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4:34
This is Tim Ferriss and welcome to another episode of the Tim Ferriss Show.
4:39
This one was such a treat for me and I really hope it is for you as well.
4:42
This is an interview that I had hoped to set up and tried to set up for close to I'd say five years.
4:50
And here's the question I'll pose.
4:54
At the end of our lives, what do we most wish for?
4:56
And how can knowing this, if we can know it, help you to live a better life now? Well, it turns out B. J. Miller, M. D. , Dr.
5:04
Miller, knows exactly this. B. J.
5:08
is a palliative care physician at Zen Hospice Project in San Francisco, where he thinks deeply about how to create a dignified, graceful end of life for his patients.
5:18
Now, this is of course not one of the usual suspects you would expect to see making the rounds on the podcast.
5:24
And this is precisely why I wanted him on and why I hope you listen to this podcast. B. J.
5:31
is an expert in death, but important, he's also learned how we can dramatically improve our own lives, often with very small changes.
5:40
When you consider that he has guided or been involved with roughly a thousand deaths, it's not surprising that he has spotted patterns we can all learn from.
5:50
On top of this, BJ has developed incredible empathic abilities.
5:54
He is a triple amputee and his 2015 TED Talk, Not Whether but How, which is a moving reflection on his vision to make empathic end-of-life care available to all, ranked among the top 15 most viewed TED Talks of the year.
6:07
I absolutely love this conversation and without further ado, please enjoy the wide-ranging dialogue, conversation, rambling exploration between myself and BJ Miller, MD. BJ, welcome to the show. Thank you, Tim. It's nice to be here.
6:31
I have been wanting to talk to you, or I should say I have wanted to talk to you for years now.
6:40
And to to illus- to to give a few examples and illustrate that, the first was an article that I came across in the Princeton Alumni magazine, uh Princeton Alumni Weekly, about your work.
6:54
And then the next was a profile in a magazine here in San Francisco.
7:01
Following on the tails of that, Adam Gazzaley, who is a a an just an incredible neuroscientist at UCSF, who's been on the podcast, reached out to me.
7:11
And that was related to a I think it was senior partner at IDEO, who had also reached out to him to suggest that you be on the podcast.
7:19
So, I feel like this was fated to be and uh I've been increasingly over the last few years thinking about death and the the value of meditating on death, among other things.
7:37
But before we get there, and I suppose we'll get there rather quickly.
7:43
When people ask you what do you do?
7:46
How do you How do you answer that?
7:49
Well, I guess the I guess I generally say, you know, generically I'll say, "Oh, I'm a physician."
7:56
And if people seem like they actually really want to talk things out, I say, "Well, I'm a palliative care doc."
8:02
And then people want to talk up from there, I'll say I work at a remarkable place called the Zen Hospice Project and do some work at UCSF.
8:11
And do increasing amounts of speaking and and and beating the drum, I like to say.
8:16
So, depending on how interested the the person asking the question is, that's what they might hear from me.
8:20
Uh let's say they're very interested.
8:23
Uh I don't know if you drink, but let's say the the other person's had two drinks, so pleasantly drunkenly curious.
8:33
And they say, "What drum are you beating?
8:34
I'm really interested to hear more.
8:35
What What is the What is the drum?"
8:39
Well, the drum, I suppose, is really is getting uh society to pay attention to the inevitables in life.
8:45
Uh getting helping helping each other look at hard stuff.
8:51
Helping each other to live with hard truths.
8:54
I'm trying to get people to pay attention to the fact that we all die.
8:58
And that the way we die could be a lot better than it is in general.
9:05
So, let's let's dig into that because I really enjoyed for instance your TED Talk and maybe you've given multiple, but at least the one that I saw Just one, yeah.
9:15
Which is And one is enough, by the way. No kidding.
9:21
But let's let's look at a sample experience.
9:26
So, you have a new patient come into uh your facility. Mhm.
9:32
What What the first meeting look like?
9:35
And what does that first day look like for them?
9:41
Well, so let me pre-answer your question because it it so depends.
9:45
You know, so for example, at Zen Hospice Project by virtue of coming to our place, by virtue of enrolling in hospice, many corners will have been turned just to get to that place.
9:59
So, when we're meeting folks for the folks for the first time in Zen Hospice, they they for the most part are aware that time is short, are aware that they're dying soon, are aware that there's really not much more to beat back their disease uh to be done.
10:18
So, uh and there's plenty of work to be done even or you know, on the far side of turning that corner.
10:23
Um but I think another uh uh um um you know, a more I don't know.
10:28
An interesting another way of answering your question is really, you know, upstream of hospice.
10:35
When folks are um struggling uh gone to war with their disease, engaged in that fight, whether it's chemotherapy or whatever, um Now, that that's the kind of person I'll meet in clinic at UCSF.
10:52
So, I a part of my job is on faculty at UCSF and I work in a clinic that's called the Symptom Management Service.
11:00
It's about 10 years old and that's just basically a euphemism a euphemism for palliative care.
11:06
The cancer center wanted us to call it the Symptom Management Service because it felt that the palliative care phrase had too much baggage around it.
11:14
And is palliative care, I'm just going to plead ignorance here, is that synonymous with hospice care or is that are those different things?
11:20
They are they're related but different and thank you for asking that question, Tim.
11:24
I mean, this is part of the drumbeat.
11:25
Uh so, so hospice is that portion of palliative care that's at the end of the road.
11:31
So, and hospice is an insurance designation as much as it is a philosophy of care.
11:38
So, so hospice is by definition end-of-life care.
11:42
Uh palliative care makes no it does not time is not an issue in palliative care.
11:49
You just have to be suffering.
11:49
So, you know, you can see folks in palliative care for many many years uh far in advance of their death.
11:58
So, yeah, all hospice is palliative care, but not all uh palliative care is hospice. Got it. All right.
12:07
So, palliative care, just to kind of make it is basically the you know, within the context of dealing with illness, palliative care is the pursuit of quality of life. Period.
12:17
You know, that that's that's it.
12:20
So, the fulcrum in palliative care is suffering.
12:24
You know, are you suffering in some intractable way more than you're struggling more than you need to?
12:28
And if so, then, you know, come see us in palliative care. We'll help.
12:33
And in palliative care, you can receive our support and continue on with your more aggressive invasive life sustaining interventions as well.
12:49
You don't have to give up one type of care to add palliative care to the mix.
12:53
Whereas, once you're entering hospice because of its insurance details and vagaries, you do have to in general you have to give up curative intended care to qualify for hospice.
13:02
So, we and we could spend a lot of time on this.
13:07
There are a lot of wonky details, but does that sort of make sense to you in the US? makes sense.
13:12
makes sense. And I mean, it would The first thing that leapt to mind for me and that will lead to a lot of tangents, I apologize in advance, but was that the way that you define palliative care would seem to include almost everyone on the planet in
13:28
some respect suffering more than they need to and we'll we'll dig into uh the the learnings and and philosophies and so on that that you've cultivated but so let's say they have gone through the paperwork and the process to get to the Zen Hospice Project. Uh-huh. What does Uh-huh.
13:46
What does their first day look like?
13:51
So the first day at Zen Hospice is usually there's always the the folks by almost by definition are pretty fragile state.
13:58
So just the ride getting to the house and into the house uh is often plenty overwhelming.
14:03
So very often the the resident will just sleep much of the first day.
14:11
But as soon as they're beyond the logistics of the trip over uh the first day is generally our nurses, our volunteers the kitchen crew sort of swarming around that resident and their family and just getting to know them.
14:26
That's where all the potency comes is it's it's inherently a relationship.
14:30
So there's some details around medications etc.
14:35
but most of the early work is just getting to know people and making them feel that this is their home now.
14:39
This is they're come to live here.
14:42
Yeah, they're going to be dying soon but they're here to live until they die.
14:47
So that's you know the it's a very non-medical establishment and the first day doesn't feel anything like being in a hot admitted to a hospital.
14:58
Um you know and pretty soon you as you get to know someone within the first day you invariably questions get asked like you know you tell us what's most important to you now, you know.
15:08
You want something to eat, we can whip you up something in the kitchen or we'll tend to the family. It's very casual.
15:13
It's meant to be feel like you're entering a warm embrace of a familiar setting.
15:18
And What does the just to highlight also the differences.
15:21
Can you describe upon the patient's death Mhm.
15:27
what happens in Zen Hospice Project versus in a conventional hospital setting. Mhm.
15:34
And you can present either first. Yeah, well.
15:40
So, so much of, you know, hospice and palliative care in general, but certainly places like Zen Hospice Project in many ways they were created as antidotes to the hospital.
15:51
So, in some ways they're they're really they'll feel like opposites.
15:57
And that that's to some degree by design.
16:01
Um but a death in a place like Zen Hospice Project um is usually very peaceful because we've gotten to know that person, we've been living with that person, we've know what they want, what their idiosyncrasies are, and we work with, you know, local teams of hospice agencies who come in and provide the medical care.
16:21
So, for the most part uh people can enjoy um and expect a much more comfortable and peaceful death at Zen Hospice Project and places like it.
16:34
Um that's what the all of the expertise is geared to towards.
16:36
You're not distracted by beeping machines and other things and other agendas happening, research agendas, whatever it is.
16:45
Um and to your question, uh Tim, you know, so the person dies, that invariably the mortuary needs to come and retrieve the body.
16:55
So, and we have this uh ritual that we offer people, which is on their way out the building, you know, the mortuary guys have picked up the body, and if there are family or friends around and certainly staff and nurses and volunteers will gather around and we'll all we'll all gather on the porch,
17:17
and we will do this we our our flower ceremony, which is basically we gather around and the the mortuary guys pause for a moment and we maybe say a few words or sing a song or whatever it is, just reflect on our time and remember the person who is just leaving us. And then we'll sprinkle the body with
17:35
And then we'll sprinkle the body with uh flower petals.
17:37
You know, it's just this very simple, gorgeous moment.
17:39
And then the body bag is zipped up as it has to be by law and the body heads out the door.
17:51
But, you know, it's it's it's just very stunning, poignant, gorgeous, simple moment.
17:56
And you can feel everyone entering into the sort of grieving phase more fully, especially of course the family.
18:03
And you can watch folks have this little bit of closure perhaps.
18:08
But more to the point is you watch them uh swarmed with warmth and love and easing into the grief process cuz there's space for it and there's this sweet segue.
18:19
And you can just feel that something's been completed there and then the family now have to live on, but can do so with some imagery that's sweet and beautiful to remember rather than traumatic.
18:35
So, now you know, counter that with the typical hospital death.
18:41
And and by the way, Tim, I'm looking to talk about all sorts of things together.
18:44
I hope we do, but you know, no knock on hospitals.
18:46
Uh they're incredible places.
18:48
They're they're just not really designed to have a beautiful experience per se and they're not really designed to help you die well.
18:56
Um so in and you feel that mismatch.
18:56
So, I've worked in a lot of work in hospitals as a patient, but also as a physician and you know, a typical hospital death is is in a more sterile room, usually lined with a bunch of machinery um and all the sounds and lights uh emitted. And it's very cold.
19:16
I mean, the second a person dies, you can feel the cleaning crew waiting to descend on the room, and they need to get the body out of the room because someone invariably is waiting for the room.
19:28
And there's no ushering in of grief.
19:31
There's a sort of a a snuffing of it.
19:34
And it's very disorienting for everybody involved, including the clinicians, cuz there's no pause moment to reflect on the experience you've just had with this person.
19:41
It's just kind of onto the next.
19:45
Uh, and it's a stark, stark contrast.
19:49
How many since you began your work with palliative care and hospice care, Mhm.
19:54
how many deaths have you witnessed or uh, experienced even in the periphery, not necessarily watching someone die, but under your care or in your periphery, how many deaths have you experienced?
20:13
I'm you know, my guess now, I mean, I finished my final bits of training, and then there's all the deaths during residency and fellowship, of course, but I've been out of my final training now for 10 years.
20:24
You know, I if it's not a thousand people, it's approaching a thousand.
20:27
Uh, I don't know that for sure, but it's certainly many, many hundreds.
20:33
What and this is a huge question, so we can certainly find slice it and and feel free to tackle it any way you like, but what has observing that many deaths and the march towards death taught you about living and specifically your own life? Mhm.
20:59
Well, that's the perfect question, man.
21:01
I mean, you know, there's like a those of us who work in the field of hospice and palliative care, you know, we it it can feel like you're sitting on a secret and and because I think the assumption is that oh, wow, that's got to be very morbid. Uh, you know, it is.
21:16
I mean, it's got to be a very morbid work or very depressing work.
21:21
And sure, it is a it is loaded.
21:21
I mean, it is emotionally laden work without a doubt.
21:25
I don't mean to make it sound easy, but those of us who work in the field, you pretty quickly get a get a get a real sweet hit that you know, paying attention to this zone of life is very mm, there's a lot it's very nurturing.
21:43
This sort of this sort of secret is that paying attention to the fact that you die can help you live a lot better.
21:53
So, a lot of my colleagues and I are very, you know, are aware of the clock. You know?
21:57
And I'm sure that can make you anxious as well, but we you know, we know we're aware of our finitude.
22:01
And so, we're just a little more likely to be kind to ourselves and others.
22:06
And we're a little less likely to squander that time.
22:11
Cuz we have all these mm, you know, sort of remarkable vicarious deathbed moments with our patients and their families.
22:19
And you can learn a lot of you can learn a lot.
22:22
And and one of the things I love thinking about a real organizing theme for me is is avoiding regret essentially.
22:33
And we avoid regret by again, paying attention to our decisions, paying attention to how precious things are.
22:40
And getting very good at forgiveness and reconciliation.
22:43
And these are themes that play out in this work all the time.
22:47
So, in a sense, we're exercising these muscles on behalf of others that all of us need to exercise on behalf of ourselves at some point.
22:53
We just get pretty well practiced at it.
22:56
So, uh, yeah, so this is where the work gets extremely beautiful and really nurturing and can help you live better.
23:02
And I guess that's part of the drumbeat.
23:04
Why do we want to talk about this?
23:05
Well, there there's some systems issues, there's some economic issues, but there's these these beautiful civil issues on behalf of kindness, on behalf of uh justice and equality, the fact that we all die.
23:17
Well, paying attention to this has all this potential to for for this to be a a bond among human beings.
23:26
The fact that we die and the fact that we're cognizant that we die.
23:31
Uh that's part of this drumbeat.
23:34
And it in the case of paying attention to decisions, um what would be examples of some specific decisions you've made or habits you've developed uh that have been impacted by this work?
23:54
Um so, to one thing, you know, caveats, I'm I like anybody else, I'm flawed and I'm a work in progress and I forget all the lessons that I've learned a million I have to learn them over and over again.
24:05
So, you know, I got all sorts of work to do on myself, but And as as as we all do. Yeah. Yeah, amen, brother.
24:13
So, but um but I do think I've gotten a lot better at you know, when I I I I I'm pretty good as a hyper-educated person at rationalizing all sorts of things and behaviors and I can convince myself to stay in relationships or in situations uh that don't don't necessarily feed me or that aren't working very well.
24:37
And I I think I've gotten a lot better at calling that.
24:39
Uh for everybody's sake, you know, so I might be I think I'm a little bit better these days at not squandering my time.
24:49
Um and in terms of friendships and relationships, navigating them, not taking them seriously, so that we're just not wasting each other's time.
24:57
So, I feel that in my relationships, I feel these lessons in my relationship to nature.
25:07
So, that's a great salve for me is being out on Mount Tam out here in Marin County or just about anywhere.
25:14
And feeling letting myself really delight and bask in the the crazy grandeur of being alive at all.
25:22
And I get thrilled that I can feel anything. Sometimes even pain.
25:27
I can the way I deal with my own pain is I just I remind myself that I'm glad to be to feel anything at all.
25:37
So, my relationships uh I think are impacted, my sort of orientation to Mother Nature's impacted.
25:45
I think I'm a lot lot I've got a lot lot better at forgiveness. So, not holding grudges.
25:50
You know how we walk around with anger at others and ourselves and it's just so unnecessary. It doesn't help anybody.
25:55
So, I've got a lot better I think at letting go of certain things.
26:00
So, to to drill into that, I apologize for interrupting, but because this is a particular Achilles' heel of mine and I've improved, I think I'm trending in the right direction over the last few years, but I have always had a lot of difficulty letting go of grudges.
26:14
And those loops that we tend to repeat or at least I tend to repeat and reinforce like a groove in a record that that can just create this bitterness might be a strong word, but it's not totally uh it's not totally out of place.
26:31
When when you find yourself when you catch yourself angry with someone or not letting go, what is what is the internal dialogue?
26:42
What do you say to yourself?
26:44
How do you ameliorate that?
26:47
Well, this is where uh you know, meditation, mindfulness, self-awareness, whatever you want to call it, can be so helpful cuz one one one thing to just get better at at realizing you're doing it in the first place, even be you know, even before you're able to change it at all, is there's great potency in just being aware that you're doing it.
27:09
You know, I could I I was I used to be much more I could walk around for months with grudges and chips on and bitterness is etc.
27:16
before I really even realize it.
27:18
I would just be really moody or whatever else.
27:20
So, you know, job one I guess is just paying attention to yourself and seeing it for what it is.
27:25
And then the next step's actually that's the hard part I think, at least for me.
27:29
I mean, the next step is actually kind of easy cuz then then as you watch yourself spinning out then you can kind of call it the silly useless thing that it is and you kind of take the wind out of its sails, you know, you disempower the anger.
27:46
And and for me, you know, in my life, man, I the the absurdity uh the being in touch with absurdity has been very very helpful. Yeah.
27:57
So, that's my next step is the awareness and then is sort of watching the the silliness of it all and then that the anger and maybe with some deep breaths or whatever else or a walk to sort of bleed off the physical anxieties of it.
28:12
Um but then I can sort of unspool, unwind.
28:17
And maybe even quickly kind of laugh at myself.
28:23
And that's great cuz A, you've let go of the junk.
28:25
And B, it's an exercise in humility and forgiveness, which is always pretty dang useful.
28:33
And for those people listening who might have these same issues and a lot of us do, of course, there's a book with with a very bland title called radical acceptance by Tara Brach that I found very very particularly helpful to me in this in this instance.
28:51
You mentioned mindfulness meditation.
28:51
Do you have a regular meditation or mindfulness practice? You know, uh not really.
29:02
Well, I guess your whole job in a way is a mindfulness practice.
29:04
So, I that that that perhaps might be overkill to just add another session on top of everything else you're doing.
29:11
Thank you for that way out, brother man. You're welcome.
29:16
But yeah, I mean it's you know, it there is some truth in it actually.
29:18
Um this is where it's another reason why this work is so potent and fun is your personal and professional lives are deeply intertwined almost necessarily because to so much of this work is is just being aware, is listening, is paying attention and bearing witness, and coming to terms with all the stuff you can't control.
29:40
And whether it's on my for my sake or on sake or my patient's sake.
29:44
So, there is some real truth that I I kind of feel like doing this job well and empathy is job one in this world in this work.
29:51
And so, I do feel that much of my daily life, the daily grind for me is itself pr- you know, it's sort of meditative.
30:00
But I also I also want to be clear.
30:02
I mean I do I I have my own relationship.
30:03
For me it's uh a bike ride or it's time with my dog or it's time sitting in my backyard just looking out at the hills.
30:14
And it feels to me uh like a meditation. I like movement.
30:19
It's something ever since I became disabled, you know, I think I'm particularly primed to appreciate movement.
30:27
So, I like a walking or bike ride and it feels like meditation, but so I feel like I'm doing it a lot in a way, but I also want to honor those folks in the audience and elsewhere who truly have a meditation practice.
30:42
And that is really its own discipline.
30:44
Uh so I I don't really have that, but I got those other things.
30:49
And I Well, I think they're all present state mindfulness practices, right?
30:54
I mean, if you're riding a bike Uh now, you mentioned something we haven't covered.
30:58
Uh and I didn't cover it very deliberately, but it makes sense, I think, at this point to rewind the clock.
31:06
Could you tell us about the Dinky? Yeah. I'm sorry.
31:12
I love the I just love Speaking of absurdity, you know, the Dinky.
31:18
This What a I mean, I lost three limbs to a thing called the Dinky.
31:24
Sorry I'm laughing, but You should laugh.
31:26
I mean, this I laugh No, please laugh.
31:29
I mean, it is kind of silly.
31:31
But anyway, so as you know, um fellow tiger, the um you know, there's this commuter train that runs on the campus of Princeton University.
31:40
Although, I guess it doesn't run on campus anymore, but uh and it's a commuter train.
31:44
You know, it's called the Dinky uh with affection to some.
31:49
And the the Dinky runs from Princeton to Princeton Junction, and commuters can take the trains into Philly or New York or whatever else.
31:56
So, that's what the Dinky is.
32:00
Um so uh the why it's significant in my life in particular is, you know, one night, it was November, I was just after Thanksgiving uh vacation sophomore year.
32:13
So, it would have been uh November 27th, 1990.
32:18
Um a couple friends of mine and I were out, just hanging out, having fun. Not a not a crazy night.
32:24
Um but we were walking Well, you remember the Wawa Market, Tim? I do.
32:26
I was at Forbes, so I walked by the Dinky and the Wawa every single day, multiple times. Right. So, you know.
32:33
So, late-night visit to the Wawa Market was pretty common.
32:37
And so, we were heading over to get a sandwich or whatever, you know, and so when we were just walking by the Dinky and um it was just parked there.
32:45
So, it was not is it not operating hours and uh you know, it has a ladder on the back and we just walked by it and just decided to climb it, you know, like you would climb a tree or whatever.
32:58
It did It didn't We really did not think we were doing anything that daring.
33:01
Or put it this way, we've done a lot more like a lot stupider things besides that, at least we thought.
33:06
So, um but I just happened to be the first one up on the up on top of the train and it the those trains run like the buses in San Francisco, with wires that run overhead and then there's this metal thing called a pantograph, I think is what it's called, and that connects the uh train itself to the power source.
33:27
And it's this big metal pole.
33:32
And so, when I stood up on top of the train, I had I had a metal watch on and I happened to be close enough to the power source and the electricity arced to the watch and uh yeah, entered my arm and then blew down the feet. Now, how was that?
33:49
So, what happened at that point?
33:52
So, well, I should say I don't really I I actually don't remember anything about the the that night, um but my friends who were with me uh pieced it back together, but there's you know, there's a big explosion and I was thrown some distance uh and one friend came up on top of the train while the other friend ran and called 911.
34:17
Um and I think I can imagine, I mean, both of my friends were freaking out and extremely right into action mode.
34:26
And you know, getting up on top of the train that had just in ways they couldn't have understood and just electrified their friend and yet they got up on top of the train to help me.
34:35
I mean I just ever a daily shout out to my friends Jonathan and Pete and Tommy, too, for all they did for me that night and oh god and so many nights.
34:48
Um but yeah, so so Pete held me down cuz I guess I I guess at some point I I came to and I was just thrashing about and you have, you know, electricity enters your body and so you've got all this heat you burn from the inside out apparently it's very common that people it wake with extreme energy.
35:04
I mean you are you are electrified.
35:08
So I mean I'm just flailing, punching him, throwing I'm just a wild tear apparently.
35:17
So Pete, who was very particularly large, strong and sturdy, heroic friend of mine, held me down so I didn't roll off the top of the train and make things worse.
35:26
Uh and then the ambulance came and then uh and I don't blame them one bit, but the ambulance drivers refused to get on top of the train as as they should have.
35:36
Um but between my friends and a and a police officer Princeton police officer by the name of uh Officer Dawson, I believe his name was.
35:46
Uh who went on to become who was promoted, I think, after that to Sergeant Dawson.
35:51
But anyway, Sergeant Dawson got up on the train with Pete and together with Jonathan they got me into the stretcher and handed me down to the ambulance.
36:00
Guys in the ambulance whisked me off to the local hospital and the local hospital did a these things where they basically just slice open the skin to allow the heat out.
36:10
Uh it's called this fasciotomy so that so that you stop burning yourself essentially and uh and then I was flown to the uh burn unit at Saint Barnabas Hospital in Livingston, New Jersey, which is New Jersey's one and only burn unit.
36:22
At least it was at the time. And that was that.
36:27
And uh flash forward to when you became fully cognizant of what had happened. Mhm.
36:35
Wha- what you open your eyes Mhm.
36:41
what does the scene look like?
36:44
Well, you know, so uh it's interesting.
36:48
It's like it's it's I was conscious.
36:48
I was awake uh throughout the ordeal.
36:52
Uh and it's just more the the sleepiness of memory.
36:59
So, there really it's not it was not like coming out of a coma where I was asleep and then awake.
37:03
So, there was not a sort of a singular moment Right. reprisal, you know?
37:07
But, I'll tell you the first memory which I I actually I some freakish reason I love this story.
37:14
It just I don't know why, but I'll tell it to you anyway.
37:17
Um I I I do like the story, so I will tell it to you anyway. Uh please do.
37:23
So, uh it was so, you know, your your blood pressure's unstable.
37:27
You're you're just a hot mess.
37:29
So, surgery can't happen until you're more stable if it can be avoided.
37:33
And so, it's it's common to wait several days before surgical amputation of the dead tissue.
37:42
And then also in part because it's not totally clear what tissue's viable and what tissue's not and not.
37:46
So, anyway, it takes it was maybe day five or day six before the first amputations.
37:54
And uh woke up the night before.
37:57
I remember this very very well.
38:00
You know that uh that feeling where you um you wake up from a dream and it's been a bad dream and you there's a moment of sort of panic and then you sort of orient yourself. You look around.
38:12
You orient yourself and you realize, "Oh, thank God.
38:15
You know, that was that was just a dream." Mhm. You know that sensation?
38:19
And it's an incredible somatic, you know, it's a beautiful feeling of relief that washes over you.
38:25
So, anyway, I somehow I looked around a burn unit, which is a particular environment.
38:31
It's not like our guest house that I was just describing a moment ago.
38:34
At Zen Hospice, it's it's it's a very technical, sterile, intense environment.
38:40
And somehow in my stupor, I looked around and saw all these machines and still managed to think, "Oh, thank God that was just a dream."
38:50
And so, I I had a sensation I had to use the bathroom.
38:55
And so, I got I said, "Oh, well, I'll get out of bed and go to the bathroom."
38:59
And uh so, in this state, I ex- I was intubated on a ventilator.
39:05
I I extubated myself Oh, Jesus.
39:07
Not Not easy to do by any stretch. So, I extubate myself.
39:11
I pull out have all these lines running into my uh jugular veins in my neck. I pull those out.
39:20
I just decouple myself from all these machines and get out of bed on my crispy little feet and start heading for the door to go to the bathroom, you know, I just obviously out of it.
39:31
Um but in my mind, very clear, everything's fine.
39:35
And then the um you know what a Foley catheter is, Tim?
39:37
Uh I don't know what a Foley catheter is, but a catheter I would understand is something that's probably in your urethra. There you go, pal. You got it. So, yeah. That's right.
39:49
And the way it stays in there is there's a little balloon on the tip of it.
39:51
So, the tip is fed through your urethra into your bladder.
39:56
Uh and the catheter just is there to is spontaneously drain your bladder.
39:59
But the way that thing stays in there is they inf- there's a little balloon that gets inflated once it's in your bladder so that it doesn't slip out of your bladder. Mhm.
40:08
So, there's this, you know, small ping pong ball at the end of it uh that's now inflated.
40:13
So, I'm walking to and they usually clip the catheter and the bag onto the side of the Ah, So, you know you know where this is going.
40:22
So, anyways, I'm walking to the door, and the thing runs out of slack, and it yanks the dang catheter, of course, and it comes not all the way out, but like partially out. Oh.
40:35
Sorry to you and all your listeners.
40:35
Oh, so this is like a Wait, are we talking like a small python that ate a golf ball kind of situation?
40:43
No no offense I mean large python that ate a No no no no, a small python.
40:48
Uh yeah, so no, that's right, man.
40:49
So, I mean this is hot as it so Got it.
40:53
the total reverse, that total warm bath of relief that you experienced thinking it was a dream, so that just goes totally in reverse, and in a millisecond, I realize that all of this was not a dream.
41:05
I fall down to the floor, cuz all of a sudden I really can't walk, either.
41:10
I just fall to the floor, and I'm screaming, and I'm pulling on the I'm trying to break the rubber tubing of the catheter, which there's no way I could, um and to somehow relieve the pain.
41:20
And anyway, finally, a nurse comes running in, uh and gets me back in bed, and that was that.
41:27
But so anyway, that's my first real memory. Oh my god.
41:29
I can see why it's vivid. Oh, yeah.
41:35
I'm I'm sort of bent over as I'm talking to you, um but that God.
41:37
Uh so, let's let's contrast that with one that I've heard you tell, but I don't recall the details. And this is snowball. Am I getting this right? Uh-huh.
41:51
Could you Could you tell the snowball story?
41:55
So, yeah, so you know, so a burn unit uh is like I said earlier, a particular place.
42:00
Uh they're gruesome places.
42:03
Uh they're very difficult environments.
42:05
The pain that the patients are going through is gut-wrenching, and so working in a burn unit it is is is very difficult.
42:13
Uh people often don't last in a burn unit very long um as a clinician.
42:17
It's It's incredibly difficult work.
42:19
Um And it's And we learn from uh wars over time, is my understanding of certain medical history, that that the way burns often kill people is by is indirectly through infection.
42:32
So, once you've disrupted the integrity of your skin, you're much more vulnerable to infection. Right?
42:39
And so, the thing that often kills burn victims after they've survived the initial trauma is infection.
42:44
So, burn units are incredibly sterile environments.
42:47
So, everyone's gowned up, masked, gloved uh for the first maybe several weeks.
42:52
I could only have one person in my room at a time.
42:55
Uh you know, it's just like you're in a bubble in other words.
42:58
And And therefore, you're cut off from everything.
43:03
You're There's no day, night runs together.
43:05
There was no window in my room.
43:08
There's no, you know, you're in a little cell.
43:10
And And even when people are at your bedside, there There's all this garb in between you and them.
43:14
So, there's no You have no relationship to the natural world. You can touch nothing.
43:26
And And also, you're in a fair amount of pain, of course, which does not necessarily reward your paying attention to anything.
43:31
So, it's just It's not fun.
43:35
But uh So, this was November.
43:35
At some point in De- December, maybe as early January And honestly, I can't remember who brought me the dang snowball. I can't remember.
43:45
There were two nurses in particular I was felt very close to.
43:49
Um and it may have been one of them.
43:52
Uh I think it was It may have been Her Her name was Joy Varcardipone.
43:54
And I It may have been been Joy.
43:56
But anyway, it was snowing outside, and I didn't know that.
44:01
I didn't know if it was night or day.
44:02
And uh and she had the uh bright idea of just smuggling in a snowball to me so I could hold so I could feel snow.
44:13
And man, it was so I mean it was just stunning.
44:15
You know, what a simple little thing, right?
44:18
little thing, right? But she put it in my hand and just feeling the contrast of that cold snow on my sort of crisp like you know, the burnt skin, the obnoxious inflamed skin and and and also watching it melt and watching the snow become water and just
44:37
the simple miracle of it uh was just a stunner for me and and it really made it so palpable that we as human beings as long as we're in this body we are feeling machines and if we're cut off we can't if we can't take if our senses are choked off we are choked off. And it was the most therapeutic moment I
44:56
And it was the most therapeutic moment I could imagine and I would never have guessed this but just holding that snowball first of all this this sensation but also the implied inherent perspectives that it helped me make, right? That everything changes. Snow becomes water.
45:12
It's beautiful because it changes.
45:14
Things are fleeting and it just felt so beautiful to be part of this weird world in that moment, you know?
45:19
I just felt part of the world again rather than removed from it.
45:24
And it was it was it was potent.
45:26
BJ, what did you study undergrad or what were you planning on studying or studying at the time?
45:32
I always forget when people make decisions in undergrad even though I went through it myself.
45:37
Yeah, well, like you I mean I started out, you know, 10 I start I was at Princeton '89 and '93 and I started out I went there uh really high on the idea of learning things that that were foreign to me, you know, totally seeing a different world view and really delighting in the liberal arts education.
45:54
And so with that Tiananmen Square had just happened before freshman year and I was so China was on my mind.
46:03
And so I I was I started studying Chinese language and was heading for a major in East Asian studies.
46:09
Um but when I was out uh with this injury uh art, which I'd always been interested in, especially music, I became much more interested in art.
46:20
Not just listening to it or looking at it, but the idea of art.
46:25
So I I switched my major to art history, and that's what I ended up studying.
46:32
What do you mean by the idea of art?
46:36
So why the hell do What are human What is this art stuff, right?
46:38
I mean, why do humans We seem to be unique as a species that we reflect on our lives, we reflect on our mortality, we reflect on our experiences, and we one way or another we reproduce them.
46:51
We use them as creative grist.
46:55
So either in our sort of daily lives or for those of us who make art um you know, we use it to make art.
47:04
We We It's It's this And you know, what's the purpose of making art?
47:08
Art is inherently kind of useless, and that seems to be part of its charm.
47:15
Um so So I That seemed to me the fact that we as a species make art and care about it seemed to me really important because I was trying to figure out, well, who am I now?
47:27
Like what what Am I my less human because I have less fewer body parts, you know?
47:33
Am I Is that the measure of of what it means to be a human being?
47:37
Well, no, but I couldn't really answer the question what what was my humanity, what did it mean to be a human being, why was I happy to be still alive.
47:48
Those are the kinds of questions I was trying to kind of wade through.
47:49
Like essentially questions of identity. Mhm.
47:52
So So studying art, the hunch was, well Mhm.
47:58
Well, this seems to be a peculiar the situation I'm in was a sort of peculiar to being a human being that one could survive injuries like that and go back out into the world in this damaged way and make their way again and return ostensibly to some sense of wholeness in themselves.
48:15
And it seemed to me rightly placed to focus on uh something like art as as a as a guide to help me get creative with the reality I was now facing. Mhm.
48:27
In a in a way it was the thing I was trying to learn how to do was was make perspective.
48:35
And that's what art really helps you exercise that muscle.
48:38
It helps you learn how to see, how to listen.
48:44
And that was really empowering because I there's so much I would have loved to change about what I was seeing.
48:48
You know, when I looked at my body, I would have loved to have changed so much about it, but I couldn't.
48:55
What I could change with this knowledge, I could change my perspective.
49:00
I could change how I saw myself.
49:02
And there's where So, that's that's what art helped me learn and where I focused my energies.
49:07
And it you know, it really paid off, I have to say. It's very helpful.
49:12
I'd love to I'd love to explore that some more because I've been in the last few months in particular uh asking myself over and over again why do humans care about music, create music like a compulsion, and dance?
49:32
Every every group of humans on the planet, and it just seems so peculiar, yet unsurprising if you look at, say, birdsong and animal mating calls and mating dances and all this that and the other thing, but it there's there seems to be many layers.
49:47
There seem to be many layers to it.
49:50
So, what did you find How did it pay off?
49:54
I mean, you gave one example already in terms of changing perspective.
49:58
Uh but were there any particular classes, teachers, books, pieces of art that really influenced you?
50:11
So, boy, let's see here, man.
50:11
So, let me Yeah, so really so much of I mean, art history the way the curriculum was set at the time, it really didn't actually dig in so much around why humans make art.
50:25
It just presupposed that we do and that that's interesting and were and went from there, which was cool.
50:30
I mean, it just put me in basically put me in front of a lot of art and helped me tweak my eye and my ear. And that was great.
50:38
But for on the sort of identity, sort of philosophical front, like the existential, like why do we do this?
50:46
What's the meaning of this?
50:46
That was actually kind of left up to me as an individual and in my relationships.
50:51
And there was one of my dearest friends, a guy named Justin Burke, who is he is a philosopher, an art historian.
50:58
I mean, that's what he studied through and through his through his doctorate.
51:02
And frankly, a lot of stuff we're talking about right now, Tim, and the and the benefits I reaped from it was really in from conversations with Justin.
51:11
Fed the backdrop by this this pounds of artwork that I got to spend time with, but working through this philosophical stuff was really with my buddy Justin. Uh so, that's one point.
51:21
Uh and there was no particular work of art.
51:23
Again, it was more the idea of art than it was any particular piece of art uh that was so potent for me.
51:31
And even to this day, I mean, I love going to museums, but I just like being around art.
51:35
Sometimes I don't even look at it.
51:37
Um I just like that it exists and I like to reward places to help it exist.
51:41
So, I Yeah, so anyway, um there's no one work I can point to.
51:48
Although, I would say probably the the painting of Mark Rothko has proven to be very, uh, poignant and potent for me.
51:53
I just any chance I get to stand in front of a Rothko, I will I will do.
51:57
How do you spell that last name?
51:59
I'm an ignorant person when it comes to this type of thing. Oh, Rothko, r o t h k o.
52:02
Mark Rothko, abstract expressionist mid-20th century guy, made these big, beautiful, color form paintings. Non-representational. Yeah.
52:16
Quick, random anecdote that might be entertaining.
52:23
So, I grew up on Eastern Long Island, where Jackson Pollock basically turned himself into one of his paintings by driving his car into a tree.
52:29
And, uh, he actually used to show up at one of my relatives' homes completely shit-faced drunk all all the time.
52:37
And, he would bring his poor dogs in the car, and he'd show up at like 9:00.
52:42
And, this man and his wife would would say to themselves, "Oh, no, it's [ __ ] Jackson again."
52:50
And, they would pretend to be going out to dinner, no matter what time it was.
52:53
They'd go, "Oh, we're so sorry, we can't stay.
52:55
We're just on our way to dinner."
52:57
Because, what would happen is he would stay, the dogs he would forget about the dogs, they'd [ __ ] all over the car, he would take the dogs home, leaving the [ __ ] intact in the car, and then blame it on my relatives to his wife, who then had to contend with the whole mess.
53:14
So, anyway, related but totally unrelated.
53:18
Uh, the But, if we're talking about abstract, uh, if you were this is an awkward transition, but here we go.
53:25
Um, that's kind of my MO.
53:29
If you were, uh, brought in as a physician {slash} let's just say mentor, guide to someone who had just suffered nearly identical injuries to yourself. Mhm. 20-some years old.
53:46
Uh what would you what would your conversation be like with them?
53:52
Or what resources were reading or otherwise would you point them to?
53:59
You know, so I do I find myself every once in a while I'll get called by friends in the hospital come visit with someone who is in similar shoes, you know, and actually I wish I remembered his name, but someone did that for me when I was in the burn unit.
54:10
He'd had a similar accident.
54:12
I think he lost two legs below the knee.
54:16
Uh I should say both legs.
54:16
Um Anyway, uh and I he you know, and and I learned a lot from how I how I gained from his visits to me I have just sort of reproduced, which is basically walking in these rooms uh with almost no agenda, almost no plan to advise in any way.
54:37
The the potency, especially early on, was just seeing someone in similar shoes.
54:44
Uh but my early questions when I was in the bed was like, "What is What am I going to look like?
54:47
What's it going to feel like to walk on prostheses?"
54:48
And that's kind of what you know, it was that nuts and boltsy kind of stuff.
54:53
Will I ever have a Will everyone Will anyone want to date me again?
54:57
You know, I mean, I don't know. It it was on that level.
55:00
Uh and and so when this guy would come visit me, it was just seeing him. Just seeing him upright.
55:09
Just knowing that he by virtue of the fact that he had entered my room, he came from somewhere else, he was out in the world, knowing he was a functioning human being out in the world.
55:18
And just seeing him look me in the eye uh with some kinship, that was the therapy of it.
55:26
Um I think I've gotten in trouble when I've tried to uh come in with some uh predetermined idea of advice giving.
55:35
Often times that's not really what's needed.
55:36
is more just some the camaraderie and the bearing witness.
55:38
And so that's So to answer your question, when I do go into folks' room, I'm there and I'm I'll I'll avail myself to any questions they have, but I think most of the power of visit is just visiting, just being together uh and sharing this this awkward body.
55:56
So the the from what I've heard and read of yours, one of the recurring themes appears to be and I I please correct me if I'm getting this uh off at all is how powerful simple things can be or maybe are and that our our tendency is to perhaps undervalue the things that are not expensive or difficult to obtain. Yeah. The snowball.
56:26
Uh could you talk about the things you've noticed that most help uh people in hospice care.
56:36
And the reason I ask is specifically related to cookies uh which maybe you could talk about, but I'd be curious to hear sort of what really brings the most peace to these people. Well, so you're right.
56:52
I mean, I think one of the joys about the one of the upshots or silver linings about the end of life is that if you want it to, if you let it, you can let a lot of the rules that govern our daily lives fly out the window.
57:07
Because you realize that we're walking around in systems and society and much of what consumes most of our days is not something that, you know, is not some natural order.
57:18
We're all navigating some super structure that we humans created.
57:23
That is the the work day, the work week, whatever it is, you know, it's it's not and if I think part of the trick is if when you're dealing with serious illness or some natural trauma or or facing the end of your life, often times that becomes crystal clear.
57:44
Like where you've been hanging out and spending so much of your time and energy and worry has been on is like living in someone else's dream.
57:50
You know, it's not it's sure.
57:52
I mean, society and what we've structured there is a lot of importance to it.
57:56
I don't mean to dismiss it. But we inherit that.
57:58
We don't spend a lot of time creating our realities in a most of us don't in a sort of in a clear intentional way.
58:10
And so when you have this excuse to forget all that, it can be really liberating.
58:18
Um a little bit scary too cuz a lot of people then invariably realize that they feel like they've been wasting so much of their time on things that actually weren't that important. Right.
58:25
Um and that's part of the trick of checking yourself and you know, over time.
58:29
You know, in a daily way, am I doing things that I really care about, etc.
58:33
So, back to your question.
58:35
So, you know, to this point about simple things.
58:39
I mean, the simple things uh the small things ain't so small, you know, actually.
58:44
Um the like I say about the snowball, just the joy of feeling anything, of having a body at all, of being capable of movement at all.
58:56
Uh that that is so profound. It's so potent.
59:02
And yet, you know, I don't know many of us take that I think most of us take that for granted, you know.
59:08
Um so, as a clinician and as a person, I love looking for moments where the rules get to go out the window.
59:15
I love when I have you know, I love having residents at the guest house at Zen Hospice who smoke, frankly, you know, or you know, anything that just kind of gets to that kind of reorients us and puts things in proper proportion relationship to the natural world and rejiggers our priorities.
59:31
I I I love that I love that reorienting feeling and and and again it does seem to be one of the silver linings for folks in this zone.
59:43
So, you know, like I don't know how many of us like I think about this most most nights.
59:47
Like every night depending on where you are of course, but you can look up and usually find a star.
59:53
I mean I feel like you know, when when any of us is struggling with just about anything, you know, look up.
59:59
Just ponder the night sky for a minute.
1:00:02
minute. And and to just to realize that we're all on the same planet at the same time, you know, and that and it as far as we can tell there we're the only life only planet with with life like ours on it anywhere nearby and then you start looking at the stars and you realize that the lights that are hitting your
1:00:21
eye is, you know, ancient and that the stars that you're seeing may no longer exist by the time the light gets to you and just just sort of mulling the the bare naked facts of the cosmos for me is enough to just thrill me, awe me, freak me out, and kind of uh put put all my neurotic anxieties in their proper place. No? Right. So, yeah, and a lot of people No? Right.
1:00:47
So, yeah, and a lot of people when you're standing at the edge of your horizon on death's door, you know, you're you're you're can be much more in tune with that cosmos than you are with what the body is doing in in a you know, in a day-to-day kind of way.
1:01:02
Does that make sense, Tim? Can you imagine?
1:01:05
No, it makes perfect sense.
1:01:05
And the So, just because I brought it up and I don't want people to be harassing me about it on the internet, Mhm. the cookies. Can you mention Yeah.
1:01:16
Yeah, well, you know, I mean the smell of fresh bread or for most of us the smell of the chocolate chip cookie does magical things, you know?
1:01:22
It's First of all, the food is primal, you know?
1:01:25
Our sense of smell, I mean, the shortest I mean, it is an It is one of our oldest senses. It is primal.
1:01:32
You know, you can walk by someone who may be wearing a cologne or perfume of someone you knew 30 years ago.
1:01:39
Like I I still when I It's been maybe a few years, but there's a perfume that I would smell that my babysitter wore when I lived in St.
1:01:47
Louis when I was in preschool, and it would throw me back there instantaneously.
1:01:51
And so, the power The sense of smell is is potent.
1:01:53
And food is primal and potent.
1:01:56
I mean, it's nourishment. It's nutrition.
1:01:57
It's how we live in some ways, right?
1:01:59
So, there's all this symbolic stuff happening, too.
1:02:04
But there's also there's the basic joy of smelling a cookie.
1:02:06
It smells freaking great.
1:02:09
And it's like the snowball.
1:02:09
Like in that moment, I am rewarded for being alive and in the moment.
1:02:13
Smelling the cookie is not on behalf of some future state.
1:02:19
It's great in the moment by itself, on behalf of nothing.
1:02:23
You know, and this is another thing back to art. Art for its own sake.
1:02:24
Art is part of its poignancy in music and in dance is its purposelessness.
1:02:32
And just delighting in the wacky fact of perhaps a meaningless universe and how remarkable that is.
1:02:40
Uh you know, that's the That's kind of what I'm shooting for.
1:02:42
And that's a way for all of us to live until we're really dead, until we're actually dead.
1:02:49
Uh is to prize those those little moments.
1:02:51
And the You guys, I might be fabricating this, but uh make cookies at the Zen Hospice Center for this precise reason, right?
1:03:00
And So, you mentioned absurdity a few times.
1:03:02
This is something I've been thinking about a lot.
1:03:04
I mean, um and for reasons that may inferentially become super clear in a second.
1:03:10
Uh but just the being able to try to laugh at the cosmic joke, so to speak.
1:03:18
I mean like the the meaninglessness, this if there if it is in fact meaningless. Mhm.
1:03:22
Uh of things, uh as opposed to taking all things so damn seriously, which you know, in a way prevents you from doing a lot of the serious work you would like to do. But Mhm.
1:03:35
the the the question I was going to ask is uh to get your opinion on a modality, we'll call it, or tool.
1:03:41
And uh I'm going to I'm going to explain this vis-à-vis uh an anonym- a friend I'll keep anonymous.
1:03:50
So, this is a a female, young woman, Mhm. Mhm.
1:03:52
who used to work in hospice care.
1:03:55
And she found, just as you allude to earlier, that she felt like she was sitting on a secret.
1:04:01
It was It gave her incredibly joy and presence to do that work.
1:04:07
She really loved the work.
1:04:10
Uh at some point became very frustrated with the is insurance policies and vagaries of our health care system. Mhm.
1:04:19
And now does something that is illegal, but I think should not be, which is guided work with psilocybin.
1:04:26
And she said, "Now I get to experience people dying every weekend.
1:04:32
The only difference is they come back to life."
1:04:36
And uh many people listening to this will have read or should read uh an article that was titled The Trip Treatment by Michael Pollan in the New York Yeah. Yeah.
1:04:48
the use of I believe specifically psilocybin, for those people not familiar, which is extracted or the psychoactive compound in magic mushrooms.
1:04:58
Uh for end-of-life care in terminal cancer patients.
1:05:03
And so, I I just love to hear your opinion on the use of compounds such as those in end-of-life care otherwise. Mhm.
1:05:14
Yeah, well I'm so glad you're asking this question.
1:05:16
I mean this is a So there's all sorts of stuff coming out of the closet these days and it's it's really wonderful.
1:05:21
Uh and you know, there's So there's a there's a there's a movement afoot to revisit uh psychedelics uh from a therapeutic perspective.
1:05:33
And I don't pretend to know the full history of how psychedelics became went from considered therapeutic to considered, you know, you know, toxic and and the devil's work. Um but here we are.
1:05:45
We're There's a There's a revisiting happening uh with fresh eyes and serious eyes.
1:05:49
So it's not folks who are just with a wink trying to justify their own recreational use of these Like UCSF, UCLA, Johns Hopkins.
1:05:59
Johns Hopkins, you got it right. NYU.
1:05:59
Uh friends at the River Sticks Foundation have been funding some of this work.
1:06:05
They do beautiful They They The people I know who are involved in this work are deeply thoughtful, caring, loving people.
1:06:12
Uh so anyway, so as a that's a sort of a preamble, but you know, to get to your question, I am thrilled for this um for a number of reasons.
1:06:21
One is just the the counterculture fun kind of things coming out of the closet.
1:06:27
The another is a whole generation, i. e.
1:06:29
the the baby boomers, who are now the focus of so much of our efforts in health care and the aging population.
1:06:35
How do we cater to this population?
1:06:37
Well, uh a lot of folks of that generation have experience with these compounds and and now they get to sort of be above board potentially.
1:06:45
So anyway, I love the subject for many reasons, but as a as a clinician, you know, I'm I'm particularly excited because we're pretty good at treating nausea, treating pain um as a rule.
1:06:59
And what what where we get where things get very difficult and and in palliative care we talk about this.
1:07:06
We call it existential distress.
1:07:09
And And basically, existential distress is is a is a crisis of of meaning ex- it in some way or another.
1:07:15
So, it's particularly potent at the end of life when people don't have much time left to make meaning and they realize they haven't been making living a very meaningful life or haven't thought much about it.
1:07:27
It can be really traumatizing to realize, "Oh gosh."
1:07:29
To take all of a sudden to take that seriously and then realize you don't have much time to do much with it.
1:07:36
So, anyway, this idea of existential distress is huge in medicine and palliative care. It's It's very nascent.
1:07:43
I mean, the way we treat it now is well, if someone comes to us and they're miserable, well, we rule out and or treat pain, uh nausea, other anxiety, depression.
1:07:51
We We look for a diagnosis that we can treat and then we treat it.
1:07:59
And if folks after all that are still miserable and shut down, then we'll sort of invoke this phrase, "existential suffering" or "existential distress."
1:08:10
Uh And this This is what we call medicine a diagnosis of exclusion.
1:08:12
So, and no one knows what the hell to do about this.
1:08:16
So, I mean, Diagnosis of exclusion. Yeah.
1:08:17
So, you just rule out everything else that you understand and if you're then then whatever you're left with, you just call it this bucket term.
1:08:24
And in this case, that bucket term is ex- existential suffering.
1:08:29
Not Not a particularly inspired. Right. Right?
1:08:31
But But, this is where it also gets thrilling.
1:08:33
This is my favorite thing about my field, which is So, palliative care, first of all, organizing around the human condition and suffering and what it means to suffer, this highly subjective state that we all have some experience with in our lives.
1:08:46
So, that's total ubiquity, you know, absolutely un-esoteric field, absolutely relevant, you know, no one I know has not suffered.
1:08:54
It seems to be elemental to being a human being.
1:08:56
And this is our fulcrum in palliative care.
1:09:00
And what's more, we have named this thing existential suffering, which is so mysterious, right?
1:09:05
And and there's so much it's so ripe to invite the arts into this mix, philosophy into this mix, like we've already talked a little bit.
1:09:14
So this is this is my favorite sort of strategic zone to upload into health care all these otherwise non-medical issues.
1:09:20
So there's a ton of reasons why I love the space and I'm getting around to an answer to your question, which is So we we have named I'm not in any rush, man. This is a long podcast. Okay. It always is. Good. Good. Cuz I love this subject.
1:09:35
So So we have the leverage, now that palliative care is accepted and part of health care, and and has has called out the the the nature of suffering and has called out this thing existential suffering, we have this portal to upload all these other fields and interests and to keep them to make them relevant.
1:09:56
So this is where it gets thrilling.
1:09:58
Meaning you have a channel, because you've wedged your foot in the door with palliative care, through which you can insert other things that wouldn't otherwise have an easy gateway. Exactly. You got it. Right.
1:10:09
So now enter, you know, now enter the relevance of the arts, philosophy, design, you name it.
1:10:15
There's I mean what field isn't relevant in some way or another to the human condition, right?
1:10:22
So all of a sudden there's this huge invitation, or at least possible invitation, to the rest of the world besides the medical that sort of narrow medical sciences per se. All right.
1:10:34
So that's that's really exciting.
1:10:35
So now So back to psychedelics, well, so we can call out this existential suffering, but to date, as clinicians, we don't really have much to offer it.
1:10:48
We're aware that we've talked to and and non-abandonment, accompanying people in their struggles is itself a great salve, and that's beautiful work.
1:10:59
Um but what else can we do?
1:10:59
Well, um I often find myself prescribing people for their existential suffering, you know, to uh remember what it is that they love, to keep an eye out for aesthetic moments in their days where they feel something, anything, man.
1:11:16
Just Whether it's that snowball or sun on your skin, some just to note when you feel happy to be alive.
1:11:24
And there's our little toehold to work from. Right?
1:11:26
So So there's a lot to build around this, but what we haven't had is we certainly haven't had any chemicals to offer people to help in this way.
1:11:34
And it seems the data to date seem really robust that it may be that uh compounds like MDMA, psilocybin, and then other things may be radically helpful in fostering um uh a meaning-making moment for someone, a fostering a sense of belonging in this sort of cosmic way.
1:11:59
Uh and so in other words, we have potentially with these compounds a way to respond to this this wacky thing called existential suffering.
1:12:08
So this is just thrilling uh for all those reasons.
1:12:14
Yeah, I couldn't agree more.
1:12:14
And for people who want to dig into this, and I would encourage everyone listening to take a closer look at this, there's a great organization uh I I think that they're really well organized and comprised of very good MDs and PhDs called the Heffter Research Institute. H E F F T E R. It's just heffter. org.
1:12:36
And they do some incredible work uh with not only patient-focused studies, but also research studies using things like fMRIs and uh different types of neuroimaging to look at the specific effects of different types of psychedelics, whether you call them entheogens or psychoactive, psychotropics, whatever it might be.
1:12:57
So, it's a very very a lot of interesting interesting work and you can learn a lot about how these compounds function just by looking at, for instance, some of these studies uh and examining sort of the methodology, right?
1:13:11
The protocols that they use.
1:13:13
Uh So, if we look at And by the way, Tim, can I just interrupt interrupt?
1:13:18
I've also had some really fascinating conversations with other folks in this space and another organization to point your listeners to is a group called Compass. Compass?
1:13:27
they're Compass and they are beginning to do also support research in this vein and also starting to try to align health care systems and other uh institutions to participate in this work one way or another and to sort of pull this stuff again out of the closet.
1:13:44
I'm not sure where they are in their development, but it's another group to be aware of and I think they're I think their website is compasspathways. org.
1:13:51
So, just another group in this space that's doing cool stuff. Cool.
1:13:53
And you know, I'll throw one more in there uh MAPS uh which is uh which is doing a lot of uh investigation interesting work related to policy and the legal side of things as well uh and that that's worth checking out.
1:14:09
And for for people wondering, these will all be links to all these things will be in the show notes at um fourhourworkweek.
1:14:15
com/podcast, all spelled out.
1:14:18
But, coming back to your story uh and your life, I mean, I I really uh I have so much I would love to ask and we'll dig into some of them, but we're not going to have time for all of them, which is fine.
1:14:34
Uh the the question that I'd love to ask next is what you feel you do on a daily or weekly basis that is different from most people.
1:14:47
Routine-wise, thinking-wise, self-talk-wise, anything. Mhm.
1:14:53
Different from other physicians or just people in general?
1:14:59
Uh people in general because I don't want to make it exclusively professional.
1:15:02
This is because I'm looking for what I'm fishing for are practices that you've adopted or developed, habits, whatever it might be, that people listening might be able to test drive for themselves. Mhm.
1:15:18
Well, let's see here, my friend.
1:15:18
I have two I have two answers to that question.
1:15:22
So, the one is we you know, we've touched on a little bit, but uh I I find myself increasingly interested uh in the aesthetic domain.
1:15:31
And by aesthetic, I mean just the life of the senses.
1:15:37
Not just beauty, but just the felt environment at all. Mhm.
1:15:40
That is the world of the aesthetic domain.
1:15:45
And uh I and one of the reasons I'm particularly interested in the aesthetic domain, besides just delighting in having a body to feel anything like we've talked, is is it's how it prizes purposelessness.
1:15:58
So, so I am all for meaning.
1:15:59
I I I see human beings as meaning-making machines.
1:16:02
And and we talked about this a little bit like whether there is some grander meaning in the universe, I I don't really know.
1:16:10
And frankly, I'm fine not knowing.
1:16:12
I I enjoy the mystery of it.
1:16:12
Um and I'm okay if there's meaning on a on a grand scale or not, frankly.
1:16:18
But meanwhile, I am aware of our talent as a species to make meaning for ourselves and to string together narratives and stories and to make sense of our lives.
1:16:29
And it's a I think it's a profound impulse and a lot of good comes from it.
1:16:34
And uh and I also just increasingly want to carve out a space for meaninglessness, purposelessness. Mhm.
1:16:43
Uh so, like again, like the snowball or anything that makes us feel in our bones feel happy to be alive in that moment.
1:16:54
On behalf of nothing else but that moment.
1:16:58
And that uh is is I I think we could all benefit from letting ourselves delight in things that don't necessarily have any meaning, but just feel good that don't that you know, and and don't hurt anybody else, but just give ourselves a space to delight delight in purposelessness.
1:17:17
I I that that to me is is a huge deal, and I see it's therapeutic relevance for my patients very often who are beyond their life of purpose.
1:17:27
They can no longer do that job they loved or their role in their family has changed.
1:17:31
And and they're so crestfallen because they don't have that reason to get out of bed.
1:17:38
So, let's find new reasons to get out of bed.
1:17:41
Let's repurpose ourselves. Yes, yes, yes.
1:17:45
And let's get really good at at honoring just the joy of smelling a cookie. And that can be enough. Watching a ball game. That can be enough.
1:17:53
It doesn't have to be big.
1:17:55
It doesn't have to be a means to an end.
1:17:57
So, anyway, I think that's So, that's one answer to your question.
1:18:01
I don't know how many of us are out there prizing purposelessness, but I I I I I do.
1:18:09
Well, I it made me think of and this might be a strange connection, but made me think of Kurt Vonnegut, the writer who I actually consider a fantastic philosopher in a lot of ways if you read his fiction.
1:18:24
But, one of his quotes that I've always loved is, "I tell you we are here on Earth to fart around, and don't let anyone tell you Don't anyone let Don't let anyone tell you different."
1:18:35
And there's a story, I think it's actually in a dialogue with another writer at some type of event, and I'm sure someone will be able to find it.
1:18:44
I'll try to put it in the show notes, but it might be tricky to find, where he talks about this this this long walk that he takes to mail something at the post office, and his wife doesn't scold him, but just laughs and asks him why he wasted so much time.
1:19:00
And he's like, "No, no, no, no, no, you don't get it.
1:19:03
I didn't waste time because" and he runs through all of these seemingly meaningless uh seemingly trivial, but to him very important kind of absurd interactions with multiple people along the way. Mhm.
1:19:18
And it's just a very good meditative exercise because I feel like it's extremely easy to think that the big overarching abstract things are the important things and the small tangible things with sensory inputs are the unimportant things.
1:19:38
And I am not convinced at all that that is the case.
1:19:44
Uh in fact, it might be quite the opposite.
1:19:46
And uh if you had a patient come in, they are finally getting comfortable at Zen Hospice Project.
1:19:59
Very introverted and they say to you, you know, "I'm going to want to talk to everybody and get to know them, but I'm not quite ready. I just want to read.
1:20:07
What What one to three books would you suggest I read?"
1:20:15
So funny because I mean, I'm laughing because I am probably the least well-read person you will ever meet.
1:20:22
And especially one with like degrees college and stuff.
1:20:28
I I if I I am All right, if they said give me one to three things that I can watch, do, absorb, look at, etc.
1:20:36
without human interaction, what would your answer be? Thank you. That's better. Uh, for me.
1:20:45
I mean, hey, I'm all for books, too.
1:20:47
Those are apparently are cool.
1:20:49
Um, but for me, you know, I love film, I love music, I love art, I love doing nothing, I love being outside.
1:20:59
So, those That's for me to live me.
1:21:02
Uh, so, but I would put uh, big picture books in front of people. I mentioned Mark Rothko.
1:21:07
Staring at Mark Rothko work is just a gorgeous splendor, but it, you know, it suit your taste.
1:21:15
So, for me, I guess I put some a picture book of of Mark Rothko paintings in front of them.
1:21:22
I would put probably any music from Beethoven, uh, into their ears.
1:21:30
Um, and I probably would reserve that third thing for staring into space.
1:21:37
Before they stared into space, if they wanted to watch a movie, Mhm.
1:21:41
what would you put in front of them?
1:21:45
Mhm, man, there's so many good ones. Ratatouille. No.
1:21:51
Well, I I I think, you know, I I have a real soft spot for Waiting for Guffman.
1:21:59
Um, not that it has this great meaning per se, but but speaking of absurdity, I just think it's hilarious. Waiting for Guffman?
1:22:06
I've never even heard of it.
1:22:08
You've never heard of Waiting for Guffman? No.
1:22:10
Wow, just a string of ignorance on my part in this conversation.
1:22:13
Although, you don't read books, so I feel that even this out. Oh, yeah.
1:22:16
And you But, this is good news cuz, man, you have so much to look forward to.
1:22:20
I mean, so this so this movie is by Christopher Guest and company, the guys who did Spinal Tap and uh, you know, wow.
1:22:26
Uh, you know, Best in Show. Sure, sure.
1:22:28
How do you say Guffman or how do you spell Guffman?
1:22:32
I think it's g u f f m a n. Okay, got it. I'm on it. It's freaking hilarious.
1:22:38
Uh, so that I I just always a long-term favorite.
1:22:42
I mean, as a kid growing up Kentucky Fried Movie.
1:22:44
My god, I haven't thought about that in decades. Yeah. Wow.
1:22:49
And that was like really an important movie in my childhood.
1:22:51
We watched it probably, I don't know, a hundred times? I mean, uh every day.
1:22:57
I mean, that and Groove Tube.
1:23:00
I mean, it was you know, formative for us.
1:23:04
Uh and I heard that you asked another question specifically about documentary film of other guests and I was thinking about that and you know one that leads to mind, I I don't I don't know if you really even consider it a documentary, but I guess it is.
1:23:20
It's you know, the movie Grizzly Man. Oh man, oh man.
1:23:22
Yeah, that's I consider that a documentary. Yeah, sure.
1:23:26
Let's call it a documentary.
1:23:27
So yeah, of course it is.
1:23:27
I mean, it and it is I any piece of art where I simultaneously or I'm not sure whether to sob or laugh hysterically that I love that feeling.
1:23:41
Where you just could go either direction, you're not even sure which is the correct emotion.
1:23:46
You're simultaneously attracted and repulsed to something.
1:23:47
That was my experience watching that film.
1:23:52
And I so I just think it's a beau- like a amazing piece of filmmaking.
1:23:56
And I also particularly like its poignancy around our humans silly dance around nature and how we humans think of ourselves as somehow opposed to nature.
1:24:08
And yet when we try to reinsert ourselves into the wild, it doesn't necessarily go very well. Uh Right, right.
1:24:15
and how we romanticize how Mother Nature can coddle us.
1:24:19
And you know, I spend a lot of time in the desert in southern Utah as much time as I can.
1:24:23
I just love that landscape and speaking of perspective making you know, thinking on geologic time and making myself feel very very small and inconsequential is is really deeply therapeutic for me.
1:24:37
Uh so um and I when I go out in Utah and I got I've gotten lost twice walking around in this particular area.
1:24:44
And it's the same feeling I had watching Grizzly Man which is mother nature as far as I can tell is pretty indifferent to us. Yeah, I would say so.
1:24:51
So anyway, there's my answer for you.
1:24:54
So that that brings to my two things.
1:24:56
The first is you mentioned that that feeling which is two sides of the same coin almost that of being simultaneously repulsed but wanting to laugh and unsure of which way to go.
1:25:12
That seems to me to be a very primal emotion like a singular emotion in a way.
1:25:19
Um when for instance I've I've watched uh nature footage of chimpanzee troops when one of them is torn to pieces by a jaguar or some such on the ground and the response tends to be breaking out into what would be considered by primatologists hysterical laughter.
1:25:39
And this seems to be something very very hardwired.
1:25:41
So returning to that in some way and it being therapeutic doesn't surprise me.
1:25:47
The second is just to tie together a few things you've said related to sort of the meaninglessness which may be too loaded a term for some people and might come off as very negative but it seeming inconsequential or small and meditating on that or or not even meditating on it experiencing in a very visceral way by being in the desert or looking up at the sky.
1:26:10
I think it's very compatible with something that struck me which was told to me by Tony Robbins who's also been on the podcast.
1:26:16
And he said that uh and I'm paraphrasing, but that that most human suffering comes from a focus on me, like a self-focus.
1:26:29
And if that is true, it makes perfect sense that focusing on this expansive geological timeline, which which puts our like shitty week into a just hilarious diminutive perspective. Uh Mhm. Makes a lot of sense. Mhm.
1:26:50
This is uh this is unrelated, but what's uh what What do you think of or who do you think of when you hear the word successful? Mhm.
1:27:03
I think of Well, you know, you just pointed to something.
1:27:05
The relationship of self and the silliness of self and the power of the self.
1:27:10
And I think we do ourselves disservices by by playing in the polemics around, you know, selfishness or selflessness.
1:27:22
Um So, there's a lot to say about that.
1:27:24
But to to to segue to your question about success, um you know, on one hand, I sort of think of it in terms I guess I think of it as a sort of a self-actualization.
1:27:33
Someone who has realized has played themselves all the way out.
1:27:38
And that might be seen and appreciated by practically no one and therefore not make the measure of some external success.
1:27:47
But someone who has sort of become themselves, delighted in themselves, including their quirks and awkwardness, uh and and played that self out, uh and you know, insisted on itself all the way to the end, to me that may be a version of success. All right.
1:28:03
So, that's a So, I guess one part of my answer your question is I I think of it as as really an internal process.
1:28:10
Um But then beyond that, too, I I'm a little torn here because I I agree that that what I just said sort of focuses us back to focuses us and success back into the self.
1:28:23
And I suppose the second half of the question really has to do with orienting oneself to the other, to everyone but oneself, and to the relational dynamics between the self and the other.
1:28:37
And so I think probably success may be or the second half of it has to do with um in a way maybe seeing yourself in others and others in yourself and realizing the unseen connections between us all.
1:28:52
And this is another reason I love our mortality is it is it has the potential to be this equalizing, uniting force.
1:29:00
So uh so anyway so success may be this sort of self-actualized piece, but part of that self-actualizing is it is is exploding the sense of self and feeling part of everything around you and vice versa.
1:29:13
That that that consonance with the world around you, that seems like great success.
1:29:19
Is there anyone who embodies that for you or comes closest? Hm man.
1:29:27
Man well some of yeah gosh Hm well I recently had the joy of sitting with Oprah Winfrey and watching her make use of her life and now point and and and also point her energies to promoting and helping others is is a very I mean a remarkable life's work and it's just a name we all know and wow.
1:29:52
But you know I'm also interested in all the gazillion successful people we walk by every day and don't even know it, you know.
1:30:00
This kind of happiness, this kind of success doesn't necessarily brag about itself and I I love the uns- I love presuming it when I don't when I when I'm unaware of it and and assuming it it exists in others that I walk by on the street.
1:30:13
And in a way you find yourself kind of imbuing others with with an idea of success and it changes how you look at them and how you treat them.
1:30:21
And that's a sort of a sweet favorite daily exercise of mine.
1:30:27
Um so no, I it's hard for me to say a single person that I would point to as embodying all this.
1:30:32
So let's let's you you actually touched on a much more interesting uh answer or point than my question deserved, which is your morning practice.
1:30:44
So could you elaborate on that, please? When do you do it? How do you do it?
1:30:47
So you're walking just to take us through this morning exercise.
1:30:51
How I get up in the day to start the day?
1:30:54
No, what you just talked about, sort of assuming the presence of this type of success.
1:30:59
You said that it's morning exercise of yours. Oh.
1:31:01
I'd love to just hear you elaborate on that. Oh, I don't know.
1:31:05
I I I didn't remember saying morning.
1:31:07
That's what tripped me up.
1:31:09
That's sort of a daily daily exercise perhaps. Ah, there we go.
1:31:11
Yeah, I could have made up the morning part. Who knows, but sure.
1:31:14
But it's sort of any time of day or night is useful.
1:31:17
You know, it's kind of like just the power of mean of of of meaning well, of of wanting well of others.
1:31:22
And when there's a choice in the matter to see to choose to see good.
1:31:29
And and if you can't know, assume good.
1:31:32
And this kind of builds an argument through your day of gratitude and happiness and some amount of uh comfort.
1:31:40
So so I'll, you know, I'll catch myself being bitter or I get kind of road ragey.
1:31:45
I'm very aggressive on my motorcycle and car and actually just today I was really annoying someone by following them too close and whatever.
1:31:51
I get I get in my [ __ ] zone pretty quickly.
1:31:55
But when I'll catch myself and then so when I walk by, you know, particularly here in the Bay Area, the homeless epidemic is enormous.
1:32:03
And it's just I'm I'm particularly uh acutely aware of this exercise when walking by someone who otherwise the world would assume uh in a in a sense that they have are failures in one way or another.
1:32:14
I like to invert that whenever possible.
1:32:16
So, I'll just fill in the blanks whenever I see a homeless person that I'll assume that whatever they're going through is vital to them and that maybe however uh whatever junk we project onto them that inside maybe maybe they're all right with who they are.
1:32:32
Maybe they're way more all right with who they are than a lot of people I see striving and otherwise looking successful. Mhm.
1:32:37
Uh so, it's really it's just simply that.
1:32:40
I actually learned this My mother took me to a Deepak Chopra conference when I was pretty young.
1:32:46
It was a long long time ago.
1:32:48
And the one thing I heard that stuck that was really interesting to me was is getting in the habit of saying, you know, in when anyone when you hear anyone sneeze either say it out loud or to yourself, say "Bless you."
1:32:59
It's just a It's like a nerve like a neural loop of goodness.
1:33:05
And it just means in that quick second you meant well towards somebody.
1:33:07
And even if you don't say it out loud, even if you don't share it, say it to yourself.
1:33:12
And I got to believe that that res- resonates and registers somewhere, you know, that that lands somewhere, that that lends itself to a vibe.
1:33:19
So, that's the kind of stuff you walk around and you see people and you just project uh project well wishing onto them.
1:33:29
Now, I hate to focus on something maybe superficial, but you said riding your motorcycle.
1:33:33
How Now, I apologize if this sounds like a weird question, but you have three limbs that have been damaged.
1:33:47
How do you ride a motorcycle?
1:33:49
So, yeah, so, you know, this is This was a sort of long dream that recently came true. Congratulations. I mean, it's awesome.
1:33:57
I'm just so curious about the logistics. Thank you.
1:33:58
Well, it's interesting you ask cuz right now there's the man who helped make this dream come true, uh Randy.
1:34:06
Randy, uh he he ended up being my patient and our resident at Zen Hospice Project not long after he converted my motorcycle.
1:34:15
So, there's a lot to this story, my friend.
1:34:18
Uh um So, cheers to Randy and his family and his wife. I mean, and his mother.
1:34:22
Helen and her whom I'll be seeing next week, actually.
1:34:27
Uh but so, that's one piece of the story.
1:34:30
But, the other is it's I'd always I'd love I love two wheels.
1:34:32
I love gyroscopic gyroscopic lifestyle.
1:34:35
I love uh the feeling of it.
1:34:37
So, I've always loved riding bicycles.
1:34:41
Um and then I'd always wanted to get on a motorcycle, but I kept going to shops and you know, people would sort of look at me and no one no one got into it.
1:34:47
No, I could never find a mechanic who was willing to take it on and and try to help make it happen.
1:34:55
A fellow named Mert Lawwill, who's an old motorcycle racer champion.
1:34:59
He's sort of legendary in that world.
1:35:01
He happens to live around here. He lives in Tiburon.
1:35:06
And he built a prosthetic component.
1:35:08
I don't know what the story that inspired Mert to do this, but he he's a machinist himself and a handy fellow.
1:35:13
And in his retirement, he got into this business of building this prosthetic component that uh lends itself very well to mounting an arm onto a bicycle or a motorcycle.
1:35:24
So, the first piece of this puzzle was discovering Mert's invention and getting a hold of it myself, which allowed me to get my prosthetic arm attached to a handlebar in a in a very functional way.
1:35:37
Um Now, does that does that connection So, you have throttle, rear brake, and then typically front brake on the left. Mhm.
1:35:45
Do you have uh how are those controls modified? So, okay.
1:35:50
So, Randy, what he what he figured out.
1:35:53
So, first was to get the arm piece and then what Randy figured out was and then well, then Aprilia uh and I know Honda had made a a version of this as well, but they Aprilia makes a a model, the Mana, m a n a, that is clutchless.
1:36:08
So, that was a huge piece to get out of the way.
1:36:13
So, this is essentially an automatic transmission.
1:36:16
So, that do away with the clutch clutch and gear changes.
1:36:19
So, that's a huge piece of the puzzle out of the way.
1:36:22
And then Randy uh figured out a way to splice the brakes front and rear in a certain ratio into the into a single lever.
1:36:30
Uh so, I'm doing nothing with my prosthetic feet except to hold on to the bike.
1:36:36
Um I'm doing nothing with my prosthetic arm except for holding on the bike.
1:36:38
So, all the actions in my right hand uh what brakes into one lever then Randy built this box and moved all the controls, the turn signals, horn, and all that stuff over to the right size right side of the bike and in in uh in good distance for my thumb to reach them.
1:36:58
So, I have throttle, brake shift uh brake lever, and then the uh uh turn signal box all going with one hand. And That's so awesome. That's it.
1:37:09
You know, it's that's a way a way you go.
1:37:14
Okay, I just have to pause here for a second and just ask everyone listening what [ __ ] excuses do you have for not going after whatever it is that you want.
1:37:27
Like, please uh write in, tell us on the social media why these are real excuses with hashtag [ __ ] after it. Oh my god, man.
1:37:38
That's such a great story.
1:37:40
I'm so glad I asked about it and what a what a really fantastic workaround. Man, congrats. That's awesome.
1:37:49
Well, thank you and thanks Randy and thanks for the folks at Scuderia, the bike shop in the city.
1:37:53
I mean, I it a lot of people helped me make this come true and it took a long, long time time of of trying to find the right folks to make it happen. So, amen. Amen to that.
1:38:03
So, just just a few more questions.
1:38:06
I want to be respectful of your time, but I'm having a blast here.
1:38:07
The What $100 or less purchase has most positively impacted your life in recent memory?
1:38:18
I'm guessing not the motorcycle.
1:38:18
No, that was a little more than 100 bucks. Holy cow, man. Wow.
1:38:26
You know, I would probably point us to a beautiful Pinot Noir from Joseph Swan up in Sonoma County.
1:38:35
You know, it's like the artwork of Andy Goldsworthy or anyone who delights in anything ephemeral.
1:38:40
The the the charm in a bottle of wine, the craft, all the work that goes into it, and actually delighting in the fact that it's perishable and goes away, I find really helpful.
1:38:53
So, I've gotten a lot of miles out of a beautiful bottle of bottle of wine, not just for the taste and the buzz, but the symbolism of delighting in something that goes away. Here, here.
1:39:07
And I I have a practice that some folks might enjoy, which I didn't come up with.
1:39:12
I'm I'm pretty sure I borrowed it from some past girlfriend, but I have a small glass jar, and I keep the corks from bottles that I finished with friends at home, and I have each of them write something on the cork.
1:39:33
So, I have this collection.
1:39:33
The bottles are gone, the wine is long gone, but there's this vestige. Is that the right word?
1:39:39
Maybe that's not the right word.
1:39:41
I'm trying to GRE to to sound intelligent, but the the quirks in this sit I'm looking at it right now.
1:39:46
It's on this floating shelf on the wall and so I see it as I walk by it.
1:39:49
Yeah, so no no matter how sort of lonely I might feel at times, I think we all do at moments.
1:39:57
Uh it's sort of a reminder of how close by how within reach sort of friends and that type of experience are. Mhm.
1:40:02
Uh If you could put one billboard anywhere with anything on it, what would it say? Ooh boy. That's a doozy. Uh let's see here, man.
1:40:16
Well, you know, it makes me think of this biggest billboards are.
1:40:19
You cannot You can only put so much on them and it makes me think of the my favorite bumper sticker.
1:40:27
And I guess and it seems like such a potent I I I just love I love it and so I would love to see it on a billboard which and and the basic bumper sticker, I'm sure you've seen it, is don't believe everything you think.
1:40:35
I just think that's I've actually never seen that.
1:40:40
That's a really good one. Oh, it's so good.
1:40:42
I think it's such a sweet, hilarious, true reminder to not take ourselves so dang seriously.
1:40:50
Uh I'm on you know, so anyway, I that's that's probably my choice.
1:40:51
Don't believe everything you think.
1:40:54
Don't believe everything you think.
1:40:54
I was really waiting for what this was going to be.
1:40:57
I was I was really wondering.
1:41:00
Uh I saw one This is I'm really going to lose any shred of respect that people have for me by saying this, but I saw one recently that was a It was not a bumper sticker.
1:41:08
It was surrounding the license plate.
1:41:10
I I'm not sure what the license plate casing, I guess.
1:41:12
It said Uh if you're on my ass, you better be pulling my hair.
1:41:21
I thought that was pretty clever.
1:41:21
Uh but it shows you where my level of emotional maturity is.
1:41:25
In any case, uh don't You're I you know, I thought I might I might lose you with that one. That's okay.
1:41:31
I'll I'll try to really reel you back in with the next few questions.
1:41:34
Up to Yeah, don't believe everything you think. That's awesome.
1:41:35
Uh I'm I'm astonished I've never seen that. Yeah.
1:41:42
What advice would you give your 30-year-old self?
1:41:45
And if you could place us with where you were, what you were doing, that'd be helpful also.
1:41:53
Ooh, wow, that was a particularly poignant time for me actually.
1:41:54
So there was a lot going on.
1:41:57
I was in I was deep in med school.
1:41:58
It was my last year of med school.
1:42:02
Um boy, I had kind of a really ex- sort of experimental tour of my 20s and I was sort of settling into a new rhythm.
1:42:11
I was I had finally let go of a a fair amount of of guilt around my own accident and the effect on my friends and uh I was, you know, I was I was uh pretty neurotic at that time and my sister had just died.
1:42:31
So it's uh this may not be the intention of your question, but 30 happened to be a really sort of heady, heavy time for me.
1:42:39
So but I'll I'll still roll with the question and I think I guess I would have helped myself get uh You know, I this sounds way too tidy, but I might have said something like, "Hey man, you know, don't believe everything you think.
1:42:54
Don't, you know, let it go.
1:42:58
Uh you know, don't take it all.
1:42:58
Don't I I I do mean to take life very seriously, but I mean to take things like playfulness and purposelessness very seriously.
1:43:07
So I want to take you know, uh so I don't mean to this is not this is not meant to be light.
1:43:12
But I think I would have um somehow encouraged myself to let go a little bit more and say and hang in there and don't don't don't pretend to know where this is all going and you don't need to know where it's all going. Hm. Yeah.
1:43:30
Yeah, you don't need to know where it's all going. for sure. You can't.
1:43:37
What have you changed your mind about in the last few years?
1:43:47
Well, for all my talk of purposelessness and all this stuff, you know, I have in the last several years allowed myself to feel that I have a true vocation in this work around palliative care and and helping uh helping us as a as a as a species uh deal with our and dance with our mortality.
1:44:09
Uh I had convinced myself that, you know, hey man, I'd gotten to very loose and I was whatever.
1:44:16
I didn't feel the need to accomplish so much per se and I was uh But in these last few years, I've let myself I think in a way, man, I think I've let myself get more ambitious in a way. Mhm.
1:44:33
And to take my work even extra seriously.
1:44:38
Uh more seriously than I perhaps I I had been.
1:44:41
And letting myself feel like this could all work and letting myself feel like actually the health care system could be fixed.
1:44:50
And So in other words, I guess in a word is to reacquaint myself with something I'd talked myself out of, which was ambition.
1:45:00
I'm I still think of that word in negative with negative connotations.
1:45:02
I see bad behavior on behalf of ambition a lot and I'm sure you have too in and around where we live and places like Princeton and people stepping all over each other to get ahead and that's not what I'm talking about.
1:45:16
Um Maybe it's aspiration. Yeah. Yeah. Mhm. Yeah. I think that's right.
1:45:23
Well, on that point do you have any any last requests, asks, suggestions, or otherwise for the people listening? Oh, thanks, man.
1:45:38
That's such a great invitation.
1:45:39
I mean, one is uh folks, hey every- everyone I I hope we could start seeing the remarkable amount that we all have in common uh by virtue of being the same species on the same planet, et cetera, and mortal beings at that.
1:45:52
And I guess I would ask that we start looking looking to make make that uh make that all real.
1:46:01
I would ask that we prize kindness.
1:46:01
I would ask that we learn to forgive in a daily way.
1:46:10
Um but more strategic, I would ask you guys um if you're so moved to get involved um reifying and supporting hospice and palliative care.
1:46:19
If if you're in and around the Bay Area or just so moved, we would love your support at Zen Hospice Project.
1:46:25
These places uh rely heavily on philanthropy.
1:46:30
Um so if you're moved, please come check us out zenhospice. org.
1:46:35
And if otherwise, think about what's going on in your own geography.
1:46:38
Support hospice and palliative care.
1:46:40
It's work that needs to be developed and and built.
1:46:44
Um Yeah, I'll leave it at that. That's that's plenty.
1:46:46
And I just I I really I've been so excited to chat with you for so long and uh I've had so much fun in part because it's exciting to me to think that in studying and refining how to die, we can study and refine how to live.
1:47:04
And that like you said, with the foot in the door, the wedge that is palliative care, you have the ability in this laboratory called Zen Hospice Project to do a lot of experimentation that could actually translate much more broadly to life not just at the end of life, but throughout life.
1:47:29
And I find that very, very uh inspiring and exciting.
1:47:34
Uh so I think it's it's a real tremendous opportunity and and a potential point of leverage that you have.
1:47:42
And so people can find you at zenhospice. org.
1:47:46
Uh z e n h o s zenhospice. org. Zenhospice. org.
1:47:54
Uh Facebook is Zen Hospice Project.
1:47:54
Uh Twitter at Zen Hospice.
1:47:59
And I'll put all this in the show notes, of course, for everybody listening.
1:48:05
Can I also on that note, Tim, can I just give a shout out to the work that's also the great work that's being done at UCSF Absolutely, of course.
1:48:10
the symptom management service in the UCSF Cancer Center, the outpatient palliative care program there.
1:48:16
Mike Rabow and all the work going on around there is is gorgeous.
1:48:20
And uh that's another thing to consider supporting, but that's another place to find my work, too. Definitely.
1:48:26
Yeah, UCSF is just spectacular and I've I've done I've I've also been involved with uh well, the Gazelle Lab and and other folks at UCSF.
1:48:35
I'm just continually impressed.
1:48:38
Uh BJ, hopefully we'll get to do a round two maybe with some wine sometime, but uh I really appreciate uh number one, first and foremost, the work that you're doing and how you've dedicated your life.
1:48:50
It's tremendously important and tremendously impactful.
1:48:54
And also uh on a smaller level, of course, the time that you carved out today for this.
1:49:01
It's such a pleasure, Tim.
1:49:01
And that went really fast, man.
1:49:03
And thank you so much for having me on the show. It's such a joy.
1:49:07
And to everyone listening, you can find the show notes, links to everything we discussed at 4hourworkweek.
1:49:11
com/podcast, all spelled out, or just search Tim Ferriss and podcast.
1:49:18
And as always, and until next time, thank you for listening.
1:49:30
Hey guys, this is Tim again.
1:49:30
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