of the brain. But it is a very thoughtless thing, as you mentioned when
you drank the water. It's not something we have to think about, thankfully, or we'd be thinking
about it all day. There's a lot we don't understand about the basic mechanisms, perhaps about how
the nerves fire and how they coordinate on the microscopic level, how ions rush into and out
of nerve cells to create that electrical signal. But we sure understand a heck of a lot, and it's
very fascinating. So moving on to chapter two, we'll jump around. You actually said the liver
does a lot of things. I also saw you retweet something where it said, showing that the liver
is bigger than the heart, which is the body or the universe's way of saying you should drink
more and care less, which is a good line. So you give props, like you said, to the kidney,
to the liver, to the organs, to the parts that don't often get as much credit as they deserve.
But let us go for time to the human heart. We get chest pain. We talk about it when we talk
about love for some reason. Why do we talk about the heart when we talk about love?
There sometimes can actually be some chest pain involved in love. I remember when I was a med
student, I was very smitten with another medical student. It was totally brilliant and beautiful.
And it actually does cause this kind of burning in your chest. I don't know what that is. I don't
think it's from the heart itself. I don't know if it was like acid reflux because I was so nervous.
I'm not really sure. But I definitely felt something in my chest whenever I saw her. I don't
know what that is. But you could see why someone might think, oh, maybe it is your heart. That's
kind of the most prominent organ in your chest. And when people come to the ER with chest pain,
the big question is, is it my heart? And that's my main job is figuring out if it is or not.
So I could see why. The way ancients saw the functions of different organs is fascinating,
but often hard to explain. Would it be fair to say that if you look at the entirety of human
history, the way most people die has to do with the heart? Well, like in America today, cardiovascular
disease and coronary artery disease is one of the most common, perhaps the most common cause of
death. 100 years ago, 200 years ago, it was probably not people were not living as long and
people were dying of infections that we tend to die less of these days. Sure. That's true. But
in terms of things to stab, so I'm trying to sort of introspect like why talk about the heart
and love. My thought would be that is because the heart was seen as the most important organism.
It would be like the origin of life comes from the heart, the originator of life and the way you
figure that out from sort of an ancient perspective is when you stab things, what is likely to lead
to issues. It's possible to imagine that the brain is not as special as we might think from
when you don't understand modern biology or physiology or neuroscience, all those kinds of
things, especially because pain is painless too. If you stab it, the brain, I mean. Yeah. Anyway,
so that's really interesting. I'm sure there's a kind of a poetic answer to maybe the way people
wrote about it, but what to you is the wisdom in the design of the heart? I mean, the main function
of the heart basically is to push blood through the cardiovascular system, through the branching
blood vessels to feed every cell in the body. I believe our ancestors started off as single-celled
organisms floating in some ancient brew and they were surrounded by the medium that would bring
them all the nutrients they needed, so there's no issues there. Then once you start getting
multicellular organisms that are thicker and the ones on the inside aren't in contact with that
sort of nutritious brew that they're growing in, you kind of need a way to distribute those
nutrients to every cell, and so that's what the heart and the branching vascular tree do.
The biggest disconnect between how the organs talked about in poetry and through history
versus this actual function is probably the heart because we ascribe all these things like love and
passion and life itself sometimes to the heart, but actually it's just a simple mechanical pump,
you know, that's all it is. I don't want to downplay it, it's amazing, but it just pushes,
it fills the blood and then squeezes it, fills the blood and squeezes it, and just that squeezing,
that pushing creates the blood pressure that you need to get blood to every cell in your body,
especially when you're standing upright to get blood to your brain, you need a certain amount
of pressure to get it up there. Isn't it amazing to you how much volume of blood just gets pushed
through by this, by this pump? Absolutely, they say every red blood cell takes about five minutes
to circulate and come back to the heart, and that circulation kind of, you know, starts in the womb
and continues and kind of until the moment that we die, but the volume is tremendous and it can
never take a break basically. And it's sort of propagating all kinds of stuff throughout the
body, it's a delivery mechanism, blood for all kinds of good stuff and bad stuff, nutrition,
drugs, all that. Right, medications too. Medications, such a fascinating design.
And it also takes the waste away, you know, it kind of brings the nutritious stuff, brings
the nutrients, especially oxygen, but many other things. And then it also, as it passes,
the cell takes the cells waste. So it's sort of the freshwater and the sewage system in one.
So about blood, what to use fascinating about blood? So we talk about the pump that spreads
the blood, but the blood itself. Right, so the blood itself is sort of, I mean, it's the most
important bodily fluid, of course, it, you know, from moment to moment, every cell in the body
needs a flow of blood to bring it most importantly, oxygen, but also again, all the other nutrients
and to take away waste. And if that stops for even a few moments, you can be in big trouble.
So blood is sort of, you know, the most important medium, it's also,
doctors use it to kind of evaluate the body, it does have this kind of all seeing quality to it,
where, you know, we can evaluate organs through the blood, I can tell you about your liver,
your heart, your kidney, just by taking a sample of your blood. So it's sort of like this crystal
ball in a way, and we use it kind of all the time, you know, to assess someone's health,
to assess their disease. Is it also the attack vector for diseases, for bacteria, for viruses,
and all that kind of stuff? So viruses seem to attack either the throat, maybe you can correct
me, but they seem to attack different parts of the body, depending on how easy it is to access
and how easy it is to get in deep, depending on what you prefer. If you want to do a little bit
of hard work, but you get in deep, or you don't want to do the hard work, but you don't get in
deep, those are the choices viruses have, but is blood one of the sort of attack vectors,
what's like, if you were trying to break into the human body, like a parasite, a virus, a bacteria,
how would you do it? What would be the attack vectors you would explore?
Right. So you got to look for the body's weaknesses, of course. We have inherent
weaknesses, for instance, like our respiratory tract. We have to breathe, we have to get air in
from the outside, and so that's one of the entries into the body. And so when we inhale,
let's say a poisonous gas, it's an easy way in. You have to breathe, can't hold your breath very
long, but air in our lungs is still kind of contiguous with the external atmosphere. It's
not really inside the body until it does cross across the lining of the alveoli into the blood,
as you said. That's when it really gets inside. And the other besides the respiratory tract,
the gastrointestinal tract is another way, kind of a chink in the armor. We have to eat, we have to
drink, and therefore we're taking the external world into ourselves, into our gut, in order to
extract from it what we need and let the rest kind of flow out. So those two, the gastrointestinal
and respiratory tract, there's a reason that respiratory tract infections and gastrointestinal
infections are kind of the most common that afflict us because those are the ways in to the
body. So I would definitely pick one of those, not just be a lazy cold in the nose, but really
a more aggressive pneumonia down deep in the lungs and get across that barrier into the blood.
But also the whole sex thing that humans do. So speaking of which, let us go for a time
to the genitals chapter. So what are genitals? I think I've heard of those. I think I've read
about a penis and a vagina. Can you explain to me how those work? Just asking for a friend,
but also what's fascinating about it and maybe what's misunderstood or little known about them.
Sure. So they're very unique organs, I would say. One of the things that I like to point out is that
while every organ from moment to moment keeps us alive and ensures our survival, the genitals are
in a way the opposite. We don't need them from moment to moment. You don't even have to use them
at all. And in fact, they often make us do stupid things that are the opposite of enhancing survival.
They've affected the brain and you can become focused and nuts based on those desires that
kind of stem from the genitals. So they can be dangerous organs too. But sexual dimorphism
helps with genetic variability as it does in so many other organisms. You take two people and
mix them together. They're genetics. You just get a lot more variation and more opportunities to try
different genetic codes and see what'll enhance survival as we talked about sex and death.
I talk about in the book a lot of, for instance, the female genital tract, how the uterus is very
unusual because it doesn't even sort of wake up and start doing its thing until the second decade
of life. Even though babies, female babies are born with all of the eggs they'll ever have in
their ovaries already. They're just sort of in this stasis until they start waking up kind of once
a month. And it's this cycle. There's so much in our bodies that are cyclical and rhythmic,
the heartbeat, the breathing, but menstruation is kind of a very strange rhythm that takes over
a decade to start. And only the rhythm beats once a month, which is very slow compared to
every other rhythm of the body. The other unusual thing is in medicine, when rhythms of the body
cease, when they stop, those are emergencies. When your heart stops, that's a cardiac arrest.
You need CPR, maybe an electric shock to restart it. When your breathing stops, you need a breathing
machine to breathe for you or something to reverse whatever might be causing the suppression of
your breathing. But when the menstruation stops, it's the point of menstruation in the first place.
The whole reason that the uterus grows aligning and sheds at each month is to one day get
the ovum to get fertilized and for it to implant in the lining, and then the rhythm
ceases. And that's obviously not a medical emergency, unlike most other rhythms,
sensations. It's the point of the whole thing in the first place.
So these particular penis and vagina are that whole thing, the uterus, whatever. Am I not
using the wrong terms? I don't know. I'll just keep saying...
You use those terms. There's more technical. There's parts, various parts. In medical school,
you learn every bump and every little part of every little organ, including the genitals.
I never really thought of it this way. As you said,
is that most organs are kind of full-time employees. Like 24-7, they're doing something.
And then there's some organs, penis and vagina being representative of this, they're not functioning
all the time. They're only functioning every once in a while and then get us to do stupid
stuff or awesome stuff and all that kind of stuff. But they're not essential for human survival
on a second-by-second basis. Then the whole cyclical nature of the human body.
How many other cycles are on a monthly basis? Like that far apart. That's a fascinating design
that the human body would do that and wouldn't start until the second decade of life. It's almost
like, what do I want to say? There's some kind of meta-planning going on. Like this is the optimal
solution for the sexual selection mechanism among somewhat intelligent species. It's useful to,
after the brain has developed sufficiently long, to now be making sexual selection decisions.
Like you need time for this computer, this really powerful computer to load in the info.
Interesting. You also need the body to develop. A child simply isn't big enough.
It's enough to be pregnant and deliver another baby.
I wonder if there's animals in which this happens much more accelerated pace in different stages.
Definitely, especially certain kinds of insects. Like Drosophila,
a lot of the fruit fly, a lot of experiments are done on because their life cycle is so rapid.
A lot of insects and other creatures are almost ready to mate as soon as they're born.
Not us. Not us. Is there any improvements to the design?
A lot of people are very interested in these particular body parts. If you were to step back
as a geneticist, biological designer, or maybe a computer scientist, computer engineer trying to
build human 2.0 or maybe a robot, how would you improve the penis and the vagina?
Well, the penis for starters, I mean, let's also discuss the testicles. They're very important,
too. They're fragile and they're important, and yet they're hanging off the body in danger,
basically. Does that make sense? They begin in the womb, they begin inside the abdomen,
and they slowly descend. And sometimes before birth, sometimes in the first year of life,
sometimes never, they pop out of the body and end up hanging in the scrotum. There's a reason,
because the chemical reactions that create sperm function best at a few degrees cooler
than body temperature. And so that's why you might notice in the warm weather, they might
hang further down. And in the cold weather, they scrunch themselves up to get closer to the body
to maintain that ideal temperature a few degrees cooler. So it's hard. If you could create a
sperm production mechanism that did not rely on that lower temperature, that would be great.
Keep them inside the body protected like the ovaries are.
Oh, then you wouldn't rely on the lower temperature. I thought you meant
create some kind of weird internal cooling mechanism.
Well, I guess that would be one solution, but just maybe a different type of chemical reaction
and would not be reliant on the lower temperature, let's say. It would be great to design
sperm metagenesis or sperm production process that would function best at body temperature.
And then we can keep those delicate organs inside the body and not have them hanging out in danger.
Or maybe the argument for this design is maybe it's nice to put them in danger,
so you are constantly concerned about it. Could be. Maybe that's beneficial for male psychology,
I'm not really sure. There's a psychological element here about the evolution that could be.
So that's the testicle's penis. A better way to do it. I mean, it's pretty good as it is.
When it's time for it to work, it grows and stiffens. And when it's time for it not to work,
it kind of shrinks and hangs out. I saw this on a Seinfeld episode, so I know how it works.
Shrinkage. Yeah, that was a good one. But that's also a bit unique, I suppose,
the way it has this erectile tissue. Actually, they're similar in the mouth of certain
baleen whales. There's a certain similar kind of erectile tissue that helps cool them off
because they have so much blubber and create so much heat in moving around and feeding that they
have actually a similar to the penis organ in their mouth that helps cool their bodies,
because it's a big problem. They have to store all that blubber for fuel, but it makes them too
hot. So as a compensation, they have this kind of erectile organ in their mouth. Okay. What about
vagina? The fact that miscarriages sometimes happen because of sexually transmitted diseases,
because of trauma. It would be great if the uterus where the growing fetus is sort of even
more protected from those things. I guess that's a side effect of the fact that people still have
sex when they're pregnant or still exposed to injury. There was a way to make it more protected,
perhaps that would be even better. I did see an article recently about artificial wombs,
which are rapidly becoming a reality. In animal studies, they're able to prolong the
gestation of a fetus by a month in an artificial womb. Can you explain the artificial aspect
of the artificial womb? Sure. I believe it acts almost like a heart-lung bypass machine. So when
someone's getting bypass surgery, their heart is stopped. Literally, they throw ice in the chest
and they give a potassium infusion through the blood, which stops the heart. But the blood is
run through a machine that basically does the work of the heart and lungs together. It gets oxygen
into the blood and then pushes it back into the body. I believe it's a sort of similar mechanism
to keep blood and nutrition flowing to this fetus. It's just not inside the body of a parent.
It's in some kind of other device. But I think that science is going to rapidly improve. One benefit
is babies are born premature. While neonatology is able to continuously lower the age of viability
through better technology and understanding what medicines and other things you can do to
premature babies when they're born, ideally, if premature labor begins, you can't stop it.
That baby's coming out one way or the other. If you could just then stick it into an artificial
womb where it can continue its development, that would save a whole host of problems off.
And those babies born very early suffer from damage to various organs, including the brain
for the rest of their life. So that could be a very important technology.
So some aspects of the human body, we can develop technologies that outsource them,
sort of offload some of the stress and the workload from the human body to do it elsewhere.
Like dialysis does that for kidneys. People can live decades without kidneys as long as they get
dialysis, which does the work for them. Not every organ can do that. For instance,
the liver, there's no dialysis version for the liver. Like if your liver fails,
you need a liver transplant. And that's the only thing that's going to do it for you.
So that's the world's first artificial womb for humans. And we're looking at a picture
of what looks like gigantic balloons. Matrix, here we come. This is very matrixy. How are they
floating? What are we even looking at? There's giants, red spheres. This really looks like the
matrix. I wonder where it's from. So there seems to be a paper on this too.
I don't know too much about it, but I did see that. It's advancing very rapidly.
The world's first artificial womb for humans. Scientists in the Netherlands say they're within
10 years of developing an artificial womb that could save the lives of premature babies.
Premature births before 37 weeks is globally the biggest cause of death among newborns.
But the development also raises ethical questions about the future of baby making
and so on and so forth. Wow. We're going to be facing a lot of ethical questions
as we start to mess with human biology. In an effort to help
human biology, we might start to mess with it. That's going to be very interesting.
Let's take steps towards the matrix. All right. What about the neighbors, poop,
feces? There seems to be a lot of interesting stories in that particular output as well.
What to you is fascinating? What to you maybe is misunderstood or a little known about poop?
Well, it's hilarious for one thing that we do it. The word is great as well.
There's so many different words. When I'm talking to the parents of pediatric patients,
I use the word poop. I don't often when I'm talking to adult patients try to choose a more
mature word. Poop is amazing. I guess it's the dirtiest, the most vile, the most hated aspect
of our bodies. It's the grossest. We don't want to think about it, talk about it, have it anywhere
near our food or social interactions. With good reason, I mentioned gastrointestinal infections
are one of the most common infections the human body suffers from. The way they spread from person
to person, grossly enough, is referred to as the fecal oral route, which means a bit of someone's
stool is getting into your swallowing it through water supply. For instance, diarrhea is actually
quite a brilliant mechanism of these microbes. Let's say you're in the intestine of one person.
Your goal is to get into the intestines of another person, brilliant to just trick their
intestines into secreting all this fluid into the intestines to increase the volume of stool and
its runniness so that when they do poop, it gets into the water supply and then everyone else ends
up getting infected as well. That's brilliant. Just the same way like tuberculosis or coronavirus
kind of infects your lungs and makes you cough. You send it out into the air and it ends up in
other people's lungs. That's all evolution. Yeah, it's brilliant. So diarrhea is intelligent.
It's a big takeaway lesson. It's one of the most intelligent things we can do as an entirety of
an organism, not just a particular cognitive organism, but we're made up of bacteria and viruses
and there's a lot of visitors and so on. As the entirety of the system, diarrhea is one of our
better accomplishments as fascinating. Why is poop funny? I think a lot of that is socially
constructed, just how it's supposed to be hidden away, yet something we always do, something we
chuckle about as children. But even in healthcare, it becomes this big topic of conversation because
you end up talking about it constantly. In the ER, people come in. They're complete strangers,
sometimes like a nice old lady who resembles my grandmother and all of a sudden I have to ask her
all about what's happening in the bathroom, like is she straining? What color is it? What's the
consistency? Does it float on top of the water more than it should? Is it hard to flush? I mean,
there's a million different questions you learn as a medical student and you're like this poop
detective when people come in with issues. And so it's funny. I guess in the exam room,
with the doctor-patient relationship, there's sort of no barriers. You talk about everything and
you're talking about the most intimate details of a person's life, even though you just met them
a second ago. It's so different than normal social interactions. Yet there is this social aspect. A
lot of what I do is social. It seems like doctors, what they do is mostly scientific. But actually,
it's just relating to another person and you have to maintain your professional demeanor and this
normal human-level interaction even though you're talking about poop. And that's a skill. That's
an art and a science. Well, okay. Actually, I want to linger on that because I'm a fan of just
diving into conversations right away with strangers. Just getting no small talk. And this
is like the ultimate. I don't know if it's the ultimate, but it's one version of no small talk.
You get right to the point. That's really powerful from a psychology perspective. You're a kind of
therapist or you have the power to be a therapist. I don't mean just about the medical condition of
the body, but the psychological. There's so much fear connected to this concern. Also self-doubt,
insecurities, even sort of existential thoughts about immortality. All of those things are right
there in the room. So I think one way doctors deal with that is they kind of have this cold way
about them. They almost have that dual mode. One is like, I'm going to be friendly on the surface
and cold about the brutal honesty of the biology. But I wonder if there's like a skillful middle
ground, this dangerous place where you can help people deal with their psychological insecurities,
concerns, fears, all those kinds of things. Is that just really tough to do?
Yeah. It's a huge part of being a doctor is dealing with the psychological aspects of
whatever's going on with the patient's body. In the ER, you deal with psychiatric emergencies
kind of left and right more than ever these days. That's a huge issue, not to mention sort of
drug use, alcohol-related stuff. That gets into psychology and the human love of intoxicants
and changing the brain's chemistry and habit, of course, where creatures of habit and that plays
in as well. A big part of, for instance, pediatrics is reassuring parents and kind of convincing
them, giving them the confidence that what's going on with their child is not serious, will go away
on its own, does not need any particular intervention. But adults, too, reassurance
is a huge part of the game. In the ER, you see humanity at its most raw. I feel like you get
this tremendous insight into people, how they live, what they worry about, what they think about,
how their body works, and also how their mind works, that you almost don't see anywhere else.
It's a really interesting place to work. Also, the way our society is shaped, the ER is where
people go for almost everything. When they're suicidal, they come to the ER. When they're too
high on drugs to walk, they come to the ER. Children who have been abused, sexually abused,
physically abused, come to the ER for us to investigate. It's sort of like the all-purpose
waste bin for the dregs of society, what people do to themselves and what they do to other people.
You mentioned you're interested in the darkness of humanity. It made me think of the ER, where you
really see what human life is like in the ER. You tweet about, you write about, you think about
the emergency room ER. That's really fascinating. Just the little window you give to that world
is fascinating. What lessons about humanity do you draw from this place where you're so near to
death? There's so much chaos. There's so much variety of what's wrong, so little information
or the urgent nature of the information inflows such that you can't really reason
and sort of thoroughly and deeply and collect all the data on those kinds of things. You have to
act fast and then everybody's freaking out. Can you just speak to the human condition
that you get a glimpse at through the ER experience?
Yeah, I think you do see all those things. I think on one end of the spectrum, it is this very
unique place where you get all these unique insights. On the other end, it can become a
ho-hum workplace just like any other, which is sort of surprising. As I mentioned before,
humans seem to be able to get used to almost anything. Doctors can get ho-hum used to dying
of a heart attack, actively in labor in the baby's half out. Ho-hum, I know what to do,
going about my job and go home and have dinner with my family and not think too much about it.
That's amazing. I do try to maintain both my fascination. I think writers in general tend
to think more about what they see, write more about what they see, maybe draw connections with
what they see to other things. I do think that writer's perspective does help me
kind of maintain my fascination and more of an insightful perspective than just a ho-hum,
water cooler conversation. You do see a lot. In a way, medical problems are sort of the great
equalizer, right? Class, race, culture, background, the failings of the human body, the way it fails,
and what we can do to help in those situations is almost universal. I always liked this quote from
Chekhov was a doctor and a writer. He treated a lot of peasants very low class and also treated
a lot of aristocrats. He wrote that they all have the same ugly bodies basically, which I think is
really right on. You can see people underneath a superficial layer of clothing. Maybe it's the
most expensive clothing bought from the fanciest places, but underneath their body is still
failing in the same way. They still have the same anxieties, the same worry about mortality,
the same concerns about whether poop turned green today, all these things that they bring
to the table. In a way, it is this great equalizer where people are kind of all the same in some
ways. Yeah, I feel like people sometimes, class, money, fame, power, makes you for time forget
that you're just a meat vehicle. Just as good and just as bad as the other meat vehicles
all around you. In that sense, there's this question sometimes raised, are some people
better than others? I usually answer no to that question because of that. Yeah, some people might
be better at math. Some people might be better at music, but in the end, we're just meatbags.
Beautiful as we are. There's a poem that just a small tangent I want to take. I just saw it
just acting that you have written. Would you classify it as a poem? Yeah. At first, if I
may read it, at first you enter the clinic shoulders weighed down by white coat pockets,
bookstuffed, timid, you act out a role, your white coat, a costume, your questions, a script,
your demeanor, a rehearsed act. No one is going to buy this. But then, as you play the role again
and again, repeating the lines and the motions, the script slowly dissolves and the interaction
becomes thoughtless. And the rehearsed act slowly fades into a profession. You suddenly find yourself
unable to tell if you're still acting or if you're doing it for real. And now you're a doctor.
Jonathan Reisman, MD, Harvard, Massachusetts General Hospital Medicine Pediatrics Department.
Beautiful. So that is what it is to be a doctor. You're just acting. Fake it till you make it.
Exactly. Fake it till you make it. And I think I imagine every medical student has this feeling
when they first go into a room. Like I talked about asking this nice old lady about the color of her
poop for the first time. And you're just like, what am I doing here? Like, does she believe I'm
a doctor? You know, this just feels absurd. But then it's, again, ho-hum becomes normal.
Now, there's not a sperm chapter in your book. You mentioned offline that this is a second and
a third book that you're working on all about sperm. No, I'm just kidding. Or maybe I'm not.
Humors tends to make way for reality. So the tweet was that an average human male produces
500 billion sperm, I believe, which is about four to five times more than the number of people who
have ever lived. And each of those sperms is genetically unique. So you can think of them.
You can kind of imagine the possible humans they could have created. And they're all different.
They have similarities, of course, but they have peculiarities that make them different.
And you can think of all the different trajectories, all the Einstein's, the Feynman's,
the Hitler's, and all the people who have died, who would have died during childbirth,
who would have died early in their years, given the different diseases. It's fascinating to think
about an average human. Yeah, we're all winners of a very competitive race. So the people who
make it, we're winners, hashtag winning. Is there something that you find fascinating,
interesting, beautiful, ugly, surprising about sperm?
I think sperm is, yes, it isn't a very interesting bodily fluid. Maybe I'll write about it in a
second or third book, we'll see. But I guess sperm is interesting because it's kind of the
only projectile bodily fluid from the body. Vomit can be projectile. Usually,
that's a disease state. That's not the expected kind of normal, healthy state.
Oh, sneezing. Would you classify that or no?
True. I guess there's some particles in the air. I guess it's not a fluid, I mean, not a liquid.
But true. I mean cough, in addition to sneeze, right? Sneeze is how our nose gets rid of something
that shouldn't be there. Cough is how our lungs get rid of something that shouldn't be there.
Vomiting is sometimes how our stomachs get rid of something that shouldn't be there.
All projectile, sometimes in their own way. Sperm is sort of interesting. It's
created with the food for its journey. Sperm mostly feed off of fructose, a kind of sugar
for the few days that they live inside the female genital tract. But I like comparing
our genitals to the genitals of the plant world, which is flowers. And in the same way that
touch me not, for instance, the kind of flower where when you brush up against it,
it sort of launches seeds into the distance to try to survive. In a way, the sperm is doing
something similar, launched into the female genital tract, and then all trying to find this
competing against each other to find this egg. It's really amazing. And when you learn about it
from the biological perspective, the most amazing thing is how many things can go wrong,
just in the sperm not surviving long enough for it making it to the egg, and then some genetic
abnormality causing a miscarriage. It's sort of astounding that it works as often as it does.
And I think the lesson there is just that people have a lot of sex. And so statistics just
favor it's going to work out a good number of times. Yeah. And there might be intelligence in
the design of just the sheer number of sperm. Maybe that's yet another way to inject variety
into the system. And redundancy, I guess, you know, we have two kidneys, we have two hands,
if we lose one, we can still go on. We have, you know, however many millions of sperm get
sort of launched in every ejaculation is, you know, if a bunch fail or don't make it inside.
There's papers on this, by the way, that I read for some reason, not read, but skimmed for some
reason, which is talking about which sperm usually wins. Like what are the characteristics of
sperms that are winning? And it's not the fastest. So it's apparently, apparently there's some kind
of slaughter that happens early on, people will correct me, but it's not the fastest. It's,
there is an aspect of it's the luckiest. It really is like the body tries to make it a random
selection that tries to make it fair in making it as random as possible. Interesting. And also
interesting that they're fueled by fructose. I didn't really think about that. So they're a
carb-loaded athlete. Right, with food for the journey. Food for the journey. Because I'm somebody
that actually does a lot of running on, I guess you would call me a fat adapted athlete. So I do
sort of meat, heavy diet. And so you could do a lot of endurance kind of stuff when you don't
eat any carbs, any glucose, any of that kind of stuff. And any are very low. It's interesting
to think that sperm are like, no, they're total bros. Let's go to the gym, sprint, performance,
short-term performance is everything. All right. Well, that sperm, returning to the liver,
the place that deals with all our poor decisions. No. Many of them.
Many of our poor decisions. You said that the liver does quite a few things.
What do you, is fascinating, beautiful about the liver?
I would say its primary function seems to be as the sort of gatekeeper for what we eat and absorb
the entire gastrointestinal tract from the esophagus to the rectum. The blood flows from it,
not back to the heart, but to the liver, where it's first examined kind of things are evaluated,
packaged, processed, detoxified perhaps. And it's kind of this great overseer of what we digest
and absorb. And so it kind of keeps track of what's coming in the outside world that comes
in and will become part of us. That's why partly the liver suffers sometimes the injury from
certain toxins like alcohol. But beyond that, the liver is also the place, as I said,
it metabolizes things too. So it metabolizes alcohol and why it can be injured by alcohol.
It metabolizes drugs like Tylenol, which is why Tylenol can be very toxic to the liver
when taken as an overdose. So even beyond that, the liver produces a lot of different things
that float in the bloodstream. It packages cholesterol and fats and sends them to where
they're needed. It deals with protein in the blood. It deals with clotting factors in the blood,
helping the blood clot, processes things like bilirubin and other things that really,
as I mentioned, is like 15 organs wrapped into one. Maybe that's why it's sort of the biggest
internal organ. The skin's bigger, but it's not an internal organ.
Right. The biggest organ in the human body is the skin.
But the liver is the biggest internal organ, and it really is a powerhouse and does a lot,
which is why when people suffer from liver failure, kind of everything goes wrong in a way.
And in terms of replacing organs, what are organs that are easily replaceable, which are not?
Like on the list of things that are hard to replace and not? What would you put in number one?
What would you put at the bottom? Well, let's say the kidneys are, nothing's easy,
but kidneys are easiest in a way. Partly, I mean, maybe a big factor there is that other
people have two of them and can give one to you. So you don't have to wait for people to die,
which is the case with hearts and livers. Sometimes you can take a part of a liver
from someone who's alive, and the liver does have this kind of mythological ability to regenerate
itself. In the myth of Prometheus, he's chained to a rock and the bird eats his liver every day,
and it grows back every day. And that's actually biologically accurate. Not that you can completely
get rid of it, and it'll appear again. But when pieces of it are removed or injured,
it does regenerate itself pretty amazingly. So I'd say the kidneys, the fact that they're
more around. Also, the kidney is a smaller organ. It's often just, you don't have to
put a transplanted kidney where the kidney should be in the back of the abdomen. You can just kind
of stuff it into the pelvis there because it's a smaller organ. The liver would be hard because
it's huge. And I guess we just have the most experience with kidney transplants because
they are the most common. And the heart and the brain are probably quite difficult. Brain,
as far as I know, hasn't been successfully done. The heart is done. And definitely,
I've evaluated a lot of patients with a heart transplant. It does work pretty well. The mechanical
heart substitutes are also advancing quite rapidly these days. For a failing heart,
there's certain kinds of devices they can surgically implant. Like when a failing heart
isn't able to push hard enough, you know, that's the heart's job is pushing blood with sufficient
pressure to create blood pressure. When it fails, there are actually these devices you can strap
on to the heart to help it pump harder. Those are rapidly advancing. Many of those were not
available even 10 years ago when I got out of med school and now they're commonly used.
So maybe heart transplant won't be as necessary in the future if those
mechanical things do advance. And as I said, the heart is basically a mechanical pump.
So perhaps it would be the easiest organ to replace with some mechanical device.
Now for something completely different, returning to testicles for a time. You posted
an Instagram post of testicles as food. Perhaps eating them doesn't help libido because
ingested testosterone is totally metabolized in the liver or turning to our liver,
leaving none to reach the bloodstream. That is why testosterone only comes as injection or
a topical foam, not as pills. On the other hand, estrogen and progesterone can be absorbed
orally, hence the pill. But testosterone is mostly responsible for libido in women too.
I was not expecting for this biology lesson when I was looking at an Instagram picture of
are we looking at testicles? Yeah. Are these like which species?
I believe all those are from cows. From cows, cow testicles.
Technically females though, bulls. Well, speaking of which,
just we'll jump around a bit, but you've also traveled the world quite a bit.
What is the craziest food you've eaten across the world? What have you learned about the extremes
of the culinary arts by traveling the world? I would say, I guess I've always been
extra fascinated with the diets of natives of the far north. I spent some time there in Russia
and in Alaska and always loved their diet. When I worked in Alaska in emergency room and did some
other travels in Arctic Alaska, they eat a lot of fat. Traditionally, before contact,
more than half of all calories in the Inupia de Eskimo diet came from
blubber marine mammal fat or also fat from fish, fat from ducks and other birds that go up there
to mate in the summer. Things like raw whale blubber was especially interesting for me and
very exciting. I had some beluga whale chowder, things like that. There's just all these very
unusual dishes. There's a dish called Mickey Yuck, which is whale meat fermented in whale blood,
which is quite delicious actually. Is it cooked? Is it eaten raw? How do they like their fat in
the same way up north in Russia, as you mentioned? They often eat it raw. The raw whale blubber is
called muck duck and it's often just sliced thin. It's sort of cold but not frozen when
often when they eat it and they slice it thin. A lot of people assume it would be very chewy,
but it's not that chewy. It's quite pleasant actually and has this kind of sea smell to it
as you're eating it. I quite like it. What's the culinary culture like,
meaning is it just source of energy or is it art? Traditionally, there's not a lot of cooking
in the Arctic. A lot of things are eaten raw partly because there's not a lot of
fuel for making fires. In some of the big rivers in Russia, for instance, that flow north,
they will bring dead trees and logs up to the north and they can get some wood that way.
And same thing in some of the rivers flowing northward from the Brooks Range of Alaska,
you do get some trees but just not enough to really produce a culinary art that requires
cooking with heat. They do have traditionally blubber lamps where the blubbers of seals and
whales are used to create a little flame. Often that's for light and for a little bit of heat,
and less for cooking. But eating things raw is definitely a huge part of the culture there.
I went on a whale hunting trip out on the spring ice in the Arctic Ocean by Barrow, Alaska.
Two of the guys, the Inupiat guys who had invited me, were kind of talking about how
eating things raw is sort of the most essential characteristic of Inupiat culture.
And the one guy who's half white, half Inupiat said people often doubt his ethnicity because he
looks like a white guy. So he'll bite the head off of a raw bird to show them that he is truly
Inupiat, is what he said. That's how you prove you're legit. We're looking at Instagram pic.
As a doctor, I was used to knowing fat as the most maligned of all body parts and the culprit
in an obesity epidemic. But in Arctic Alaska, fat has always meant health and survival. In fact,
the entire story of life in the Arctic, especially human life, is basically a tale of fat. And in
Barrow, what's A.K.? Alaska. Alaska, okay. A lawn covered with a whale blubber is still equivalent
of a flesh green lawn in temperature, suburbia, swelling in its owner with pride. And that's
what we're looking at is a lawn full of whale blubber. Beautiful. And so this is, I mean,
there's a lot of calories there. Oh, yeah. And this can feed a lot of people, a lot of energy,
a lot of warmth. Absolutely. And it's delicious. And this was like, I was a kid in a candy store.
Basically, I rounded a corner in Barrow. So when people do get a whale during the spring
whaling season, they raise a flag or the whaling captain raises a flag over his house and everyone
in town is welcome to come try some. And so before I went inside to try some, I was kind of playing
around with blubber. And I saw the, this is a bowhead whale. I saw its heart, which was huge,
like the size of a yoga ball. And that was for me just like amazing. I spent probably the next 45
minutes just looking at all aspects of it. And the stump of aorta that was attached to it was the
size of my thigh. That was really fascinating. It's similar Alaska and Northern Russia, like
Siberian out there. So where were you? I think you have some picks from that time. Where were you
in Russia? So I spent a lot of time in kind of Western Russia as well. But I did take two trips
to Kamchatka, including Northern Kamchatka. I didn't go far enough, nor I didn't go to Chukotka,
for instance, until more recently when I was a ship doctor on a wildlife cruise that sailed from
Anadyr, Russia up to, through the Bering Strait and to Rangel Island. And we stopped in some
villages in Chukotka and I got a chance to try some whale and stuff like that. Northern Kamchatka,
where it's more the Koryak or the indigenous people, they do a lot of seal hunting. So I had a
lot of seal blubber, but I don't believe they do any whale hunting quite there. But the Chukchi in
a way are sort of similar to the Inupiat in their diet and their life ways. Of course,
everyone's diet, all these people's diet has changed dramatically in the last 100 years,
as it has for actually everyone living in kind of modern societies. But for them,
perhaps more than anyone else since their diet was the most extreme, I think, of any human culture
on earth. Just to stay on the wild travel you did. And I should say I'm using the word travel, but
it really, you were a doctor there. First of all, can you just comment on the decision to go to
such places and to help people to be a doctor there? What was the motivation? What was the
thinking behind it? Well, I think I got the travel bug before I ever went to medical school and
even wanted to be a doctor. So right after college, I kind of wasn't very into college,
didn't enjoy things, kind of wanted to get out there and see the world, get out of New York
City where I was a student at NYU. The first thing I did after finishing college was I was
invited to be an intern at a research center in St. Petersburg, Russia. I spent six months there,
my first trip, and went back four more times to Russia, traveled all over, including to Kamchatka
twice and other parts of the country. I'd never heard of cities like Petrozovodsk and Siktivkar
and Pskov. I didn't even know a word could start with P-S-K, like the city of Pskov, but it can.
And I was sort of fascinated. I was actually studying the international environmental movement
and how it came to Russia after the fall of the Soviet Union and how organizations like Greenpeace
and World Wildlife Fund and the World Bank are trying to kind of push the timber industry,
which is huge in Russia, toward a more sustainable path. And so it's sort of evaluating how is it
working, if not, why not. And that seems like such a little niche, such a small detail about
Russian society. But in a way, researching that in depth was almost this window into the entire
country and the history in a place I knew nothing about. And I learned the language, traveled all
over the country, got to know the food, the history, the literature. It was just an immersive and
amazing and life-changing experience that made me want to see every spot on the globe, basically,
and learn about every culture. So I took that desire with me to medical school. I decided I
would go to medical school. And from the very beginning, I was intent on traveling around the
world. So a lot of my career has been fashioned so that I'm practicing medicine in a place with
an interesting geographic context, an interesting place, with an interesting cultural context.
And that just makes it more interesting, I find. Not only are medical services often more needed
in these remote and rural parts of the country and world, so I feel like I'm taking my knowledge
and education experience to places where it's needed. But also, for me, it's just such an
enlightening experience. The way culture, history, geography, climate affects medical disease, but
just getting to know the people, getting to know their culture, being a very useful traveler
by providing medical services in that place. And that's taken me to Arctic Alaska,
to Pine Ridge Reservation, South Dakota. I currently work in a few different parts of
Pennsylvania, Appalachia, which for me is a unique geography and culture that I didn't grow up with,
wasn't familiar with. So in some ways, it's exotic for me as well. I worked in other places too,
like Calcutta, India, Nepal. Just I think my love of travel has shaped my medical career. And being
a doctor does give you these opportunities to go to places and travel in a unique way through the
medical profession. You know, there's a documentary, Happy People, You're in the Taiga or something
like that. I think Warner Herzog voices it. It tells a story of a simple life of survival
in the Taiga. And I think they're trapping for food. And there's a lot, there's an alcoholism
problem too as well. There's like a very basic life of survival, of loneliness, of desperation.
But also there's a, I think the underlying claim of the documentary is that that simple life actually
has a kind of simple happiness to it. Hence the name Happy People. Is there, can you speak to the
life that people live in in those places when it may be simpler than you would in a sort of big city
life? It's definitely very different for sure. You know, I guess I found like in some of the
remote villages of Kamchatka, I was actually surprised how similar they were in that, you know,
there was, I saw the same family strife, the same fights, the same, you know, kind of pairing of
relationships and bickering and politics. And, you know, in a way, from the New Jersey suburbs
and yet being in this remote, you know, village of Northern Kamchatka, I remember writing an email
to my friend about how just it seemed so similar even though on the surface it was this exotic
other world, the incredible material know how they must have to get their food from the land,
you know, that the number of animal species, plant species, the behaviors of the animals,
seasons, how to live that way. In a way, it's more complicated in a way that I find fascinating,
how people live on the land and the knowledge and experience it takes to do it well and survive.
You know, obviously other aspects of modern life in a city are much more complicated
than they would be there. But I guess it's, that was something that struck me too that
it's simpler in some ways, but more complicated in other ways.
So some of the complexity that happens in life is from originated from humans,
not from the technology or the, all that kind of stuff around us.
You can take the human out of modernity, but they're still human.
They're still human. And they fill the empty space with their own human complexities.
Are there people that just stand out, memorable people, memorable experiences from those places?
Some people that maybe made you smile, made you cry, changed who you are as a man,
changed who you are as a doctor. Anything jumps to mind?
I think, you know, when I was, is interesting when I was in Russia, I found that most of the
people I hung out with were old women. I'm not sure why. I mean, they're, actually,
I didn't meet a lot of old men in Russia, which might speak to kind of life expectancy there
for men in particular. But I found women, older Russian women, including, you know,
Russian from St. Petersburg, or some of the elderly women in Kamchatka who were, you know,
some were Koryak, some were half Koryak, half Russian, some were Chukchi.
I just found them to have, to be so enlightening the way they talked about history, about people,
so insightful about humanity, you know, all they've lived through in the last 50 years in some of
these parts of Russia, just like the upheaval, societal upheaval, the destruction, the building
up, it's just something I could not even imagine. And I think their insights were just very, I'm
not thinking of anything in particular, but I just remember I could listen to some of these
elderly women talk about their lives for hours and hours. I remember there was this older,
elderly blind Koryak woman who you would have thought was the, you know, most country bumpkin
of country bumpkin, and yet she couldn't stop talking about how much she loved reading Dostoyevsky
and Tolstoy, and which might also speak to the Soviet education system as just sort of surprising
and fascinating and just those stories and perspectives on life really stayed with me.
Yeah, with Babushki. There's a wisdom, there's a kindness.
I mean, I suppose that's true for older people in general, but there's something about,
it's not just Russia, it's Eastern Europe. It's like this kind of look of wisdom and not just
like sort of middle class wisdom or something like that. It's like I have seen some shit wisdom.
I've seen it all. And on the other side, I'm left here with a pragmatism and a compassion
and also an ability to cook really well. That's for sure. Absolutely.
There's just this balance of just deep intelligence and deep kindness and,
yeah, I mean, I, part, much of who I am is because of the relationship I had with my
grandmother who is a Russian, Ukrainian-born Russian grandmother. Did you learn the Russian
language? I did. It's quite rusty at this point, but I did one of these wonderful elderly Russians
in St. Petersburg sort of adopted me. I think that was another thing that a lot of these elderly
women on every side of the country kind of adopted me or saw me as this real curiosity.
You know, it's sort of just not, I mean, this was around 2002, 2003. It just wasn't
common for this sort of strange American to suddenly show up in the middle of Khomchatko or
even St. Petersburg and just absolutely ravenously curious about everything they had to say.
So I often got adopted and one of them taught me Russian and had a ride a horse.
So the same Babushka taught me both of those things.
And like you said, also I should mention that there's something about the Soviet education
system where everybody reads Tolstoy, Dostoevsky. It's exceptionally well read. No matter where
life has taken you, no matter where you come from, the literature, the mathematics, the sciences,
they're all like extremely well educated and that creates a fascinating populace.
Like then you take that education, that excellent early education and you throw a bunch of hardship
at those people and then they kind of cook in that hardship and come out really fascinating
people on the other end. It makes me surprised sort of that, for instance, like Russian medical
science is not, you don't see a lot of sort of studies, medical studies, advancing of medical
science come out of Russia, which is sort of, I'm surprised sort of, I wish that it would.
I visited Akademgorodok outside Novosibirsk, which is an entire city the Soviets created
just for the study of science. And it's like, there's the geology building and there's the
biology building and there's the chemistry building. And I just feel like Russia has this
potential to be a science powerhouse or even in the medical sciences, but I guess you just,
I don't see it. I'm not sure why. I mean, you can certainly guess as to why. And I see the same
thing in the other, in the sciences, I hold the dearest sort of in computer science,
in engineering fields. I kind of long held this desire by long, I mean, last couple of years
because a bunch of people reached out to me from Yandex and Moscow state to give lectures there,
to sort of connect, you know, why, why so little science is coming out of there? Why so little
that we hear about? And it feels like we should be able to bridge the scientific community.
Like science, let's even say, even in tormological politics, even in global conflict,
I feel like science should be bigger than that. But why do we not hear from the scientists is
because of the limitations on human freedoms, on scientific freedoms. I feel like in China,
in Russia, in any regime of its sort, you should give freedom to scientists to,
to flourish and to interact with others. And you can only grow from that. And you shouldn't
suppress that. The sort of Cold War ideas, we should put those aside. As somebody who
spent time in Russia, as somebody who's learned Russian, do you have some thoughts that you want
to say about the war in Ukraine currently? It's tragic, of course, seemingly pointless to watch
the destruction of a country in real time. I guess it's, you know, when you read Russian history
and Ukrainian history, I guess it just, it's sort of, you know, destruction is a big part of it.
The populace being beaten down is a big part of it, you know, from the Mongolian hordes
through the Tsar and the Soviets and Putin, I guess, you know, it's just in science, in particular,
medical science, it feels like this sort of unrealized potential, you know, the culture is
so beautiful, the people are so smart and well educated. I think the word unrealized potential
is kind of how I feel. That's why I wanted to celebrate that part of the world is there's
so many beautiful people, so many brilliant people. And I just happened to know the language,
so I'm able to appreciate the beauty of those people. I'm sure the same is true in China.
I'm sure that that's one of the things that makes me sad is there's all these cultures that
I don't know about. I can't fully appreciate their brilliance, even Japan
and places like that that are sort of there's channels of communication wide open and there's
a lot of interaction is still not knowing the language. I feel like I miss some of the culture
or Portuguese and, you know, looking at South America and all that kind of stuff.
But anyway, in Russia, there's certainly is that unrealized potential in Ukraine.
So many brilliant scientists, engineers came from Ukraine, from Russia, and I hope
I hope they get to flourish soon. And I hope we put this,
I hope we stop this war because all war is hell.
Is there something to comment about the biology of war?
Is there echoes of the emergency room experience?
Do you have you dealt with patients that have been touched by wartime?
Definitely war and medicine has a very intricate and complex relationship.
I don't know if it was Walt Whitman who said it, though he was a nurse during the Civil War,
that war is the best medical school. But some people have said that.
And, you know, even advancements in medicine come from war. You know, the wars in Iraq and
Afghanistan have in some ways really revolutionized certain aspects of the way we treat trauma
patients in the civilian world as well. The importance of tourniquets, the importance of
transusing whole blood instead of, you know, red blood cells isolated from serum and platelets,
etc. The importance of pain control in the battlefield, that's changed dramatically.
Everything from ketamine injections to fentanyl lollipops in the battlefield.
So war has really improved medicine in many ways. In another way, you know, the Department of
Defense spends a lot of money on medical research and kind of really pushes the envelope. You know,
DARPA is one aspect of the military budget that really funds these moonshot experiments that
are really fascinating and really push the frontiers more than seemingly most, you know,
kind of universities doing it, doctors and researchers doing their research. So in a way,
you know, the space program, which sort of was military initially, then became civilian under
NASA also led to a lot of advances and understandings of health, you know, on Earth and in space.
So the military is, or war in general, is a huge way that that medicine advances,
not to mention the epidemics that come. You know, my grandmother was from what's today
Moldova, what was then Romania. She got typhus during World War II. So there's typhus outbreaks,
there's cholera outbreaks, you know, all these even infectious disease things can advance in war,
which you wouldn't expect. You expect sort of trauma to be the sort of main problem,
but actually infection is a huge problem throughout history in war. So we can learn a lot. It's this
kind of horrific natural experiment in medical care.
Yeah. And I've recently been reading about some of the horrific medical experiments performed by
Nazi scientists, Nazi Germany. I'll talk about it another time, perhaps, but
nothing reveals the honesty of human biology like war.
Just to stay on your wild journeys for a little bit longer,
you have a tweet about Shackleton saying, here's a photo of Shackleton's medical kit
from his storied expedition to Antarctica in the 1910s. Some paragoric for pain, some laxatives.
Only the essentials. Would you put laxative under the essentials? Anyway, sorry to interrupt.
When I worked as a ship doctor in Antarctica in 2018, I had a huge cabinet full of meds
and even EKG machine. So if you can comment sort of on that contrast, first of all,
your own journey, how harsh was it, how difficult was it? And given that context,
can you think about how hard Shackleton's journey was?
I think the difference is unimaginably stark. One thing I do want to point out is that
the use of laxatives early in the 20th century and before that,
they were used for a surprising number of ailments where they probably did not help at all.
But I think that was a holdover from sort of the old theory of medicine,
the humoral theory where you have to balance the fluids in the body and so causing people to vomit,
causing them to have diarrhea or purposely taking blood out of them in bloodletting
was a big part. And I think the crazy use of laxatives was maybe a holdover from that time.
But that being said, they were probably not eating very high fiber food on that expedition.
So perhaps laxatives could have been helpful. You know, there's a lot of seal,
penguin and seal meat being eaten, which is not super high in fiber. So I don't want to
discount the importance of laxatives in that setting.
But that wouldn't be the essential thing. If you're thinking of a tiny kit that has only
the essentials, pain, yes, laxatives, maybe not.
I think the medical kit possibilities were much narrower back then. This was before antibiotics
before I think germ theory might have been, it was known, but there wasn't much to do about it.
So the availability of medicines, that's something that exploded over the course
of the 20th century. So what I can put in a backpack today filled with modern medications,
whether injectable or to be taken orally is, you know, just many orders of magnitude greater
than what they had back then. So when I, I mean, when I went, my expedition was nothing like
Shackleton's. I was on a huge cruise ship with 160 Japanese passengers who came with their own
translators. And as I said, I had a cabinet, not just one cabinet, many cabinets full of
medications, both injectable, some patches, some pills. I was very impressed actually with what
was available there. And I didn't have to use a lot of it, thankfully, though I did use some of it
for people. But, and I slept in, you know, I got free room and board on the ship. So every southern
summer cruise ships go take people to Antarctica, the Southern Atlantic Islands, like the Falklands
and other other parts of the South Pacific. And then in the northern summer, the same kind of
cruise ship explosion happens, you know, going to Greenland and Iceland and Svalbard and Franz Joseph
Land and other parts of the North Alaska. So, and every ship needs a doctor. So it's a great
opportunity. They want specifically ER doctors, you know, to deal with emergencies. But you're
really working in the middle of nowhere. And all you have is the medications they are on the ship
and supplies and your knowledge and experience. And so it's, it's a very different experience
than working in a high tech modern hospital with every bit of technology and every subspecialist
consultant available. But I sort of like that challenge. I mean, I like going to the ends
of the earth. It's beautiful. It's exciting. It's fascinating. Practicing medicine in those
settings is extra challenging and really makes you hone some of your skills, which is part of
the reason that I sought them out. Do you see echoes of some of that same effort? I've gotten a
chance to interact with astronauts and those kinds of folks working on space missions. Do you see
some of those same echoes of challenging efforts going out into space and maybe landing on Mars
and maybe beginning to build a small colony on Mars? Yeah, I think the healthcare that is needed
will be a big part of that. You know, obviously we're probably going to send overall quite healthy
people, but there's a lot of medical decisions to make about what should be brought, what should
be expected. You know, to some extent, a lot, I've had a lot of doctors say, oh my goodness,
I can't believe you work in the middle of nowhere. What do you do if someone, you know,
gets a brain bleed, like falls, hits their head, needs a neurosurgeon? I mean, the obvious answer
is they die. You know, when things, when you're in the middle of Antarctica, things kill you that
wouldn't if you're inside a university hospital that's fully equipped to help with every problem
that arises. Mars takes that to a crazy extreme, obviously. I know that even going to Antarctica,
different countries have had different strategies. I believe Australia used to kind of just, in
anticipation, remove people's gallbladders just so that it wouldn't get inflamed because that is a
very common medical emergency. So they would just remove it beforehand, even though it was not
diseased at all, just so that while they're stuck in Antarctica over the winter, for instance,
that wouldn't be a problem. You know, there's many other issues that kind of rise, but so that
those are some decisions to make. Maybe the people who go into Mars should have their appendix
removed, their gallbladder removed. Maybe they should have a cardiac cath to see if they have
coronary artery disease, just to know their chances of getting a heart attack there, though
it's not always predictive. You know, it's hard to predict who's going to get a heart attack,
but maybe with all the data around today, we'll get better at predicting. But that
will be a huge part. You know, we can't have people, the few pioneers in a Mars colony dying
of heart attacks and things like that. Don't anticipate stuff. Would you go,
you've gone to some harsh conditions to be a doctor, would you go to Mars to be a doctor?
It would definitely be amazing, I think, because I have a wife and two small children,
probably not in the cards for me at this point. But you humans with your human attachments.
Sex and death. If you just put more priority on the death than sex, I think it would be
better off. No. I would love to go to Mars. And actually, you know, I practice high altitude
medicine in Nepal. Space medicine is sort of an extension of that. You know, the air is just
much thinner, like non-existent. You know, as you go higher in the mountains, the things that
happen to human physiology are very bizarre and strange and still not well explained by science.
And in space, it's just like a crazy extension of high altitude.
If I could just return to this, we didn't really, I think we mentioned a little bit
about the food you had. Just if we can high level say, what is the greatest meal you've
ever had? So your last meal, let's go. If one more meal, I get to murder you after this.
This is your last day. We get to spend it together. Where in the world would you go?
What would you eat? I would say the most delicious thing is bone marrow. And I would love a full
meal of bone marrow for my last, last dish. I did on my birthday in 2002, ate a kilogram and a half
of crab meat in Kamchatka. And that was also amazingly delicious. The king crab they have
there is incredible. But I would go with bone marrow, which is I think just one of the most
delicious foods. And it's sort of this weird body part. It's basically all your stem cells,
not all of them, but the stem cells that produce all your blood cells. So they
are spitting out billions of white blood cells, red blood cells and platelets every day.
And there's a bunch of fat in there as well. Just one of the places the body stores fat.
And so you basically add heat and that's all you need. It's like the perfect food.
You add heat, the fat for frying the stem cells is already there. There's naturally a bone vessel
to contain it all, probably add some flavor too. It's like the perfect food.
But does it matter which animal?
I prefer a larger animal just so there's more of it.
I actually like, oh, that's true. I actually really like sort of bone marrow from like chicken
bones. Right, just sucking it out of the bone. Yes, I'm known for leaving absolutely nothing
edible on the plate except bone itself. There's one other human I know that loves
bone marrow as much as you do. And that's Joe Rogan. So on natural, how much that man loves bone
marrow. I understand why it's amazing. I love the steak part. The bone marrow,
like, you know what, let me argue with you because I don't know, it could be an acquired taste, but
there's just too much, it's like too much with too little work for it.
Like it says, if you gave me lobster meat without the lobster having to clean the lobster,
I just feel like I'm spoiling myself. So it's very fatty. I don't know, maybe I want to work
for something that tastes like that. Well, if you start from the whole animal,
you do have to work to get at it, right? A lot of animals have the teeth and the jaw muscles
to chomp through bone. We do not. So, you know, when you buy it from the store, it's already
sold up. But I've definitely gotten marrow out of deer bones, you know, with a hatchet,
just chop off the fat end and start spooning it out.
Well, maybe I'll revisit it. That's fascinating. And where, where would you eat it?
Where, in which place of the world? Is there something about who cooks it, who you eat it with?
You're not allowed to pick your family. Right.
Right. So, like, which place in the world,
rural or in the city, those kinds of things, you've been to so many fascinating places.
I would say Antarctica, I would say, is one of the most picturesque places I've ever been.
I really did not. I didn't know how mountainous it was. And I guess I knew there'd be ice,
but just, I didn't know how much ice it was. You know, it's ice and mountains just
overwhelming. I just, you know, as, as kind of overwhelming bone marrow might seem to you,
sort of that feast for your eyes. And just ice in general is amazing.
Like the icebergs floating around Antarctica is just astounding. Like the different shapes,
the sizes are incredible. There's actually a, I believe it's US Navy website that tracks
the largest icebergs. And you can read about each of them and how big they are and just
the formations you see similar up near Greenland, though I have not been to Greenland.
Just ice in general is just amazing. So I could just look at its different forms
while eating bone marrow forever until you kill me. That is,
yeah. And afterwards we go. It's back to the death of the death and sex. I,
what is it about the ice? Is it sort of the enormity of nature? It just reminds you that
it's going to be there before you and after. And then you get to partake in the eating
of the, the thing you need for maintaining of your biological, temporary biological organism.
Yeah. I think it's a few things. One is just the shapes that you see, you know, the wave action,
just eating away at these pieces of ice. You get these arches and just these shapes. I mean,
it's just like geometry. The geometry alone is amazing. I studied math as an undergrad and I've
always appreciated geometry. And just the shapes alone are just look like brilliant works of
modernist art and just obviously no two are ever the same. Not to mention a lot of them are this
unearthly blue color that is just really startling and fascinating. The same color of glaciers,
you know, in various parts of the world, that blue color is just really amazing.
And I also just love how it's sort of this constant shedding
thing from our Antarctic continent from Greenland, you know, it's this constant process of snow
falling inland and pushing the glaciers further out to sea and then breaking loose. I mean,
obviously it seems to be happening faster these days, but it's sort of this constant shedding and
sort of, I always like thinking about how the body has something similar. You know, we're
constantly shedding and renewing and rebuilding everything. And so ice is sort of this constant
similar process. Yeah, I did not know you were a math undergrad. So that I mean, you're just
keep getting more fascinating. Can you maybe take a small step into that direction?
What do you find beautiful about mathematics? Why did you journey into that part of the world for a
time? I liked math, I especially liked so college math, I did some calculus in high school. When I
got to college math, I was amazed that there were no more numbers, you know, the digits disappeared.
It was just variables, concepts, you know, there was almost no more numbers at all. It was like this
totally abstract, you know, kind of way of thinking, but that sort of reflects the natural world and
teaches you about the natural world, though it's sort of this perfect, you know, platonic ideal,
perhaps of the natural world that can still sort of help explain what happens in the natural world.
But just these concepts are so abstract from like life and from, you know, the natural world. I was
actually getting interested in the natural world at the same time when I was in at NYU studying math.
You know, I took a tour of Central Park that was pointing, the guy Steve Brill was pointing out these
wild edible plants. And I was learning to identify the first plants and knowing what's edible, what's
not. That was totally fascinating. And sort of this kind of thing that I felt like was connecting
me to nature. And it was balanced with this utterly abstract science, you know, or utterly
abstract lessons I was getting in math class, where I was thinking through series, you know,
as we approach infinity, what happens to these equations and concepts of like rings and abstract
algebra, I don't know, it was just this dichotomy that I enjoyed both aspects of.
Yeah, the concepts, but so, so different, this kind of logical, rigorous view of the world and
the world of biology. Why the big, how did that feel to take the leap into the biological, the
mushy mess of the human body from the mathematical, which is all very clean.
Right. It does feel like a big step. I think there's more connection than you think. You know,
we talked about symmetry of the body earlier. That is a real thing, you know, fluid dynamics
of how our various bodily fluids flow and what makes them not flow as well and what makes them
flow better. And, you know, all these different aspects of science go into the body. You know,
everything from hard bone to softer kind of flesh to liquids of various consistencies.
You know, a lot of science and math does teach you about kind of how the body works,
how it can work better, what happens in sort of disease states.
Yeah, I suppose there's a connection. There's also kind of a sort of computational
biologists. There's computational equivalents of each of the disciplines which are becoming
more and more fascinating with all the work that DeepMind is doing and the work of genetics,
all that kind of stuff, simulating different parts of the body to try to gain an intuition
understanding of it. That to me is super fascinating, but sometimes it does feel like an oversimplification
of the way the body really does it because the body is an incredibly weird, complex system.
And it finds a way. The adaptability, the resilience, the redundancy that's built in,
it's weird. And it's incredibly powerful and so unlike the kind of computer based systems that
we build, at least we engineer in the software engineering world, which kind of starts to make
you think, how can we engineer computer systems in a different way that make them more resilient
in the real world? That's sort of the robotics question. What do you think about that? What
does it take to build a humanoid robot or robots that are as resilient as the human body? How
difficult do you think is that problem? Having studied the human body, how hard is the engineering
problem of building systems like that guy over there, the legged guy that is as resilient as the
human body to the harsh conditions of the real world? I think it's very hard and we definitely
haven't gotten there yet. I think we could probably learn lessons from people who are trying to grow
artificial organs in the lab to eventually transplant into people, which would solve the
huge problem of needing to get those organs from others and the rejection of putting a foreign
material inside your body. Your immune system tends not to like that. That has advanced a lot
recently. I think some advances actually have been where we pay a lot of attention to stem cells,
stem cells, stem cells. We can grow whatever we want out of stem cells, but now there's a
recognition that what we call the extracellular matrix, which is the foundation of the body,
the thing that holds all the cells into their proper shape and keeps them where they should be.
That is actually crucial. There's probably a lot of signaling that goes on. You stick a stem cell
on the right extracellular matrix. It will turn into the kind of cell that you want and take the
right shape and position and start functioning. I think that's been a huge advance knowing that
it's not just these celebrity stem cells that are the answer. It's this part in the background,
this laying the foundation, the system that you put these cells onto. We're not there yet,
but there's definitely a lot happening, a lot of research happening. I think there'll be some
advances probably soon. Now on the topic of interaction of computational
systems with biology. If you look at a company like Neuralink or the whole effort of brain
computer interfaces, now there's a neurosurgery component there. We have to connect electrical
systems with biological systems. Even the implanting is difficult. Then the communication
is difficult. What would you say from what you know about the brain, what you know about the
human body and all the beautiful methods there? How difficult is the effort of Neuralink? Do you
think it's feasible? I think it's definitely feasible. I think we need to probably know more
than we do and know how to connect it in all these ways. I think some advances, for instance,
much less sexy, but really already impacting medical care is something called deep brain
stimulation, which is done for Parkinson's disease and others where neurosurgeons implant
this device that's electrically stimulates the part of the brain that is not functioning in
Parkinson's disease. It's quite dramatic how effective it works. I remember as a med student
watching a neurologist literally turn the electricity up on this handheld thing,
and you could see the person's Parkinson's tremor go away, and you could see them start to walk in
a more steady fashion. There may be studies in the future studying the same deep brain stimulation
for everything from eating disorders to severe OCD, like paralyzing OCD, not just like,
I want to wash my hands three times. I think the potential is there, but I guess connecting
the brain in a microscopic way in a multifaceted way, there needs to be a million connections
or some very high number of connections for them to work fluidly. As far as I know,
I'm not an expert in the area. First of all, I believe and I trust in the adaptability of
the biological system to whatever crazy stuff you try to shove in there. It's going to potentially
reject things, but it's also going to, if it doesn't reject things, adapt. If we can create
computational systems that also adapt, AI systems that adapt and can both of them reach
towards each other and figure stuff out, but actually our current AI systems are not very
adaptable in the wild way that biology is adaptable, adaptable to anything. If we can
build AI systems like that, I feel like there's some interesting things you could do,
but of course there's ethics and there's real human lives at stake. There, you can't quite
experiment. You have to have things that work and maybe simulation can help, but reality is
it's a dangerous playground to play on. It is messy. You tweeted that quote,
if you look back from far enough into the future, every doctor today will look like a total quack.
First of all, that's humbling to think about. We don't know what we're doing
in the great, like there's been so much progress that we kind of have this confidence that we
figured it all out. If you look at history and you read how people thought, I mean,
there's so many moments in history where people really thought that they figured it all out.
It's almost like there's nothing else left to do at every stage in history.
Right. Then you realize, no, progress often happens exponentially. In every moment,
you continue to think you figured it all out, but if you're being honest, if you're being humble,
then you realize we're just shrouded in mystery. What do we make of this? How should we feel that?
How should you feel as a doctor? How should we feel as scientific explorers of the human body,
the fact that we're probably going to be wrong about everything we currently know?
Right. There's a saying actually, by the time you finish med school, half of what you learned is
wrong, which is quite illustrative and becoming more true as time goes on. So much medical
research going on, so much learning going on. It's really wonderful in a way, but in some ways,
we still learn these concepts from the past. I know when you take a test as a medical student,
sometimes you know they want you to give the old answer, but you know there's a new answer because
of recent science, but you know to give the old answer that's now incorrect to get the question
right on the test. That happens actually quite a bit because things change so quickly.
Yet, when I look back at doctors from centuries past, it's absurd what they were doing to their
patients. Probably for most of human history, they were doing more harm than good. They're
draining people of their blood. Bloodletting was a huge part of medical care. George Washington
died of a paratonsular abscess, an abscess right next to the tonsil, which has the great name of
Quincy, and they bled him to death, kind of adding insult to injury. Doctors are menace
and do a lot of harm, hopefully not intentionally. Even medical errors are still a huge problem,
cause of death and morbidity. We do a lot of things that are not great, but our knowledge yet,
it's very imperfect at this point. I do have some confidence. I guess perfect scientific studies
that try to get at the reality of the universe are essential because when I think of why a
certain medication works for a certain condition, it might make perfect sense in my head, knowing
the biology, the biochemistry, the anatomy. It makes perfect sense. It must work. I gave it to
the patient, they got better, and that's happened 20 times in the last year, but I'm wrong. When
you actually do a study, it actually doesn't help. Maybe it hurts. I think the way we explain
medications working in our minds is often wrong when you end up finally doing the study. Some
of the most interesting experiments involve what we call sham surgery. For instance, people who
injure their knee, arthroscopy where an orthopedic surgeon goes in there with a scope, gets bits of
bone out, shaves down the cartilage, cleans things up. It helps some people, but they actually did
some studies where one group of people got the true arthroscopy and others just got sham surgery,
where they put them to sleep, made little cuts in the skin so that they woke up with scars.
Then it turned out that it's not clear arthroscopy is actually helping.
The same, there was a recent huge study of putting a stent in someone's coronary arteries
if they have stable chest pain. Not like, I'm having a heart attack. You need a stent right
then, but chronic coronary artery disease where every time I run up the stairs, I get chest pain,
then when I rest, it goes away. Obviously, you put a stent, you increase blood flow to the
heart. How could that not work? Then when they did the sham catheterization, it actually looks
like it might not actually help better than the sham. I think those placebo-controlled studies
are essential. It is shocking, and this has been driven home during the last two years,
how hard it is to figure out what the hell is going on in the universe, especially with our
bodies. It is really hard to get at the truth. What you think makes sense often turns out.
I mean, the history of modern medicine is littered with examples where it made perfect sense,
and it seemed to help some patients, and it turns out it's not doing anything or it's harmful.
Yes, all kinds of narratives swimming around. We convince ourselves as a human civilization
that something is true. There's propaganda machines. There's just self-delusion. There's
centralized communities. There's a scientific community that believes a certain thing. There's
the conspiracy theories that believe a certain thing. Sometimes the scientific community writes.
Sometimes the conspiracy theorists are right throughout human history, I mean. We now think
the scientific community, well, now the science has really figured it out. We're way smarter than
we were in the past. Then there's these interesting studies that I've seen. I think
Robin Hansen mentioned it to me, that if you look at the entirety of medication, like the effect of
medication on human health, if you do those kinds of broad studies, does it actually help?
Does quality of life, certain measures of the well-being, if you look at human society as a
whole, does taking medication or not actually help? Those studies find there's no positive or
negative effect with medication. That's a very interesting perspective. You could probably
argue a lot of ways, but the point is because you can bring up literally a billion cases where
medication has significant positive impact on a particular patient, but you have to zoom
out and honestly look at the positive effects of medicine, of lifestyle choices, diet choices,
exercise or not. Maybe we'll find eventually that exercise actually bad for you. There's all
kinds of things that we're going to figure out. One of the things I think we're going to figure
out, everything I've learned about my body is that aside from it being adaptable, there's a lot of
very unique parameters that are opaque to me that I'm measuring through this feedback mechanism by
trying stuff and learning about it. One of the things we might learn is that medicine cannot be
done without collecting a huge amount of data about each individual human. If I show up and see a
doctor, it's absurd for that doctor to have just a couple of minutes with me. Looking at basic
symptoms, looking at such crappy data, first of all, no long-term data, no longitude, no data,
no historical data, no detailed analysis of all the possible things, not just related to your
symptoms, but related to other things that you're not complaining about, just giving you a full
picture of the data and then using AI to help the human doctor highlight the things that you
should perhaps pay extra attention to. I think we'll look back at this time as ridiculous that
doctors were expected to help anybody whatsoever without having the data, without having a huge
amount of data about the human body. You have to do so much with so little data. It's very 19th
century. 19th century. It relies on the brilliance of doctors and, of course, the intuition, the
instinct you built up over time. That's quite powerful. The human brain is pretty damn good
for using experience to teach you how to make good decisions, but still, you might as well be
bloodletting. It's humbling to think about that. It's humbling. It is humbling and it's important.
I think doctors sometimes lose that humble perspective on what they do. I think it's very
important because, as I said, medical history is just, medical dogma has been tossed into the
trash bin so many times. Something doctors were sure of was the case is not. It's important to
be cognizant of that. You tweeted about somebody that had a big impact just by reading about him
on my life as well. I still think about him. Rest in peace, Dr. Paul Farmer, a big inspiration to
me. His medical career was a testament to what one person can do to improve the world.
Who was Paul Farmer? What made him a great doctor and a great man and somebody who was an inspiration
to you? Paul Farmer was a kind of pioneer of global health. He started partners in health,
which is kind of an international health organization that operates it originally in Haiti,
also Rwanda and elsewhere. I think he was just so azealate for getting healthcare to some of the
poorest people in the world. I remember reading some of his books and a book about him by Tracy
Kitter. That's really great, Mountains Beyond Mountains, about how even when he was a medical
student, he was flying back and forth to Haiti in between exams and just with this really intense
focus and interest in getting healthcare to where it's not. I think traveling around the world,
especially to poorer places like India, Calcutta, Nepal, you really see how unevenly the benefits
of modern medicine are spread over the surface of the earth. Not only because if you're an
Antarctica and have a heart attack, you're in serious trouble, but just medications that cost
pennies a day can help people. A lot of children in India under five die of diarrhea and all they
need is oral rehydration solutions to stay hydrated. Most of them can't afford IV fluids,
for instance, to get admitted to the hospital. Really, dehydration just kills hundreds of
thousands of kids throughout the world. Not to mention, bacterial pneumonia also is a major
cause of death in children under five. Many of them not all would be saved by amoxicillin,
which is just pennies. For me, I took a path and I wanted to have a career in global health,
and I started traveling abroad to India and elsewhere when I was a medical student. I
continued doing that. Paul Farmer was one of the first to open everyone's eyes, I think,
about the good you can do with just money that we would change, that we would throw away,
just put in a person, forget it or wherever we accumulate change these days. That's very eye
opening. While medical science advances and that's good, we shouldn't forget that 100-year-old
treatments could save lives in parts of the world where they're just not available.
People should definitely read mountains, be on mountains. For me, at least, a person from
outside of all of it, it was the first person to make me realize how difficult and the amount
of humanity that's involved in being a doctor. It's not some kind of cold economics-based
argument about where to send treatments and so on. That is there too. Like you said, basic
treatments can help hundreds of thousands, millions of people in many parts of the world,
but it's also when you have a patient in front of you, there's some aspect of you that's willing
to give a lot of your time, a lot of your money, a lot of your effort to saving them,
even though it doesn't make any sense. It's irrational in some sense, but it's also human,
and that's the struggle of every doctor. When you have to choose how to allocate your time,
how to allocate your mental energy, it's a tough choice that a doctor has to make,
and it's a human choice. It's not some kind of cold game theoretic choice. It's also a human
choice, and it could be irrational in some sense. People are asking you for help. That's
basically what every patient interaction is. Someone's asking you for help. Your inclination
is to help them, and even if it means going above and beyond, a lot of factors affect how
compassionate a doctor might be on any given day or point in their career, their own stress and
burnout, et cetera, but it's someone asking you for help, and so you do what you can to help them.
You've done quite a lot of things in your life. It's been an interesting journey. Of course,
there's a lot of story yet to be written, but what advice would you give to young people today?
In high school, maybe undergrad college starting out on that journey, maybe trying to pick majors,
trying to pick jobs, careers, dreams, and goals that can pursue. What advice would you give them
to have a career they can be proud of or to even have a life they can be proud of?
Well, I think having passion, which isn't always a voluntary thing. You just have it or you don't,
perhaps, but becoming passionate about something and following it wherever it takes you, I think,
is really important. When I finished college and went to Russia for the first time, that was in
some ways the beginning of my whole career and passions in my life, and I didn't know what I
was going for, what was going to happen, what kind of career it would turn into, what kind of job
would it help me get when I got back? I wasn't thinking about anything of that. I'm very fortunate.
I got that opportunity. I was very fortunate to be able to go and see those places and have my
mind opened. I think that really just the fuel from that passion that was created during that
time is still 20 years later going strong. I'm partial to healthcare. I love being a doctor.
I think it's the perfect combination of intellectual problem solving, being a detective,
while also working with your hands when you do procedures, especially in the ER,
it's sort of the perfect combination. I'm not a surgeon, but I do use my hands quite a bit
for a variety of reasons. I always loved working with my hands. I loved crafts,
especially prehistoric crafts, before medical school. I just love problem solving, getting clues,
figuring out what's going on, following your nose, using your instincts, your knowledge,
and also just keen observation of the patient. After seeing patient after patient, hundreds of
patients, maybe thousands over years, you do get this innate sense, this gestalt about what might
be going on. It's not always a numbers thing. That's the thing. Gestalt is actually a big part
of medicine. You often in ERs or in hospitals, here, a nurse or doctor say something like,
this patient just doesn't look good. You can't point to a number, a value, a level in their
blood, a test, but something about them. A lot of that, I think, has to do with the color of
their skin, believe it or not, which can change in certain disease states. I think that it's just
medicine combines this observation, the skills, the knowledge, its art and science, it's human,
and it's robotic, algorithmic at the same time. I think it just combines all my passions all
in one. If anyone's going into healthcare, I'd strongly encourage them to do so, but I'm very
biased. With that early passion, whatever that little flame was that brought you to Russia,
were you able to vocalize it or was it just something like a gut that pulled you towards some
exploration of the unknown or something like this? I think it was a combination of things. One was
just going to a different place that was different from where I grew up. When you're in high school,
you hate them. Later on, they don't seem so bad. I'm very fortunate how I was raised and never
wanted for anything that wasn't rich, but just to get out and see a different place, a different
people with a different culture and history and language and literature and to see different
climates and geographies and ecosystems, I just wanted to see something different.
I guess that's what I've sought after ever since. That was just so fascinating,
like my trip to Kamchatka in 2003, where I was there for four months. I didn't speak English for
I think two months out of it. I remember lying on the floor, some wooden floor in a hunter's cabin
in the middle of northern Kamchatka, just being like, what am I doing here? I'm just so grateful
for the experiences I was having, what I was seeing and realizing and learning.
I was so grateful, even though I was lying on this hard uncomfortable floor. It's just like,
this is so amazing. I don't think I'll ever have another travel as meaningful and life-changing
as that particular trip to Kamchatka was, though I'm still striving after it. You never replicate
that first high, but you always try. I just think that seeing something different is kind of the
game. There wasn't really a plan, because I got a chance to talk to the CEO of Qualcomm recently,
and his advice is, always have a plan. It sounds like you're saying, don't have a plan.
Don't need to have a plan. Just listen to your gut, your passion and follow that and see where
that takes you, because it's telling you something. Yeah, I guess the plan could be specific or could
be as general as, I just want to go far away and see something very different. That's my plan.
That's one line. Just followed my nose from one thing to the next, just being interested,
following my passion. Again, very fortunate I could do that.
Are there places in the world you're kind of thinking about that your life might take you at
some point to be a doctor there for a time, to explore for a time that you haven't yet?
I have some colleagues who do kind of global health work in various countries in Africa
and Central and South America. I would really love to go to some of those places, not just for a
short trip, but hopefully for an extended period of time, with sort of the healthcare being the
ticket in, but then maybe even bringing my children or just, I guess at this point, some of the travel
I dream about is sort of replicating what I did and showing it to my kids in a way.
But there's still a lot I haven't seen and would love to see as well. But I think those
opportunities sort of lend themselves well as a doctor with kind of the ability to go there and
sort of help patients, but also teach medical students and residents. Teaching is actually a
huge part of being a doctor that's underappreciated, but that's actually part of the fun of being a
doctor is that you're also a teacher. Of course, the word doctor means teacher, but it's come to
mean something else. But in some of my jobs, I'm working alongside medical students and residents,
and I'm giving them my knowledge, my wisdom, sharing with them stories, and so that's a very
satisfying part of the job. If we could take a brief step into a dark place together for a time.
What is a dark place you've gone in your mind in your life? What would be the darkest place you
have gone for time, for a moment, and how did you survive? How did you overcome it?
That's a very good question. I would say I haven't had as dark moments as many of the people
who I care for in the emergency room. I'm fortunate in that way. I've had a pretty,
you know, enjoyable, satisfying life. I think everybody has dark moments, though,
including me. One of the most shocking things I feel like becoming an adult, my two big
realizations have been, one, no one knows what they're doing, and two, suicide is incredibly
common in all humans and all societies. That I just find shocking. I mean, I've never seriously
contemplated myself, but I wouldn't say it hasn't crossed my mind during some more stressful times
of life. I think it crosses everyone's mind, and it sort of, as a kid, I found that I never would
have guessed how common suicide is. It's an important question to sort of the Camus question,
like, why live? Why? Why? It's like life, especially when you're struggling, especially when life is
shit. Like, why am I doing any of this? And then on top of that chemistry of your brain,
it could be as simple as diet and nutrition and aforementioned exercise and things like this
that affect the chemistry such that you're more predisposed to go to the places of asking the
question why and maybe struggling to find a good answer. Because it's actually a question with no
good answer, except something in your chemistry says, well, I kind of like it, but there's no
good intellectual answer. And especially if day to day it's pain, you get to see these stories of,
you know, Robin Williams, these people that are on top of the world from an external perspective,
but from an internal perspective, it's struggle. Every day is pain. It feels hopeless. And
yeah, that's a question we all have to struggle with or learn how to ignore. Maybe because if
you ask the question too much, you're not going to find a good answer. That's a choice you make.
I personally think you should ask that question a lot. But maybe because I have the luxury of
the chemistry I have where I'm not in danger of seriously contemplating suicide, but why live
is an important question to answer constantly and struggle to answer that constantly.
But people I am, I've gotten up, I've been extremely fortunate to meet people over the
past couple of years that are really struggling. And you have probably met people who are really
struggling like orders of magnitude, more people who are really struggling. Some of it is psychological.
A lot of it is biological. And man, life, life is a motherfucker. It's pretty tough.
Very true. I do think also past trauma plays a big role there, like we talked about,
war wounds and PTSD. And a lot of people grew up, I mean, with just horrific childhoods,
they're abused in one way or another. And I think a lot of people who have, I'm not saying a majority,
but a lot of people, for instance, who I see in the ER coming in for threatening suicide or actually
trying and failing and being brought to the ER, a lot of them just have really traumatic experiences,
saw their parent commit suicide, were abused. These leave scars in the human brain and mind.
And a lot of their subsequent lives of whether it's substance abuse, alcoholism, etc., is almost
trying to escape from their own memories. And it's sort of such this overwhelming battle sometimes.
Like sometimes people get ruined, it seems, and just can't be fixed. You know what I mean?
Yes, you can improve diet and health and your life choices and seek out your passion and exercise,
and those definitely will help. But sometimes just like, you know, you bear the scars of the past
and there's no getting rid of them. Yeah, I think it's possible to live with them.
I think so too. To the struggle. I would never say give up, you know.
Keep fighting. It is a constant, it can be a constant battle for some people.
I know it can be, and I've talked to many of those folks, I know it can feel hopeless, but
keep up the good fight. Hopelessness is kind of one of the big suicide risk factors that
you sort of ask about as a doctor, you know, do you feel hopeless? And that sort of can be a
harbinger. I have quite a few dark moments. So if you're listening and you're struggling,
wearing this together, brother and sister, keep up the good fight.
Life is a motherfucker, as you said. It's really harder. I think as a kid, you know,
in a joy-free childhood, you don't realize, like, obviously there's a ton you don't realize about
life. But then when you get to be an adult, you realize just how complex and hard it is.
Is it this hard for adult animals? I don't know. I don't think it is.
So I haven't seen the honesty of biology before you. Do you think about your own death?
Do you contemplate death? Are you afraid of your own death? How do you make sense of it?
I've definitely thought about it, especially maybe while doing certain risky things,
ice climbing and others, where every time I look down, I thought about my own death. But
I think, you know, I think having kids changes the equation, for sure, should change the equation,
perhaps. So I think a lot of now when I think about what will happen when I die, you know,
there's a lot of worrying about what will happen to the people I care for, you know,
you think about things like insurance policy, life insurance and, you know, disability insurance,
that's not related to death, but more just injuries. And that's part of the weight, I guess, that,
you know, you feel as an adult that I think grows rapidly when you have kids. Though not only,
you know, there's other people you can care for, your own parents and loved ones, like a lot of
people depend on individuals. And so you think about what will happen to the other people when
you die. But also to push back, that weight might be something you've convinced yourself to think
about. It's an important way to think about. But you focus on that weight to escape the other
weight, which is at one point, this consciousness just comes to an end. And it's hard to make
sense of that. We kind of delude ourselves in thinking, okay, it just, yeah, it's ends. That's
a natural way of things and so on that makes sense. Okay, that's the way of life. But like,
I don't think it's like cognitively easy to just realize how terrifying that is. We love life so
much. That's the end of it. It just, it's something that makes no sense. And if you linger on that
thought, I think it's a painful, it's a painful, I would say even terrifying thought, not scared of
like, in a way that's almost like philosophically terrifying. Like, it just reminds you, maybe
humbles you that you don't know anything about anything. But one of the things we do as humans
really well is we, especially with kids, you realize, okay, we start caring for others in
the community and the family and so on. And that distracts us, because then we can at least focus
on other people's problems and not deal with our own. When I was a medical student, I was
particularly fascinated with kind of what actually happens as people die, like in the last minute,
seconds of life. And it's sort of surprising sometimes like what actually kills people,
you know, like, you can get a, let's say a bad head injury and, you know, what kills you. Sometimes
it's just your consciousness decreases and you become kind of comatose, you aspirate, your oxygen
plummets and you get cardiac arrest, you know, that kind of sequence of events, or, you know,
a heroin overdose, let's say you stop breathing. Similarly, your oxygen goes down, then you get
a cardiac arrest. So I was really fascinated with what actually happens, what makes people die.
And it was sort of a morbid fascination, obviously, like most of med school is.
And I had many instances where I've had patients pass. And as a medical student, I was sort of
sort of learning what's actually happening, watching it happen and, you know, not always
being able to prevent it. It was sort of a scientific exploration. Then the patient's
family comes in and are just devastated. And then it's like, rips you out of this scientific
perspective and you just realize how horrible death is. But the person's fine, you know,
it's the family, I guess. And that's why it's always, I guess that pointed out just how what
people leave behind is often kind of the horribleness of death, like just becoming unconscious
and staying that way doesn't seem, I guess to me personally, so bad, sort of like going to sleep,
not waking up, not counting the pain and stuff that precedes it.
So the actual pain, the actual suffering is often felt by the people who love the person who died.
Right. So both financial pain, psychological pain, for years missing them, all those kinds
of things. Right. Never forgetting the anniversary of their death, you know, just having flashbacks
or something reminding you. That sort of brought home to me sort of what death means. And it was
more about what people leave behind than what happens to them specifically.
See, I like those concerns because I feel like I can do a lot about those. Those make sense to me.
Then just be, if you're a father, just be a good father.
If you're sort of, you mentioned some insurance, yeah, there's like financial stuff to take care of.
What I don't know what to do with is the philosophical existential crisis of the
fact that this fricking thing ends. It doesn't, I don't know how to deal with the mystery that's
beyond death. Why are we here? Why are we born at all? What is consciousness? And you just look
at yourself. What is this? Why do I have the capacity to suffer? Why? Why? All these kinds
of why questions that don't have answers. Speaking of which, let me ask you a why question.
The biggest, ridiculous one. What do you think is the meaning of life?
Having, with this book, studied the incredible beautiful biology of life.
The components, the engineering components, they make up this human body. But when you look at the
entirety of it, what is it? Why? Why are we here? Sometimes, probably more often than not,
feel like the question of why is a trick of the human brain. And outside of our thoughts,
there is no why. Why is not something that's in the universe? It's just this trick happening inside
our brain. So why is a game that the human brain plays on itself? And then the reality of life
doesn't have whys. I do wonder if asking why is sort of an evolutionary adaptation. Like
why? Maybe hunting, gathering. Why does this plant grow there and not there? Why do I see the same
deer tracks by the same tree every three days? Why is this? Why is that? Why does this plant
make me vomit? And that plant doesn't. I guess those whys are very practical and oriented
towards survival. But then obviously, we not only use why, we use it to maybe hunt better,
gather better, survive better. But then we sort of extrapolated into these unanswerable questions
about why. Like why does life exist? And it's possible that they're not unanswerable
in the long arc of science and history. We're just striving for the really difficult questions.
Right now, we just don't know much about anything. And so we're striving. But there's long...
So most of human history, you were asking why questions for which we now have very precise
answers, including with biology and physics and all those kinds of things. And maybe the why is
this cutting edge of science of the explorer of the curiosity of the human mind. Like man's search
for meaning is the sort of the ultimate driver of the why. And it's almost like it could be an
evolutionary adaptation of asking exceptionally hard why questions that will never get answered.
Like, so you should always have like, it's like a cue, it's a stack of questions, why questions,
and that thing should never come to the bottom, should always be striving. And that's useful
for humans to come up with better and better ways of survival. And maybe from in a bigger
perspective for the universe to figure out something about itself. And it's just humans,
just a useful tool for that. Or life on earth is a useful tool for that. Well,
John, you're for people who should know you're from Philadelphia. I'm from Philadelphia. So
it's an honor that you will travel all this way from a place I love to the new place I love.
And that you'll write this really incredible book that celebrates the human body in the most
honest of ways. And thank you for everything you do for being a great educator, for being a great
doctor, for being a great person, and for spending your really valuable time with me today. Thank
you, John. Thanks for having me, Lex. Thanks for listening to this conversation with Jonathan
Reisman. To support this podcast, please check out our sponsors in the description. And now,
let me leave you with some words from Paul Farmer, a doctor who has inspired both Jonathan and me
with the way he practiced medicine and the way he lived his life. The idea that some lives matter
less is the root of all that is wrong with the world. Thank you for listening and hope to see you next time.