Transcription
If you're willing to commit to, you know, a really serious exercise program, which again, doesn't mean you're killing yourself, crushing it, running a marathon every weekend. It means if you're paying attention to a portfolio approach of strength, stability, aerobic training, anaerobic training, all those things, you know, it can add up to a decade to the length of your life. And more importantly, and I say this to my patients, if all this exercise shortened my life by a year, I'd still do it because of what it's giving me in quality of life.
[Music]
My friend Peter Attia is one of the most famous thinkers in healthcare and longevity. He's a very popular podcast himself. Let's find out why a lot of the most successful people in the world are flocking to Peter and getting his advice. I'm excited to have Ryan Holiday with me here today and our friend Dr. Peter Attia. Peter, thanks for joining us.
Yeah, thanks for having me, guys. Let's start with your background. You graduated from Stanford, you were named Resident of the Year at John Hopkins, and you left your residency early. You weren't having it, and you've become, obviously, a very, very famous doctor doing a lot of amazing things. Why did you leave your residency? What was going on?
Uh, a lot of things. I was just unhappy with, kind of, medicine in general. Didn't feel like I was, um, didn't feel like I was having an impact. Uh, felt frustrated by a number of things. Uh, felt that the system of medicine at the time, um, was not very innovative, um, and really moved at a very slow pace. And, uh, and also, I think frankly, there were just other things that were frustrating. I, I really did miss quantitative things. My background was in, you know, sort of quantitative areas, and I just had an itch to sort of do something totally different. So actually, when I left, I left and, you know, went and did consulting and worked in finance and completely left medicine for some period of time before coming back to it.
You've dedicated yourself to the science of longevity. You've become one of the great, kind of, thinkers in that space and testing all sorts of things. How'd that get going?
Uh, I mean, actually, the seed that sowed that was actually the birth of my daughter. So that was, you know, 14 years ago. And I, I think, you know, you guys can both relate to this because you both have kids. I do think there's some gene that starts getting transcribed the second you have a child. And, um, there's just a shift in thinking. And all of a sudden, mortality became something I considered and contemplated. And, you know, wanting to live longer became an interest, which, you know, previously, it really hadn't. All I had cared about was sort of performance.
And you're unique in this because you not only teach the science of longevity, but you experiment on yourself. You test exercises, diets, training regimens. Did you start doing that right away when you started becoming interested about it?
Yeah, yeah. I mean, I think that's sort of how everybody kind of gets into things. As they, they start tinkering on themselves. And then you realize, well, there's only so much you can sort of figure out this way. You have to understand more broadly what the science has to say. And then how does that apply?
You were an ultra-endurance athlete. You have a really intense fitness regime. Is this still some of you today? Is that healthy to be, to be a super intense athlete for what you do?
I mean, I think it's a very, it's a relative question. Uh, I think some people would still look at me and say I'm pretty intense and extreme. I would say by the standards of what I did from the ages of 13 to 44, I would say I'm the least extreme I've ever been. But my focus is very different now. I mean, I would say that, you know, my focus is much more on how to be the best 80-year-old or 100-year-old. Yeah, but it's, it's, I'm not, I'm certainly not focused on being the best 50-year-old. There's nobody who walks up to me in the gym today who would say, "Wow, what are you doing different?" You know, because it's not, that's not really.
So what does that mean? How do you get to be the best? Like, there's something called the Centenarian Olympics, I think you mentioned that you want to be able to compete. How do you get there and what are the types of things you want to do?
Yeah, I mean, I have this term called the Centenarian Decathlon, which is mostly just a, it's a mental model, right? It's just a way. It's not an official event, of course. But, you know, what, what is it about decathletes that are relevant? Well, they're generally considered the best athletes. Uh, you know, the person who wins the decathlon at the Olympics is generally regarded as the best athlete. But individually, they're not great at any one sport. They're not the best at the, you know, at the sprints or the hurdles or whatever it is. Um, but in terms of their well-roundedness, they are. And I think that's actually an appropriate way to think about what it means to be an exceptional 80-year-old, 90-year-old, or amazingly, if you can get there, 100-year-old. Everything. Yeah, you have to be very good at a lot of things.
Ryan's latest book is called "Discipline is Destiny." We're talking about virtues earlier. Is this discipline a big part of this, or or how do you think about it?
Depends. I think for some people, it's, for me, it's not. I mean, exercise is, you know, the discipline is to not exercise more. The discipline is to, for me personally, is to, you know, spend time doing other very unusual. Probably perhaps that's still discipline.
You strike me as, you're talking about intensity, you're an extremely intense person. So in a weird way, letting that intensity run amok is a lack of discipline, right? And to be able to say, "Hey, also, I don't want to be so, I don't want to be all these things at 50 that come at the expense of what I want at 70, 80, 90, 100."
Yes. I, I would agree that I probably exert more discipline in my life around exercise today than I did 10 years ago. And I mean, I'll give an example. I had shoulder surgery for an injury that's older than I am, basically. Should have had the operation 15 years ago. Finally had it six months ago. And, um, I have, I'm proud of myself in the regard that there are times when I'm deliberately slowing myself down in the return to, you know, doing pull-ups again and things like that, where I think the Peter of old would have said, "Like, you have to go back to doing as many as you were." And now I'm like, "No, play the long game. You don't have to do them all today." I want to push back on this a bit. The last time we hung out for an hour, we, it was really hot outside, and we had a ton of weight on ourselves, and we were walking. That seems pretty intense. Is that, is that not a little bit intensive?
Actually, that ties right into this guy here. So, what you're referring to is rucking, which is one of my favorite activities. So this is an exercise taken straight from the military. This is a very important part of how people train in the military. So carrying heavy weight is just a very important part of training. Um, and if you talk to, especially Special Forces guys, they'll tell you, like, this is, you know, the stuff that they do is legendary. 24-hour march with half your body weight on your back. So it's like Caesar's legions, he's like carrying all his weight around everybody else. So what we were doing was a third of our body weight, which I think is really all you need if you're a regular guy. Um, but what I really love about it is it's half physical, and it's, to me, half emotional health. So, you know, Ryan wrote a book called "Stillness," and I think it's one of my favorite books ever, and it, it really left an impression on me, which is that there is no substitute for being in nature, not having electronics, not listening to something, because I'm always multitasking, right? I'm listening to an audiobook or a podcast. But there's, I don't bring the phone with me when we do that exercise. And sometimes I have a friend with me, like that day you joined me. But most the time, I'm alone. And it's just looking at the fractal geometry of the world, hearing the wind. Um, and an hour of that, I think, you know, you're, you're getting this amazing physical benefit of the challenge of it. But, but I think you're just getting as much of a psychological benefit. It's a, it's a meditative thing. It's physical, and it's, you're in shape for it, but it's your mind that actually emerges stronger and more refreshing.
Yeah, and, and yeah, I do different things. Like, there are times when I will focus on an object. So one of the things I really think that's interesting, most people aren't aware when you're walking, you're generally not aware of the wind hitting your fingers as your arms swing as we walk and we swing our arms. But if you tune into that, you, you'd be amazed at how profound that wind is on the leading edge of your hand as you walk. And so there's times when I'll spend half a mile, and that's the only thing I'm thinking. That my, all of my energy is focused on that one little thing. And in that sense, it's, it's a highly meditative process.
Is meditation important for longevity? Is it important in some way? It's tied to whatever things you do.
I mean, I, I think it depends, right? I think for some individuals, it's probably an essential part of who they are. I don't think meditation per se is essential in the way that I would say exercise is essential, and reasonable nutrition and adequate sleep are essential. There is no replacement. I mean, meditation is a tool that for many people can be a really valuable way to improve quality of life. And I think having a high quality of life, having a good emotional life, is essential for longevity, if we define longevity to include healthspan.
What's lifespan versus healthspan? How do you think about that?
I mean, lifespan is the obvious sort of binary part of this, right? Which is like, you're alive or you're dead. So that's the, that's the digital piece. I think the analog piece is the harder one to sort of describe, but that's the healthspan piece. That's the quality of life. And I think there are three metrics. I think there's the physical side of that. So, um, you know, are you free from pain? Do you have, you know, muscular strength, muscular endurance, cardiorespiratory fitness, all those things? And then, um, and then there's the cognitive side. So, are you, you have good memory, processing speed, executive function, all of the things that define you guys? And then the, I think the arguably the most important, but the least, uh, easy one to quantify, is the emotional health piece, right? So what are you, you know, are you, are you fulfilled? Do you have a sense of purpose? Are your relationships good? All of those things. And I think, again, to have the others without that is, is purgatory.
How much of all this is determined by genetics ahead of time? Are these like genetics first, and then you can modify them?
No, not many. I mean, look, genes play an elaborate role in ultra-longevity. So your grandmother's, like, how old? 102, and she's doing doing great, right? Right. So, so that is almost exclusively a genetic lottery. Um, so once you're in the 90-plus category, genes are almost entirely all responsible. But if you start eating lots of bacon and stuff, that she's honestly, like, if she's Jewish, if you look at, you know, Tom Perls and Nir Barzilai, who probably run the two largest cohorts of studying centenarians and their offspring, I mean, on average, centenarians exercise less, smoke more, eat worse. They just have fantastic genes. Um, if you get away from that, um, again, I, I don't think you need to win the genetic lottery. Now, look, you can have some real genetic curses. There's no question. There are people that, you know, have a very, very strong history of cancer in their family, for example. Or, you know, there are very fortunately rare examples of people who have, you know, genetic predisposition to Alzheimer's disease, for example. You know, one percent of people who get Alzheimer's disease get it in a deterministic manner, meaning they literally get one of three or four genes that guarantees you'll get it. But for the most part, I don't think this stuff is genetic. Now, there is actually some evidence that happiness and, and a person's sunny disposition has a pretty reasonable genetic component. So I don't want to dismiss genes, but I also think we, I think we dwell too much on genes sometimes, and I think we should just probably focus on what we have control over.
I saw a commercial that reminded me of you. You've probably seen it. It's, um, it's this old man, and he's practicing with a kettlebell, doing, uh, you know, squats or whatever. I saw it on Twitter. Is it an actual commercial?
Yeah, it's a commercial. I forget what it's for. He's fantastic. And, uh, this makes me think of healthspan. So he's doing it, and then you find out, Christmas morning or something, his granddaughter runs in the room, and he's been practicing lifting the kettlebell so he can pick his granddaughter off the ground. And so it's not just the physical component, right? But it's also, um, have you lived your life? Have you made decisions? Do you have the personality that makes your granddaughter want to spend time with you, right? And so it, you know, you could be the fittest 100-year-old in the world, but if you're a curmudgeon or a jerk, or you put work and money and all these other things in front of family, there's nobody who's going to be wanting to run into your arms.
I mean, I couldn't agree with that more. And one of the things we do with our patients is I try to explain, and I use an archery analogy for this, which is we talk about what are your long-term goals? Your long-term goals is your marginal decade, the last decade of your life. So how clearly can you define what those are? And then what are your goals for the next 12 months? And as you know, because you now shoot a bow, have you ever shot a bow?
Yeah.
So in archery, you have the sight at the far end of the bow, and then you have the peep, which is on the string that you pull to your eye. And so when you are in full draw, what's happening? You are trying to acquire rear sight, front sight overlap perfectly. If those don't overlap, you will miss. Yeah. If those are in perfect alignment, you will hit. And the same thing is true. If you say, "Oh God, in my marginal decade, like I want to be surrounded by love and family and great grandchildren, and I want to be able to lift them up," but in the short-term goals, you're not doing anything about that, you know, you're going to miss, right? You're going to, you're not going to hit the target.
We've been talking about hobbies earlier. Bow hunting is obviously a hobby for you. What is that? Another thing that gets you into that sort of meditative place, that ratchets down the intensity, that is an outlet for some of this stuff?
Yeah, totally. I mean, I just, I love things that are precise. And that's, you know, archery is a very precise thing. I don't play golf, but I would imagine it's very similar to golf. But it's also something that requires great emotional control. So yesterday, I was shooting, and I mean, I was just having a really bad day. I mean, no, today. Never mind yesterday. It was this morning. I mean, I was horrible. Um, and I think what I love about that is I have to control my emotions about the podcast coming up. Um, and, you know, I think like five years ago, I would have thrown a little mini temper tantrum about how bad I was doing. And today it was just like, huh, this is really interesting. Let me be curious and not judgmental, to borrow from Ted Lasso. And let me kind of like think about like, why am I doing so badly at this today? And can I make an adjustment? Oh, I did okay. I didn't make anything better. Okay, fine. Make another adjustment. Oh, actually, I did get better. I got a little bit better. And then I got a little worse. But, you know, that to me is actually a practice. Like, that's a skill that I'm, it's almost embarrassing to say this, but there was a day when if I shot poorly, I had a bad day. Like, can you imagine that? Like, that's pretty weird to think that you could go out in your backyard, shoot a bow and arrow for 45 minutes, and if it didn't go well, the rest of your day sucks.
The hobby shouldn't ruin your day. No, it should improve the day. That's right. Yes. It's like when you play golf or something, and you have a really bad golf game, try not to let it ruin the day, right? And, and so, you know, today, something I can be very proud of is like, that's no longer the case. It just doesn't matter. I can have the best day, I can have the worst day. By the time I've dropped the bow off in my man cave, like I've forgotten about it. Also, it's another thing that forces you to be present, disconnects you from the phone, the device. Things not going well, going, if it forces you outside, doing a thing that I think the reason it's not going well is just another benefit, which is that it's humbling. It doesn't matter how long you've been doing it, it doesn't matter how talented you are, how smart you are, it's hard. And therefore beneficial from an ego perspective, because it makes you realize you're not the master of the universe, even if you are professionally master of your year.
Yeah, I, I was, I remember walking back today from the targets after pulling, and I remember just thinking, like, this is amazing how hard this is. Yeah. Like, it's amazing that this is just really, really hard.
This ties a little bit into kind of self-control, virtue, discipline, to write about. You know, if you look at the data right now, America's health overall is in a very bad place. Life expectancy has actually gone down recently. Antidepressants are, uh, you know, is going up. You study this closely. Like, what's, what's happening? How can we reverse these trends? Is it partially virtue? Is it something else?
That's a great question. I mean, we know that there are two things in the past three years that have tipped the curve on life expectancy in the United States. So the first of these is the opioid crisis, which is obviously a mental health crisis first and foremost. Um, so we talk a lot, a lot about what is the number of deaths from suicide. And that's, believe it or not, for everybody over the age of 10, suicide is the only cause of death that is always in the top 10 by decade. The only decade for which it's not a top 10 cause of death is under the age of 10. So think about that. 10 to 20, 20 to 30, all the way up to 90 and up, suicide is the only thing that is in the top 10 across the board.
Is this the case 50, 100 years ago?
I don't know. That's a great question. I should know the answer to that, but I don't. But here's my point is that suicide only barely captures it, because if you look at accidental deaths, up until the age of 55, even probably 60 now, the hands-down leading cause of accidental deaths is now overdose. So that has even exceeded auto deaths in young people, which was formerly the leading cause of death.
These are deaths of despair?
That's exactly right. These are slow suicides. Um, and so, you know, that has taken an enormous chunk out of our life expectancy. The other one is probably a bit of an artifact, which is, right, that I think probably sped up the demise of a demographic of people who were sick on average, right? So, you know, lots of people have died of who weren't sick, but the majority of the deaths attributed to are people who were probably going to be dying in the next five years.
Vulnerable people.
That's right. And so therefore, I don't know how that will reflect in the next decade. But what I don't see a trend to reverse yet is the first thing I said, and that's to me, the, the kind of elephant.
What about the obesity epidemic? I mean, we have this whole body positivity movement, which I, I think is very unhealthy. It's very controversial, maybe to say that. But it seems like there's like a big issue in our society where we're trying to say, "Oh, certain things that are bad for you are okay or are good or don't criticize." Like, is that contributing to this as well?
I just don't know the data, truthfully. I mean, my view on these things is these things really, like, we shouldn't really, I'm not interested in the subjective. So I think there's a subjective part of this that I just don't have a voice on, a review on, because it's very personal. Like, I, you know, I personally wouldn't want to be 100 pounds overweight. That's just me. It doesn't mean that a person who's 100 pounds overweight is any less of a person than me. I just wouldn't want to be it. Um, for me, what is objective is what is the impact of that weight on health? That's, that's really the question that I'm concerned with. And I think there were basically two ways to think about that, and it's through what we talked about earlier. What's the impact on lifespan? What's the impact on healthspan? And at a low level, there's actually something called the obesity paradox, right? So a low level of obesity actually seems to be somewhat protective in an aging population. When you're older, having a little bit extra weight, it's not necessarily bad.
That's correct. That's correct. That's referred to as the obesity paradox. Now, I also think that the problem is, obesity is defined by BMI, is such a crude metric that it's very difficult to really draw much of a conclusion. You know, when you look at someone whose BMI is 31, like, I mean, my BMI, I don't know what it is, but it's clearly in the overweight category.
US rigs are so strong, I need more muscles.
Well, I mean, I, I just think that BMI is, yeah, like 25 is considered normal. I'm probably like 28 or 27. And what, Matt? And so I don't, we don't look, we wouldn't even consider that metric in a patient. Like, I don't, I couldn't tell you the BMI of one of my patients.
I'm trying to build muscles as a friend told me I should do that. It's healthy. I'm having all this beef jerky recommended. And so it's like, it seems like that's probably gonna be my BMI.
So what we would care about, though, is, you know, how much visceral fat do you have? Not even body fat, just visceral fat. How much fat do you have around your organs? Because that's actually the metabolically damaging fat. Uh, are you insulin sensitive or insulin resistant? Do you have metabolic syndrome? Those are actually the metrics that matter. And, you know, look, those metrics are pretty bad. So I think right now, um, you know, I was just kind of going through some of these numbers for, as I was finishing my book, and, um, the most conservative estimate I can come up with, and, and I, there are many higher estimates out there, but if you're taking the absolute floor, it would be a hundred million American adults are metabolically unhealthy. Wow.
So that's the problem. I wish that's what everyone would talk about. It's, I imagine despair is part of that as well. It's like, what, like 70, 60% of, uh, young people could not join the military if they wanted to because they're so excited. And you think this is part of that?
I mean, a big part of it is obviously a terrible, you know, food system, and people don't have access to healthy. But a big part of it is this is a person who does not think they need to be healthy for any real reason. They're not, uh, they're not being put to use in a way that, uh, would make them feel like they are not being purposeful with the decisions that they're.
Doesn't that come back to virtue and positive masculinity and like your role as, as, or for women as well, your role in society? Like, just focus on men for a second. There's a lot of stuff I've seen about declines in testosterone levels. What's happening with that? Is that tied to this? Is a view of them as, as a man, is that, is that going away right now?
I'm not sure. I mean, I think there are probably lots of things that can explain, you know, a fall in testosterone. So, you know, not sleeping well is going to have an enormous impact on testosterone. So then you want to think, what are the things that impact sleep? How much of it is being on phones, putzing around, like, you know, drinking too much, smoking too much pot, which makes Twitter and video games. But basically, it's like, there are lots of things that if done to excess, like, I'm not going to sit here and say don't drink alcohol, or I'm not going to sit here and say, like, you know, you should never smoke pot. I mean, that's, that's neither here nor there. I'm just saying there are things that if done to excess will impair your ability to have a normal set of hormones. And I think that's probably the issue more than anything else.
It feels like the self-control thing with the obesity, as well as both of these things are tied to some form of temperance, almost.
Well, yeah, except that I think I don't believe that there has been an erosion in self-control over the last 40 years. So this is the million-dollar question, right? So why is it that 40 years ago, obesity rates, and again, I just said a moment ago, obesity is the dumbest proxy in the world. Yeah, but I'm going to assume that as much as obesity rates have gone up by two to three X in the last 40 years, with it has gone metabolic health. So yeah, given that that's, we use a proxy. Okay. I don't think that 40 years ago, people had that much more willpower than they do today. I just think that the environment has gotten so much worse that you would need more willpower today to fight the gravitational pull of this environment. So 40 years ago, I think, or let's just even say 50 years ago, because I can tell you 50 years ago, when I was born, less than 2% of people in the United States had type 2 diabetes. It was closer to 1%. That number is about 12% today. So when you have a tenfold increase in 50 years of one of the most devastating diseases, you have to ask the question, is this a failure of personal responsibility more, or is it a failure of the environment more?
And I, well, it can't be one exclusively over the other. I, I actually attribute more of that to the environment. And I think that environment is not just the grocery store is packed with more awful stuff, but also if people feel worse about things. That's right. They're more depressed. If they have less purpose, if they feel like they're left behind, you know, again, why does it matter whether I'm in shape or not? I'm not of use. I guess. Like social media, or whatever, it can make us more isolated, and then we don't see our community, and then that could lead to that. Which I think is a death by a thousand cuts. I really, you know, and I had an email chain with some, with some friends recently about this, where there was a symposium in Europe where they got all the biggest obesity researchers in the world together. And the New York Times wrote a piece on this that basically said, "Well, we just had basically all the smartest people in the room for a day, and they literally couldn't agree on one thing." And I was like, "Yeah." And I think the reason is, every one of those people is an expert in one thing. And I think each of them are partially right. They're seeing it through their, they're only seeing it through like, it's all this hormone, or it's all exercise, or it's all junk food, or it's all this. And it's like, no, it's all of the above. And not one of those things by themselves is lethal. But boy, when you stack all of those things up over a generation, it's pretty bad.
So how do we fix it? Like, what, what do we need to do?
I mean, this is the worst answer you're ever going to get on your podcast. I have no clue. And this is going to be an even worse answer. It's not the problem I want to solve.
All right. So what, what is the problem you want to solve?
I just want to solve it at the individual level. I, I don't, I mean, I don't know how many years I have left on this earth. Let's say it's 30, 40. But I, I will get far more satisfaction out of working with individuals who then can go on to solve big problems. I tell my patients, you know, my legacy is through you. So if I help you, and you go solve a big problem, that's great. But I personally will never solve a big problem. With anything that also kind of explains where we are with some of these things, which is, you know, if one percent of the population has it, it's rare. If 12% of the population has it, a lot of people have it, and it's common, and it's accepted. And it's all these things. So, you know, um, as it gets worse, it's a negative feedback loop. And as it gets better, it's a virtuous cycle. And, and we're probably in this weird thing where it's like, not that you want people to feel insecure or bad, but if everyone's letting themselves go, there's less pressure on the individual. Yeah. And I feel like there needs to be, I wish there was a way to sort of show people what, what the last decade of their life looks like under different scenarios. Um, and it's, it doesn't exist. Under some of those scenarios, yeah.
I mean, I, I was just talking to a friend of mine from high school yesterday, and his dad has never taken care of himself. Right? He's never taken care of himself. And he's, you know, in his mid-70s now. He's hospitalized with Lewy Body dementia. I mean, he's, he's dying an awful death. And we were just talking. I was like, "Yeah, it's really, it is sad to see a person at the end of their life who's never taken care of themselves because there's nothing that can really be done at this stage. Like, there is no treatment for what's going on. The only thing you wish you could do is capture this moment, transport them back in time, and show them that in a crystal ball and say, 'Look, with a little bit of effort compounded every single day for the rest of your life, it doesn't need to be this way.'"
I love the analogy you use of a glider, and you got to get the glider a lot higher because if it gets below a certain level, it's going to crash. Yeah. You know, you said you're not, obviously, you're not trying to do a big cause and fix everything. You're trying to fix people. But, you know, I thought you were really brave about pushing back on some of the orthodoxy. And we don't have to really look at all those things right now, but but are you concerned about the diversity of thought within medicine today? It does seem like you're trying to push back against some of this.
Yeah, no, it's horrible. I mean, it's, um, I, I, you know, I spoke out against mandates because I thought that I just thought they were wrong. Um, and I thought that they were wrong at the time that I wrote about it, which was about exactly a year ago, right? Which was, you know, they just, they didn't make sense. They felt punitive to me. Um, and I wanted to write this from the point of view of someone who was very profane. Yeah, right. Um, which is also to say, by the way, you can be very profane and acknowledge that they can have side effects. Like, I think what bothers me is the view of medicine today that there is no dialectical synthesis within medicine. Yeah. You have no iconoclast. If you're an iconoclast, you're kind of like, well, it's just that, you know, today I was on the phone with a patient, and we were talking about initiating a Statin. And I feel like there's two, there's only two views in medicine now, which is, statins should be in the drinking water, or statins cause every disease on the haste in the history of civilization. Yes. And it's like, no, how about neither of those is correct? Right? Statins are a really good drug under this situation. And, yeah, 5% of people get really bad, debilitating side effects and should never take them. And, you know, this is how you would use them. This is how you wouldn't use them. If you don't want to use them, you could do this. And so I just feel like that nuance is completely going away. Um, and I think that's, I think that's a problem. In in everything, that's a problem in politics. Imagine, like, think about how much politics is lacking in nuance.
Well, it's interesting. I think so much of that is a response to the fact that we have this, there is also the ability of people to misuse the tools to spread misinformation and disinformation. To, to, it's weird. It's like, there's too much nuance, so people create, uh, confusion and disorientation and all the stuff that that hurts people. And so I think the reaction oftentimes from the establishment, let's just go with this. And then, you know, that can create the blowback of like, well, what about this and that? But it, it's this problem we haven't figured out to solve, which is like, uh, bad faith is kind of poisoning the, the drinking water, so to speak. And then bad faith is often responded to with that faith. And then you're stuck. And so I got to tell you, like, I am not sure what is a bigger crisis. We've just spent the last few minutes talking about the crisis of health, which includes a crisis of despair. You could argue like, this would be a really fun if we were sitting here having dinner and we had the next three hours instead of, you know, a few minutes. What is a bigger threat to our civilization? That, or the fact that civil society can't exist between those two extremes?
This is why we can't have nice things. Yes. Yeah. Like, I don't, I'm not sure which one will sink us first. But I'd be, if I had to bet today, I would guess the latter is even a bigger threat than this. To me, they're related in the sense that there's a lot of things in the latter that are leaking out absolute form. Yeah. Yeah. But, but I, but I think the latter concerns me more. And I used to think about it through the lens of just science and policy, right? So I don't know the stats today, but the last time I looked at this, which was literally a decade ago, if you took the, what is it, how many members, how many we have 465 in the House, or something like that? 455? I think. I think in that ballpark, right? So call it 35. I think 435. Okay. So yeah, that's right. Yeah. So if you take the 535 members of the Senate and the House, when I looked at this again 10 years ago, five of them had an undergraduate degree in some form of technology, like science, engineering. People in our country have no idea. One percent of your elected officials even have the most cursory understanding of science. How can you make proper policy around? Or if the rest of them are extremely old or extreme privileged bureaucrats and lawyers and committees.
It drives me. The whole disinformation thing is just so fascinating to me around this. So in, well, it's been fifth or sixth grade, I was a little bit of a fat kid. You know, I worked out, but I didn't eat very well. And they gave us this food pyramid, and they said we had to try to eat to it. And I remember really trying hardy to. I would get up in the middle of the night and have more bread. I literally was trying to do what I was told by the government school. And I didn't feel good, but I was eating the bread for a month, you know, trying to hit it. And like, in retrospect, that was probably not the best idea. But like, the disinformation is so funny because we've gotten information our whole lives from these idiots. It's like, it's like, what is the damaging one? The damaging one to me is when there's a top-down thing that's wrong that's stopping a conversation. That's interesting. Yeah. It's just, um, it's like these are complicated adult conversations, and there's not a lot of adults who can handle complexity. And then it makes it really hard to get to the best policy decisions.
Way of doing it, or nuance, or whatever it is. Yeah. I'm just terrified. Lindsey Graham wants to work with Elizabeth Warren to regulate social media. This is like the latest thing. To like, you really think they're going to do a good job? What's their combined age? 150 something? That's terrifying. What they're doing.
I don't. No. I mean, this is, I, I'd love to get on both sides more. More doctor scientists, engineers. Why are doctors so bad at, like, pushing back and thinking for themselves?
This is, I'm going to give you a really horrible statistic. Of all the professions in the 1930s in Germany, the one that was by far the most likely to be, see, once it was a popular thing to do, were the doctors.
Where's the medical experience? That doesn't surprise me. As tragic and horrific as that sounds, because I think people confuse medicine and science. They're actually not the same thing. Um, and like, I didn't learn one shred of scientific thought in medical school. I was very lucky that I got to spend two years at the NIH in a lab of a very, you know, remarkable scientific thinking challenge. I didn't, I only learned how to, I only learned science when I was in a science lab, doing science, surrounded by scientists, going to journal club, ripping apart articles every single week in journal club. Nothing. And, you know, this gets back to the question you asked me, why did I leave residency? Like, I think in part because I got sick and tired of the anti-intellectual nature of medicine. And it needs to be that way, I guess, for a reason. Because you are learning an entirely new language in a relatively short period of time. There's just a fact base that is so wise that you have to learn this. And I think what is easy to do is to basically just say, "Okay, fine. Like, I submit. I'm just going to learn and learn and learn, and I can't question every part of this." You can't. You truly could not question everything that you use when you get through this, and you couldn't do it. So you learned, you'd learn not to question certain things.
I mean, could AI change this? Could you have like such good AI that just does all the known stuff, and then the doctors deal with exceptions and work on one of your areas? Is there, is there some bright hope for the future that, like, how do we get out of this mess? Get and get more doctors that can challenge things? They can think for themselves more easily?
It's hard for me to imagine that AI will not play a meaningful impact in medicine. I don't think it will be on the time scale that people talk about it. I think people talk about it like, "Oh, we're just two years away from this." The chatbot's not quite accurate enough. Yeah, yeah. Um, there are areas where it's already making a difference, uh, in radiology, for example, it's, it's already making a difference. Will it rise to the level of, you know, a person walks into the ER and you can gather all this information from them and make decisions? Uh, yeah, but you got to remember, you have to train the AI. And this is what makes medicine a little bit more messy. You know, you need an unbiased data set. And then you need, like, you need an unbiased data sample on which to train the AI. And then you have to be able to validate it on a sort of a comparable sample. And I think that's just harder to do with messy things like people.
What's like, what's the survivorship bias? The selection bias in any given profession? Right? And the logic or the constraints of that profession almost always create a specific type of person. And that person is good at functioning in that system, usually at the expense of not functioning well in other things, or or being good at other things. That makes sense. Especially for doctors, because they have to do so much fine-tuning to get to be good in the work in that system.
Yeah, I think your point is really a good one, which is we are selecting, generation after generation after generation, for a subset of people who do well. And who, and who, and, you know, like, I don't ever want to live in a world where we don't have really good, competent, capable doctors. I don't want to live in a world where the best and the brightest wouldn't dream of going into medicine. I can't speak to what the stats are today. Like, I would, I would gather that there is a historical trend line that shows a waxing and waning of where the top talent go. Like, where are the best and brightest out of college go? How many of them are going to Goldman Sachs? How many of them are starting doing a startup companies in the Silicon Valley? How many of them are going into medicine or law or business school? Like, you know, and my guess is medicine is falling behind.
Is there some hope over the next 10 or 20 years? Are there new paradigms? How do we fix this? Like, what's the positive outcome here for how healthcare and medicine is is better 20 years from now?
You know, look, I think the knee-jerk answer is technology, right? We can sort of talk about that as like, kind of a throwaway term, like technology will fix everything. Um, and I think it will fix some things. We have the fundamental problem in the United States with healthcare, though, which is, if we're not careful, it will bankrupt us. Right? So we, we, it's, it's not become very fashionable to talk about this anymore. We've sort of forgotten about this. But, you know, we do, on a per capita basis and in absolute dollars, spend more on healthcare than any country in the world. We're not even in the same zip code as the next countries. And our ROI across the board is not great. We have a, we have a very high ROI for the people who can access the best healthcare. But if you consider the entire population, we're actually doing a pretty bad job, especially when you consider what we're paying for. So, um, I, I actually worry a bit about that problem, which is that, you know, if you start spending 37% of your GDP on healthcare, like at some point, you can't keep up. Like, you can't have enough GDP to make that equation. I spend a lot of my time on health policy. And my framework is, there's like five or six areas of healthcare that are each just captured by cronyism and captured by cartels. So it's like, there's like the healthcare groups, including the non-profit hospitals, they buy everything and they raise prices. There's, there's pharma companies doing all sorts of sketchy things to kind of keep drugs longer and keep patents and harder to work with the PBMs in the middle, middleman. Frankly, the, the AMA and the doctors groups do all sorts of things to stop the AI from being allowed to work with nurses, even if the nurse plus AI is better than a doctor, they'll ban it. Right? And they'll pass laws. And I think the list goes on and on and on. And then you can't even start a new medical school these days. It takes longer to start in medical school than it took us to fight World War II. I mean, it's just, it's just insane how these things work. Well,
I think it's a lot like the Obesity change or diabetes change over 50 years. There's no one thing, but all of those things do add up. And and I think, you know, one way that I think is, uh, that I reflect on this is basically looking at what's good and bad about other systems, right?
So I grew up in Canada, and as you know, Canada's got a very socialized system. And I don't think it's a great system, by the way. So yeah, one of the things that vexes me is when I hear Americans talk about, "Oh my God, if we just had Canada's healthcare system." I'm like, knock yourselves out. Like, I wouldn't want to live in Canada if my life depended on it. No offense to my Canadian brethren. And the reason is, um, you can't get anything done. Like there's, you know, if you need an MRI, like you can have it in a year. You have to wait for everything because there's no markets at all.
But here's where Canada's better. Nobody falls through the cracks. So it seems to me the solution has to be a hybrid that takes the best of both systems and abolishes the worst of both systems. 100%. And the worst of the American system is the risk ownership piece. This is the problem. There is a total disconnect between demand and risk.
So I'll give you an example. So I had a friend who used to, he was an expat that lived in Saudi Arabia. And anybody who's been to Saudi Arabia will know, you don't really want to spend summers there. So, you know, he would come back to DC from like June till September. And I don't know how it came up one day. We were having dinner and I, I sort of said, "Oh, dude, what's it like when you get back to your apartment in September? Is it like 150 degrees?" And he's like, "No, it's 70 degrees." I'm like, "How?" He's like, "I leave the air conditioning on the whole summer." And I'm like, "What are you talking about? That's insane. How much does that cost?" He's like, "$20." When you don't bear the cost, when you don't have skin in the game, it doesn't matter. And that's the fundamental issue with the U.S. healthcare system. Nobody has any skin in the game. Nobody has anything.
We need, we need more markets on some parts. I mean, take care of the bottom. On the other parts, you need a uniform system that nobody falls through the cracks. Nobody should be going to an emergency room for general health. Right? Nobody should use an ER, which is marked up 87 times, as their primary care doctor for general health maintenance, for preventative health. But at the same time, we can't live in a place like Canada where a person should be able to have private insurance. Where if they want to pay a premium, they should be able to get a service. A lot of things like this in the world. Take the best part of what the Democrats want, one of those Republicans want to merge the wisdoms together.
I want to end on, uh, I went on personal habits and advice. Um, just get a lot of people. You can go listen to it. You have a podcast, millions of listeners. What are some of the things you work with some of the most talented people in the world? Listeners, all my friends listen to you. So I thought it was millions. I don't know, maybe amongst a certain class of people. Uh, but what are some of the most common types of advice you, you give people in terms of people come to come to work with you? Like, what are some of the key things people need to know for their health?
I, I mean, honestly, I think I think we've talked about the most important things. I mean, I, I, you know, I generally put kind of probably exercise and emotional health or at the top of the list because I think exercise, in terms of interventions that people think about, has the greatest impact on the length and quality of your life. So if you, um, you know, if you're willing to commit to, you know, a really serious exercise program, which again, doesn't mean you're killing yourself, crushing it, running a marathon every weekend. It means if you're paying attention to a portfolio approach of strength, stability, aerobic training, anaerobic training, all those things, you know, it can add up to a decade to the length of your life. And more importantly, and I say this to my patients, if all this exercise shortened my life by a year, I'd still do it because of what it's giving me in quality of life. And what I think about that last decade of my life being so, so that's one thing.
And I think the other thing I would say is, you know, this, this other stuff we talk about that is kind of soft, I think is is really important, which is, you know, are you setting yourself up to to to to sort of live the life you want to live at the end? Because I, I think for me, that's always been a big struggle. Is it's just it's so easy to be maniacally focused on the goals, the objectives, the here and the now without realizing, for example, like we all have young kids. Like this is a very narrow window of it's a sliver of time before our kids are gone. And, you know, it's obvious, but it's, it's still stark. Like once your kids go to college, like they never live under the same roof with you again outside of unusual circumstances. And even my daughter who's 14, her interest in hanging with me is way lower than my eight-year-old and my five-year-old. And in some ways, it's almost a gift that I've got to experience that because it makes me so much more appreciative of just hanging out with my boys, even when they're being really bad. And even when it's sometimes not that fun to be with them, but I realize this is going to be gone. And it's going to be gone in a blank.
Peter, you have a new book coming out in the spring. It's called Outlive and it's available to be pre-ordered now. Awesome. Outlive by Peter. It's here. Peter, thanks for joining us today. Yeah, thanks for having me, guys.