The Surprising Reason Some Terminal Patients Live 25% Longer | Atul Gawande

Key Takeaway

Start one values-based conversation today with someone you love. Instead of asking only about medical interventions, ask: “What matters most to you if your health worsens?” Follow with questions about their hopes, fears, tradeoffs, and minimum acceptable quality of life. Write down what you hear and revisit it over time. Clear goals help families and clinicians choose care that supports the person’s life—not merely extends treatment.

Episode Overview

Atul Gawande explains why humane care for serious illness begins by identifying what makes life worth living for each individual. Drawing from his family’s experiences and palliative-care research, he argues that goal-centered conversations can improve quality of life, reduce unwanted interventions, and may even help people live longer. He also reflects on aging, purpose, mortality, global health, and AI in medicine.

Full Transcript

Transcript of The Surprising Reason Some Terminal Patients Live 25% Longer | Atul Gawande from 10% Happier. Auto-generated from episode audio; may contain minor errors.

Hey everybody, welcome to the 10% Happier podcast. I am your host, Dan Harris. As a Buddhist, I am simultaneously galvanized by and terrified by the unavoidable fact of death. Galvanized because being aware of your mortality can make life more vivid and vibrant in the present moment. And terrified because, like, who's not afraid of dying? Today though, I'm talking to a very famous doctor who argues that we can make this process which again is coming for all of us, much more humane. Dr. Atul Gawande is a renowned surgeon, a Harvard professor, a writer for the New Yorker, and the best-selling author of many, many books, including the one we're going to focus on today, which is called Being Mortal.

Now you might be thinking, didn't Being Mortal come out in 2014? Yes it did. But that was before I had a podcast. And I've been meaning to have Dr. Gawande on the show for a long time. And then I found an excuse because just a few months ago, the New York Times listed Being Mortal as one of the top five books that will lift you up in hard times, which reminded me that I wanted to have Dr. Gawande on. So here he is, Dr. Atul Gawande.

Welcome to the show. Thanks for having me, Dan. When my dad was still working, he was the head of radiation oncology at the Brigham and Women's Hospital in Boston. And he used to rave about this brilliant young surgeon who was writing articles for the New Yorker. And I should read those articles. And he was talking about you. So it's very nice to finally meet you. What's your dad's name? Jay Harris. Oh my God. Yes. I've shared patients with him. That's amazing. That's your dad. He's in a very different situation than when you knew him.

He's had a lot of health problems. He had a stroke and has a form of Parkinson's. So he's sometimes walking a case study in impermanence. Tell him hello, but also you're going through what everybody goes through dealing with a family member who's got significant challenges now. Yes. So that brings us to your book, again, Being Mortal, just one of many, many books you've written. One of the big through lines in the book was your experience with your father. Maybe let's start there. Yeah. My father was a surgeon himself.

So I'm a surgical oncologist at the Brigham and Dana Farber in Boston. My father was a urologist. My mother was a pediatrician there. I grew up in Athens, Ohio, and he developed a tumor in his brain stem and spinal cord that started causing him to have pain in his neck. And a scan revealed a tumor that was too large to actually remove. And that began our three and a half year, almost four year journey with struggling through the condition he had and the life he would be facing with it.

There were things that could be done. There was operations, biopsies that could be offered, chemotherapy, radiation. He would take some of those choices. He would decide not to take those choices. What struck me was we had over a hundred years of medical training between the three of us and my sister coming in as well as a non-medical person, and we were no better equipped than anybody else to navigate it. I started writing the book really because I had reached a point in my career when I was confident that if you had a problem I could fix, I could give you a great chance at fixing it.

But come to me with a problem like the kind of problem my father had, and I was uncomfortable and I didn't know even what it meant to be good at taking care of people, let alone actually being good at it. And getting to write was an excuse to start talking to people. It's strange to go as a doctor up to people and say things like, ìHey, can I come watch you, a geriatrician, in your office today?î or ìCan I go follow you, a patient, as you navigate things at home?î But when you're writing an article or then writing a book, you're allowed to do those things, and it was an amazing opportunity.

over 200 people, practitioners, patients, family members, as they all coped with these kinds of problems. You talk about this in the book. Very few of us like to talk about death or to think about it, and yet, as I mentioned in the introduction, the New York Times listed ìBeing Mortalî as one of the top five books to read when you need to be lifted up in hard times. Why? What is it about thinking about death in the right way that can be uplifting? The surprise to me was the people who were best at managing these situations understood that it was not about death.

It was about living to the very end and what it meant to have a life worth living to the very end or to help people, your family member, a patient, navigate coming to that space. It's shocking to me that it took me all of that time, 200 interviews, etc., to figure out the ultimate lessons. At the core of it is the fact that people have priorities besides just living longer. They have goals and purposes that are very meaningful to them, and they aren't just to control the disease.

The most effective way to learn what people's priorities are is to ask them, but we don't ask. When we don't ask, the result is the care we provide as a family member, as a clinician, anybody trying to offer help ends up being out of alignment with what matters most in their life, and the result of that is suffering. Now, grasping that, interviewing lots of folks, I saw that through the lens of people living in senior retirement communities and nursing homes, people navigating tough conditions like your father is with Parkinson's disease and other things, my own father with his brain tumor, and it also gave clarity about how to approach, how to be good at taking care of folks.

One of the people who I spoke to, a woman named Susan Block, who's a esteemed national expert palliative care clinician, she described to me taking care of her father, who had become ill with something very similar to my father facing a spinal cord problem, and she was the one who helped distilled for me that the goal of a clinician is to identify what are your priorities, and there are questions that you can ask, like, what's your understanding of where you are with your health? What are your fears and hopes for the future if things worsen?

Are you willing to endure and not willing to endure? What's the minimum quality of life you find acceptable? And when she asked her father this question, he said, hmm, minimum quality of life, well, if I can eat chocolate ice cream and watch football on television, that'll be good enough for me. If I can't, let me go, and it was the best living will ever. He was telling you, not do I want chest compressions, do I want to be in an ICU, he was telling you, here's what's worth living for me, and if you can help provide it, let me do it.

If I can't, let me go. And then it became my favorite question to people, I asked my dad, and his response was first in the early days with the tumor, what matters to me is I want to stay a surgeon. I want to keep being able to go to the operating room. And so the goals were, could he keep working? Later as he started to get paralyzed and have numbness and pain shooting down his hand and he couldn't operate anymore, then he was despondent, and it's like, I don't know what's worth living for.

And then he realized what he missed most was not operating, it was helping people. And he ended up running for district governor of his rotary club in Ohio, and getting to do good through a service organization kept him going and motivated and happy and fulfilled for the next couple of years. And then when he became quadriplegic with it, it became food and family around the table. The answer changed over time. Douglas Goldstein, CFP®, is the director of Profile Investment Services and the host of the Goldstein on Gelt radio show.

How can we get better at having these conversations? It's more of a skill than I'd understood it to be. You can't simply ask someone, what matters to you? What's your priority? What are you talking about? That understanding was distilled by Susan Block into something that we actually took in our research center and turned into a set of questions that people could ask and started training clinicians and using them. And those became the questions I mentioned, asking things like, well, what's your understanding of where you are with your health?

And then being able to progress through questions like, what are your hopes and fears? What are you willing to endure and not willing to endure? What are you willing to, what's the minimum quality of life you find acceptable? And those answers help, first of all, that help the other person articulate for themselves what matters. They don't always come to those answers with clarity at the first time. But it opens the door and I found it changed and almost physically changed my position with patients as I'm talking in the office because it suddenly felt like I'd face someone who has a terminal condition, they're deteriorating, and they want something that's going to save them.

They want to know that they're fighting and what they're fighting for. And a lot of times in these discussions, you can feel like you're in conflict. Same thing with a parent who's starting to have issues. My mother, when she got older, started to have issues where we feared she was going to have a fall. And I care about, is she safe? She wants to know, can I live? And her answer is, well, what I want is to be able to remain independent in my apartment. And what I want is for her to not to fall.

And those turn out to be the same things from a different perspective. And so now we could say, here's what we want. How do we pursue that? How do we give her her best chance to remain safe and doing well? We eventually navigated. It took time. Not driving anymore, but she learned to use Uber and Lyft. She started teaching people in her retirement community how to navigate Uber and Lyft and find the cheapest ride and also talk the delivery driver into carrying your groceries up into your apartment for you and things like that.

And then I found I'd called to go see her and, oh, she's gone into town. She's doing her thing. I found myself not in conflict with patients because we were having a discussion that was different in medical school. I was taught you lay out the options for people, the pros, the cons, the risks, the benefits of option A, B, C, D. But what I found in practice was people would always then follow up with a question. What would you do, doctor? And what I was taught in medical school and residency training is you answer that by saying, no, no, no.

That's not for me to answer. Only you know what matters to you, so you tell me what your choice is. And they feel abandoned in that moment. And what this was teaching me was there's another way of being, and that's being a counselor. And a counselor understands your goals. So now if I understand your goal is to be independent in your apartment or to gather people around your dinner table and be able to enjoy that, I can then say, here's within the range of capability what we have to offer, and here's what I would recommend based on my experience at getting you that goal you're looking at or whether it's realistic to expect it at all, and we have to think about a change in goals.

You're talking about this, about having these conversations largely from the perspective of being a physician, although you have, of course, referenced your parents. For the rest of us, do you have any guidelines that you think we should follow when we're, you know, inevitably thrust into these scenarios? Well, I'm imagining your conversation with your father. We have had it. Well, and, you know, that conversation can start with a story. This guy we were talking to talked about a man who said chocolate ice cream and football on television, and that's what really matters to him.

What matters to you? Or you start it by saying, dad, what are you willing to go through in order to achieve or to live the way you want to live? And that is a conversation I think any of us can have. And then the trick is honoring that. There are periods in time, whether it's my mom, my wife's parents, where I didn't love the choices they were making. And you know, and sometimes you just know they're ultimately the one to take risks, not you. Sometimes you're paying for it.

There were periods in time when I thought, I'm just waiting. For that crisis call to come when there's a fall down the stairs that That she shouldn't have been navigating in the first place or when my father Continued to go to do surgery Even when as his hand became paralyzed and the nurses would actually help him They'd help get his glove on and he learned how to tie knots With one hand kind of stiff and unable to do it like that That was a source of conflict saying like, you know, we this is this is just gonna be an end in disaster This is not good and needing to have that but that's you know A counselor can do that a counselor when you're in that function can advocate for and say yeah Here's why you quit cigarettes.

Here's why you shouldn't be in the operating room and Navigated and takes a few conversations, but we we we got there Mostly it felt like a burden was off my back. That's that they're living their life and trying things and Going to navigate and give them some of that chance to do that There are so many times in my life and I suspect this is true for you where you just need a little reset some little hack to get you out of a thought spiral or To help you fall back to sleep when you wake up at 3 in the morning or help you recover from some sort of temper Tantrum, you know what I'm talking about, which brings me to a little meditation challenge We're launching over on my app 10% with Dan Harris starting on Monday, September 21st.

We're kicking off a five-day Meditation challenge it's called reset and it's all about getting back on solid ground when life throws you for a loop Which is inevitable in all of our lives. This challenge is guided by the amazing Diana Winston. Who's really legendary and Fascinating and very nice meditation teacher and crucially she has crafted each daily practice to be something you can actually do in a moment Of suffering when you're struggling in some way large or small these practices can literally help you reset September 21st through the 25th reset with Diana and friends and me over on the 10% with Dan Harris app You can sign up now at Dan Harris calm I'm as worried about artificial intelligence as the next person In fact, we just recorded a whole episode and posted it recently on how to manage AI anxiety A lot of people are worried about what AI is gonna do to their jobs one thing I know AI is not gonna replace or quite strongly believe it is not gonna replace is Teamwork with actual human beings.

However, I do think there are some cases where AI agents Working with actual human beings can expedite Teamwork which brings me to one of our sponsors today notion The notion AI workspace is designed to strengthen human teamwork not replace it Notion is an AI workspace where your team's knowledge projects and agents all come together in one place teams using notion move faster cut friction and costs by consolidating tools and Staying aligned in notion your documents meetings projects and more live in one connected system where AI has the context It needs to help you do your best work It's seamlessly integrated infinitely flexible and beautifully easy to use because everything lives together notion has the context It needs to answer questions instantly automate busy work and keep work moving It's AI designed to strengthen teamwork not replace it learn more about how notion can support your business at notion comm slash happier That's all lowercase letters notion comm slash happier to try notion today And when you use our link you are supporting our show You You know this but a lot of patients and And perhaps is even more true for the family members want folks in medicine to do Everything, you know, like let's do everything we can and yet there's and you talk about this in the book There's interesting data around moving into hospice or palliative care where you're just trying to treat the symptoms So and keep people comfortable.

I have a friend just by this is anecdotal I had a friend who Was put into hospice and lived there for six years I was told he had three days to live Three days and he lived there for six years. And so yeah, just be curious about your your view on this so one thing I'll start with before I get to the research is just saying we talk about this as you know, I want to do everything and That the debate is not do we want to do everything or not?

The question is Everything for what everything that we can do to accomplish? What is it control of the disease at all costs? Is there anything you would not want to sacrifice in the course of your care, you know, my mother She died just this past year. No, I'm sorry. Yeah well, she was 89 though and she had six years with stage 4 ovarian cancer and She You know We had a clinician who asked her these questions I knew which clinicians to go to who'd gotten the training and I and I went to one who did she was great and And so, you know my mother as I said Wanted to keep her independence in her living facility.

But what but enjoyed her life and wanted to be able to to Do the things she did from ping-pong to taking walks at sunset and and so she did take the chemotherapy, but you know the the oncologist also identified that one of the drugs Causing a neuropathy a loss of sensation in her feet that could cause a fall and when she started to get that Numbness would stop that that treatment And that's what she did That she got surgery to remove the tumor Partially and that she navigated a colostomy Understanding that that was something she was willing to work to navigate All of those kinds of things but then as The treatment started to be take away things that were important to her That after six years she finally halted it she got much longer with stage four ovarian cancer than anybody would have predicted now one thing I'll say is that so the research study was one that randomized people with Incurable lung cancer stage four incurable lung cancer and randomized them to have their usual oncology care or Also see a palliative care clinician from the very beginning of their care Often people would say used to say Hey, you know, it's not time to see the palliative care clinician.

We still have options It was thought of as like a last thing you do when you run out of medical options and instead they said let's have people getting palliative care consultation right from the very beginning and They found that the group who got those early palliative care discussions and plans Focused on things like how do I maximize your quality of life as well as your quantity of life? Those people end up choosing to stop chemotherapy two months earlier than the group who were in the Regular arm just continue care as normal.

They had much better control of symptoms and quality of life. They had lower costs They were less likely to spend time in the hospital and they lived 25% longer Because when your answer to every question is well, let me just find another treatment to give let's get another operation put you on the table you're getting all the complications and none of the benefits and Losing the things that matter to you in your life when it's not planned in a way that's aligned with your goals So it isn't the question of do you get everything or do you not get everything?

It's do you? Get to choose the assets and the options and the treatments and the capabilities that Accomplish what's most important to you and your goals and at a certain point? your quality of life starts to become more important than your quantity of life and ironically Caring for that quality of life helps you live better and longer another main focus for many of us, especially as we get older is Staying independent But you have a whole chapter in the book that compares to grandparents one of yours and I would think a grandparent-in-law one who Insisted on living on her own and the other who just lived surrounded by his family Yeah Can you tell the story and also what what does it say about our our thirst for independence and they're both complicated cases, right?

So one was my grandfather who was in India a farmer in a rural village and living the way You know Farming societies have lived for thousands of years That you have an extended family, you know, the your children would inherit the farm and they'd become farmers And that extended family would end up taking care of you into your old age he continued he died at the age of a hundred and He continued to be, you know sit at the head of the table at dinner and Be the first one served he He was still continued to be largely with it.

He would still walk his fields. He You know, he died falling off of a bus when he was still wanting to do his thing He he was headed to the court to contest someone who'd failed to Pay back a loan and hit his head and You know that kind of society where family takes care with you of you and right to the end and you remain The the patriarch or the matriarch of the family Succeeded but at the cost of the freedom of your child in India in this case It's particularly the daughter-in-law the one who marries your eldest son Becomes the person to take care of you and then when in this case when they died because he lives so long you know, it'd be the next oldest daughter or daughter-in-law and and people as economies improved sought freedom for themselves young people wanted freedom and we became you know nuclear atomized families and you had the rise that you see in India now even of nursing homes and senior retirement communities and all of those things the other story was of the life and ultimate death of my wife's grandmother Alice Hobson and Alice lived for years in a home on her own Valued that independence but gradually became more and more isolated Started having some cognitive issues Someone working as a landscaper took advantage of that and had her write multiple checks To him for the same services over and over again and she had a car crash that Went into the yard of her neighbor across the street and the that ultimately landed her in a In a assisted living facility In a place that was more like a hospital than a home whenever we'd come to see her She'd always say well, when am I getting to go home?

and you'd say You are home this isn't home and understanding What does it mean to enable? freedom for young people lives that everybody wants to live and The fact that even when when adults even have their choices Older adults they often prefer not to be in the home of a child because now I'm under their rules I'm I'm I'm living the way that they insist that I live and so, you know Sociologists call it the people prefer an intimate distance That you live Nearby but just far away that I also have my independence and community and education and Goals and activities that go beyond bingo and watching television Those kinds of places exist more and more my parents are in a place like that And it's been very interesting to you know, my mother has her cat with her and is very was not particularly social as a as a You know in her prime but is very she's like the mayor of this assisted living facility and Yes is really thriving at one point said, you know, I'm this was the happiest period of her life if you get it, right I mean so many people I know so many parents of my friends who you know If I bring up assisted living, you know that it strikes terror in there in in their soul but but if you get it right in assisted living can be Fantastic.

Yes, the there's these distinctions between senior living communities that have in assisted living and nursing homes and the best way to understand it is that The the places that many people end up plugging into are ones where you can live in independent part independent apartments You can get services there Some end up needing assisted living where you are at a higher level of services and then some need full 24-hour a day nursing home assistance and Enabling those in environments that don't feel like you're in a hospital You know, I interviewed people being admitted for the first time to an assisted living or a nursing home level facility and They react that their experience was that it was like jail they couldn't have their own furniture They you know, you woke up and went to bed at the same time every day You know, you'd wake up you'd get changed by an orderly They'd be you'd get in the pill line you'd go eat, you know what you're told to eat and That has evolved considerably but not consistently many many places are quite different from one another my mother for example, was in a senior retirement community located on a college campus and She could take courses in the college with the students and as she was a former pediatrician So she loved the connection to young people the young people worked at their Center Sometimes, you know, some of them were learning physical therapy students some of them were staffing the cafeteria some of them were involved in activities and vice versa and She started a ping-pong club every day and I remember walking in one day to pick her up for lunch and The group was all bursting out into tears laughing three of the four were at various stages of Dementia some cognitive significant cognitive impairment.

My mother had mild cognitive impairment. Nothing. Nothing near dementia and And and she I finally got said, you know, what are you guys laughing about? And my mom said none of us can keep the score I'm the only one who can keep the score but I can only keep the score if I call out the score every time at the end of every point and I forgot to call out the score at the end of the last point and Now we're lost and what it brought home to me.

I You know if I answer the question, what what what are my priorities? You know what? What's a minimum quality of life? I'd find acceptable. I would have said Anything that would give me dementia is not an extent acceptable life and here were Here one of her best friends had significant dementia But she was having joy in her life. She could enjoy and play ping-pong You know Enough to have fun turned up every day And had lots to talk about with my mom didn't necessarily remember everything and my mom loved her and she loved my mom and that was a Extraordinary lesson to me and she wasn't you know imprisoned.

She was in a place. She actually Felt was her home Most of us can remember being about 15 and feeling completely invisible or worse Extremely visible, but for the wrong reasons I remember one here when I was a teenager I had a pimple in the crevice of my nose for the entire year I didn't like that either way Even if we have painful memories of that age Most of us tend to soften it in memory and it was actually harder than we remember it now That is the territory of Carrie streaming October 7th on prime video the first ever Television adaptation of Stephen King's Carrie eight episodes from Mike Flanagan with Stephen King as an executive producer Flanagan had described this show as a tragedy It's about a girl who doesn't feel seen by anyone and about how small everyday acts of unkindness Compound into something nobody meant to cause which happens now at a speed and scale that would have been unimaginable Not long ago What I really appreciate about the show is that the show takes Carrie Seriously as a person rather than as some sort of symbol and the season keeps circling around one major question Are you watching the making of a hero a villain or something more complicated than either of those options?

Carrie is streaming October 7 only on prime video This episode is sponsored by better help if I could wake up tomorrow and be better at one thing it would be having a calmer less anxious and nervous system so that I could enjoy my life more I have made Massive amounts of progress in this regard in the past 20 years as a result of meditation and therapy and getting better at tending to my interpersonal But it's really a never-ending process hence the name of the show 10% happier as I often argue that 10% compounds annually Better is a feeling defined by you and for better help.

It's a better help therapist who really gets you It's a focus on global emotional well-being with thousands of therapists and millions of members in over a hundred countries It's progress and it's also getting better at regulating your nervous system Sign up and get 10% off at better help.com slash happier. That's better help.com slash happier I'm relatively new to the glasses game But my wife has been wearing glasses and contacts her whole life and she has long struggled with the many arduous Aspects of simply getting a good pair of eyeglasses and she's been struggling with that for a long time So I'm going to give her a little bit of advice on how to get a good pair of glasses There's not only the shopping for the eyeglasses and all the expense of purchasing them But then there's also eye exams now comes warby parker, which is making the entire process much easier Including the eye exams themselves now, you can actually go into one of their stores and get an eye exam right there No running around to multiple spots.

No guessing if your prescription is even up to date Everything is super clean modern and honestly feels more like a wellness experience than a typical eye doctor visit And of course if you don't need an eye doctor visit, you can just purchase warby parker eyeglasses online Which my wife has done many many times She has many pairs of warby parker glasses and swears by them And she is as i've said before on this show a very very discerning customer right now Buy one pair of glasses and get 20% off any additional pairs at warbyparker.com slash happier That's 20% off any additional pairs when you purchase one pair at warbyparker.com slash happier It's now been More than 12 years since you wrote your book being mortal.

Where are you in terms of processing your own mortality? I'm now past 60. So that was a different place than when i'd written a book at in my mid-40s And I would say uh, you know when we looked for We moved to dc for work in the in the last administration And we actually decided that we would look for a place that's on one floor Just in case we're staying long enough that we should age and want to you know, make it make it convenient But I would say i'm still you know at age 60 the average American Who has access to health care access to good public health as well?

Will live 90 years on average so i'm aware on the one hand that i'm on the back end uh of the of the age curve but living my life still as The way you do when you think you have an infinite amount of time Um, I have plenty of things i'm ambitious about trying for etc But laura carson since the stanford Researcher that I wrote about has followed people as they age or as they became ill She started her study in 1980s as the aids crisis hit and it included people who suddenly became Ill with hiv aids at a time when there was no treatment available and they had a death sentence and what she saw was people who are older or facing their mortality Behave differently than younger people Who have a long time ahead of them younger people?

Will prioritize spending time with going to a nightclub on a friday night and hoping to meet new people will focus on their job opportunities acquisition of contacts income Homes, you know your status in the world And as we get older You think you're going to become unhappier you're going to become Depressed in fact as you get older anxiety and depression decline um, you develop capacity for a wider range of emotion like um, there's a the bittersweet sweet feeling of uh of nostalgia being able to live with uh You know a contradictory sense of things being bitter and sweet at the same time um and you tend to Close your circles more You focus more on family the closer friends you have relationships And less on those other things and the interesting thing was Uh during this study That's the pattern you saw even when young people became sick.

It wasn't a brain development thing. It was a perspective It's whether you had a perspective that you had A shorter amount of time or essentially an infinite amount of time and if you had less than 10 years Then you felt you had a shorter amount of time if you had more than 20 years You basically acted as if life was infinitely long And you really fell into these two categories, but there would be moments that came during the study 9 11 happened And they were doing the study in hong kong and the SARS epidemic happened And at that moment everybody reverted to a Life is fragile approach You they wanted to go home instead of hanging out in the nightclub.

They wanted to see family they cared about Pulling together and what really matters and they were actually relieved of some of the Anxiety depression things like that um, and then six months later they were back to How we live and so i'm in the um i'm still in the stage of Trying to do stuff going on a podcast with you um You know, I still have things that I i'm excited about and interested in Solving in the world and trying to address and new things. I want to try and new people.

I want to meet But I am You know transitioning to also nurturing these friendships that that have gone on now for 40 50 years of my life and Uh make time for staying close with them just came back from a week summer holiday that we take with five other families where we've been gathering together for 40 years and Those things start to matter more and more where I was kind of you know liable to blow it off a couple decades ago it's so interesting that you can write a whole book about mortality and still Kind of in the back of your mind, even though you know, it's irrational feel like you're gonna live forever because I don't have evidence every day of my mortality I have things that you know, they're Different from my 40s.

I'm aware that i'm having losses that i'm not Gaining things back. I'm not as fast as I used to be. I don't think as fast as I used to think and Finding ways to compensate for those things Um, i'm an avid tennis player and i'm now having to change my game considerably at 60 um where you know, I was Power and to some extent speed And now I have to be much smarter And I think I actually played better than I used to and i'm holding my game up at least By playing smarter.

It's such an interesting kind of bug in the human operating system that like We know intellectually we're going to die, but we we don't live like it, you know, I think there's a great line in the indian epic the Mahabharata, I think that's how you pronounce it and the the line is one character asks the other what's the most wondrous thing? in the world and the other person says that we're surrounded by aging illness and And death and yet we don't think it's going to happen to us What do you think that's about well, I mean the average lifespan of human beings Right into the beginning of the 20th century Was to your mid-40s?

And the fact that we doubled the human lifespan worked against nature And now we're living beyond our nature And in that period we have an extended range of being able to live with fragility and our management systems our internal biological management systems are made for expecting demise to occur fairly rapidly once you start having aches and pains and limitations and and you know a cardiac condition or a lung condition whereas now You can live decades with all of those things And live a much higher quality of life than ever in history Uh, and so we adjust our perspective Based you know, what really laura carstensen's work showed is that we tune our perspective based on the evidence of whether we're actually mortal and fragile and when we don't have immediate evidence of our own mortality when you're not waking up and Every few weeks realizing your cancer is progressing or your your heart disease is Bringing you to an end stage then you have purpose in things that you do live for and that's what that's why those questions matter one of the things I argue in the book is Everybody has a loyalty Something that they're willing to sacrifice themselves for even die for That um that matters to them And that might be your kids it might be an idea it might be a project an accomplishment it might be beauty religion Getting to serve figure out those things and then serve them Is what matters and can matter all the way to the very end and I think in our As we get older and get to live these long much longer lives than human beings had We get to serve purposes like that for much longer periods of time What are your purposes?

You know, what would I really sacrifice myself for my family for one my children my wife my sibling my sister number two, I would say is i've found purpose in Trying to make the systems around health better. I've been fascinated for my whole career around the idea that we have learned how to double the human lifespan, but don't know how to deliver it affordably, effectively, give people these opportunities to achieve their loyalties. I'm interested both in the human experience and how we make our systems more effective at addressing those kinds of problems.

And a lot of my work and jobs is sort of at that public level of making our systems better and more effective over time for solving these problems along the way. Those are my two big ones. For whatever reason, I get a lot of pleasure and joy out of whacking a little yellow tennis ball around a square box. And that also goes right in there as one of my priorities. I can't figure it out, but I'll do that for hours. I buy it. I get tennis elbows, so I can't really do it, but when I get a chance to do it, it's very fun.

And you're doing it with other people, you're moving the body, all those things feel good. I've been talking with my friends that there's ball people and non-ball people, I've decided. The ball people can't make any sense of people who wanna go biking three hours up a mountain or endurance running or any of those things. Runners, put me 10 minutes down a road, I'm like, what the hell am I doing? Why am I doing this? This seems crazy. But then they say, the non-ball people say, why are you chasing a little yellow tennis ball around?

What keeps you going for two and a half hours doing that? And the ball people just like throwing a ball in a basket or hitting one over a net, that talk about strange wiring. Both of those are bizarre. I'm non-binary in this regard, I like both. You do both, so there are people who are both, huh? Yeah, I mean, I do much more of the non-ball stuff because I have so many injuries that prevent me from playing tennis or doing other things, but I would, if left to my own devices, I would liberally do both, speaking of aging.

We're about to leave on a family beach vacation and my wife, in an act of kindness and generosity, went on quince.com and ordered me some more of my favorite shorts, so I'm never out of shorts to wear. A couple of weeks ago, I got this pair of shorts from Quince and I've just been wearing them all the time, so now, thanks to Bianca, I've got three pairs, which I'm very excited about. Quince focuses on high-quality wardrobe staples made with premium materials like 100% Mongolian cashmere, organic cotton, and merino wool.

Their styles are timeless, versatile, and designed to become the dependable pieces you reach for day after day. Their 100% Mongolian cashmere sweaters start at just $60. I think I have three or four of those. They give you the softness and quality you would expect from a luxury brand without the luxury price tag. Quince also makes premium pants, fitted tees, I've got a bunch of their t-shirts, and also polos and breathable activewear, quality basics designed to work across your wardrobe and hold up to everyday wear. Everything at Quince is priced 50 to 80% less than similar brands.

They work directly with ethical factories and cut out the middlemen, so you're paying for high-quality, not brand market. Find your next fall favorites at Quince. Download the Quince app for app-exclusive offers or go to quince.com slash happier. Get free shipping on your order and 365-day returns. Now available in Canada and the UK too. That's Q-U-I-N-C-E dot com slash happier. If you're a loyal listener to this show, you know that I am an avid worker-outer, and if you are gonna exercise on the regular, one thing you need, it's a non-negotiable, at least in my opinion, you need quality socks.

You can't skimp on your socks. And one of the sponsors of this show is Bombas, and they've been sending me these socks that I use when I work out. Not only when I work out, but also when I'm out in the world just wearing sneakers and I want some good-looking socks. I go to my Bombas on those occasions as well. It's become a little bit of a source of marital discord because my wife and I compete for the Bombas socks, so that's reminding me I need to go order some more.

Long way of saying they make high-quality socks, but that's not all they make. They also make footwear. Do you know what EVA stands for? Neither did I, but Bombas makes their sandals and slides from this super lightweight, cushy, waterproof EVA foam. It's like walking on marshmallows. They also make underwear and t-shirts, the best base layers you'll ever own. Head over to bombas.com slash happier and use the code happier for 20% off your first purchase. That's B-O-M-B-A-S.com slash happier, code happier at checkout. After the book, you moved to Washington, as you mentioned, and you were running USAID, which is, for people who don't know it, one of the soft power wings of the U.S.

government where we spend money to help people in other countries. And we've just lived through a time where the Trump administration gutted it. One study from The Lancet, I believe, said that this, conservatively, has probably led or will lead to tens, if not hundreds of thousands, of unnecessary deaths. I'd just be curious how you're processing all this, what your thoughts are, how you think we should think about it. Yeah, and my role there wasn't leading the whole thing. I led the global health work of USAID, which is one of its biggest areas.

My observations all stem from why I even took the job in the first place. Much of my work that I'm excited by, including this work around aging and the end of life, is around making it possible for people to get the benefits of everything we have discovered to enable a longer, better life. And one of those gaps comes from simply poverty in the world. The lowest income places in the world have half the survival rate of other places. And getting to USAID and getting to lead its global health work turned out to be the best job in medicine I've ever had, and likely the best job in medicine you've never heard of.

I had 3,000 people in 65 countries and Washington, D.C., employing on the one hand what seemed like a lot of money, $8 billion a year. On the other hand, it was about half of my hospital budget in Boston, $22 per American taxpayer out of $15,000 in the American tax bill. But with that, we were reaching hundreds of millions of people by strengthening systems for vaccination, for reducing deaths in childbirth, for addressing HIV, malaria, TB, for fighting outbreaks and preventing those outbreaks from reaching home. And the result of that has been documented to be over the last 20 years, 90 million lives saved.

In the countries where we worked, we cut the child mortality rate 32% and the overall mortality rate by 15%. It was great for the people we were serving and supporting. It strengthened countries to get onto their own feet. And I saw this in India where my parents grew up and where I would visit as a kid. Not only did we give food aid, but we provided the technology, scientific training and so on for what's called the Green Revolution where India went from a food recipient country to the fourth largest exporter of food in the world, feeding the rest of the world and not only itself.

And those kinds of accomplishments I got to build on. It was incredible as an experience. So to come out the day that I left, noon on inauguration day as the great American tradition, and the election changed the president and we peacefully handed over power and responsibility to the Trump administration. And then within hours, Trump had signed an order to freeze and halt all of the work of USAID. Like overnight, a complete dead stop. Food aid left to rot in warehouses, medicines on the shelf not allowed to be used, staff pulled out and sent home.

I've been bearing witness to what has happened. It was on an argument that USAID was a criminal enterprise, was corrupt, didn't accomplish anything. And what's difficult is that was just a lie. The work immediately had consequences. And there have been now two different estimates that have put it in the ballpark of about 700,000 lives lost in 2025 from the shutdown of everything from HIV drug distribution to TB programs to outbreak prevention and surveillance. So we are still in the bomb blast radius. There is more ongoing damage.

There's some of the work that has come back. Then there's been a strong backlash, not only from liberals, this has been a longstanding bipartisan supported effort over 60 years since John F. Kennedy formed USAID. And I don't think it's for nothing that on the one hand, there's been a cut of $40 billion for overall assistance to countries, but a rise of half a trillion dollars in the war costs that we have because we've walked away from the idea that we offer a helping hand first before we show a fist of domination to how we approach the world.

And it's not only unpopular abroad, it's unpopular at home. We see America as being a force for good in the world. USAID was one of the ways that did that and people want to have those kinds of efforts continued. So the Republicans and Democrats came together to vote a budget that restored funds for foreign assistance and keeping the shell of USAID intact. The administration is not necessarily gonna spend that. They have held that funding back, but we'll see what happens. One last question from me before we get to our final segment.

What's your take on AI in medicine and how we as patients should be interacting with AI if at all, when it comes to our health? The best description I've heard is to say that AI is not gonna replace your doctor, but doctors who use AI are gonna replace doctors who don't use AI. And as an intelligence at our side, I already see the ways that it can be dramatically useful. Most of, many clinicians have adopted AI. They call them ambient scribes that will record and do your note-taking for you.

And it's reduced the time that doctors require to write their medical notes and spend more time with patients. You'll see patients getting more, people turning to AI can get better information and more clarity. Taking it as gospel is a bad idea. I often, when I'm asking questions of an AI bot, will ask multiple ones so that I'm triangulating among different sources. It might be Claude, it might be Gemini, it might be open AI. So I think there's important value that AI is bringing and not seeing the signs that AI is different from other technology breakthroughs that have come before.

We have had technology breakthroughs that gave us the GLP-1 drugs, for example, for controlling obesity that have replaced surgery for ulcers with a pill. And AI is gonna be another one of those things. It might be very soon the best reader of your mammogram. It may be the best initial diagnostic for some dermatologic conditions. But knowing which ones it's gonna be the best for, which ones it's not, and what to do now based on what it's advising, how to deal with the risk of being wrong, et cetera, those are still things that you wanna have a copilot with.

And I'd want a clinician who uses these capabilities alongside. And as a patient, I want to use this kind of information with people I trust as clinicians. A lot of promise, a lot of peril, a lot to be figured out. Let's do this, we've been doing this closing segment. We're just a couple weeks into trying this. It's called What's Good? And we just ask the guests, what are you excited about? And it could be a book, movie, record. Don't say anything in tennis. You've already used up all of your tennis chits here.

Could be just some little practice or habit you've formed in your life. And then I'll give you one from mine. The first thing I thought of was the lunch I had today where my wife has showed me that if you put chimichurri on a ham and cheese sandwich, it's amazing. And it is amazing. So there's that. That sounds disgusting. What are you talking about? It's absolutely delicious. But life is good right now because I've finished my first draft of my next book. I've got a cool project we're working on to find new ways of addressing our shortage of mental health beds for people.

Like this, you know, I just get excited by I still get excited by things like that and a little chimichurri what's the next book and I haven't learned how to describe it really adequately, but The topic is how minds change So, how do people change their minds about things? We've at a time when we feel kind of hopeless that anybody is going to change their minds. It is Mining and understanding. How did we do things? Like we got we got cigarettes out of bars and restaurants and airplanes We have solved many problems and are in fact solving continuing to solve many problems and And and so, you know, it's understanding how people actually get things done in the face of resistance Including things that I've tried to get done.

There's many failures. I talked about along the way as well, but That's the next book. That's fascinating. Will you come back on when the book comes out? Yes, I'm gonna hold you to that It's not so probably till the end of next year, but I do have the first draft on great congratulations, I I'll give you one from my side. It's a TV show that I just started watching with my wife called furious. It's on Hulu. It's Incredibly well done all of the performances are Just incredibly powerful, but the the writing and the the subject matter are very powerful It's really about female rage.

It's about female rage it's about a female serial killer and the female cop who chases her down and In that set when I first heard the conceit I was like, I don't know but actually it's extremely well done Not again, not only just on the level of the performances, but on the issues it It explores Elizabeth Meriwether is the woman who? Created and wrote it. She wrote a she also wrote and created a show called the dropout which was about What's the name of that woman who had that?

bullshit blood testing company Elizabeth Holmes. Yes. Yes So she she did that when that one like all the awards a couple years ago Now she's back with furious and I Annoying my wife because as we watch it, I just keep saying this is so good. This is so good. That's amazing Well, it's a good that's a great recommendation. I always end up watching these You know mainly cop shows especially British cop shows and watching this Irish well Northern Ireland Irish cop show called blue nights now which is blue nights or blue lights Blue lights, you're right blue lights.

I've been meaning to check that out. It's harrowing But it is I'm I'm completely absorbed. I might use that on a future. What's good segment after watching it? Such a pleasure to finally meet you again You heard about you decades ago and have read you in The New Yorker and it's great to meet you And I really appreciate your time. Thanks for having me on look forward to it again One last thing before I let you go if you want to listen to this show without ads check out 10% happier plus Which is a subscription that is available right inside Apple podcasts If you become a subscriber, you'll get every episode ad free That's new episodes and all the episodes from our vast 10-year plus archive Look for 10% happier plus in Apple podcasts and just hit subscribe And a quick heads up if you're already a subscriber to my app 10% with Dan Harris You've already got access to ad free podcasts ad free listening is baked right into your app subscription along with everything else So, please don't pay twice You can check out the app at Dan Harris comm and you can check out 10% happier plus inside Apple podcasts Thank you very much for listening to the show.

I deeply appreciate it. See you soon deuces Thank you so much to everybody who worked so hard to make this show 10% happier is produced by Tara Anderson Marissa Schneiderman DJ cashmere David Hart and Hayden broom our recording and engineering is handled by the great folks over at pod people and Nick Thorburn of the indie rock band islands wrote our theme. Thanks for listening. Peace Insurance is not one size fits all that's why drivers have enjoyed progressives name your price tool for years now With the name your price tool you tell them what you want to pay and they'll show you options that fit your budget So whether you're picking out your first policy or just looking for something that works better for you and your family They make it easier to see your options visit progressive.com find a rate that works for you with the name your price tool Progressive casualty insurance company and affiliates price and coverage match limited by state law Tires matter.

They're the only part of your vehicle that touches the road tread confidently with new tires from tire rack Whether you're looking for expert recommendations or know exactly what you want Tire rack makes it easy fast free shipping free road hazard protection and convenient Installation options go to tire rack calm to see tire test results tire ratings and consumer reviews and be sure to check out all the special offers tire rack calm the way tire buying should be on deck is built to back small businesses like yours whether you're buying equipment Expanding your team or bridging cash flow gaps on decks loans up to four hundred thousand dollars make it happen fast Depending on certain loan attributes your business loan may be issued by on deck or Celtic Bank on deck does not lend in North Dakota All loans and amounts subject to lender approval Listen up prep is for anyone sexually active anyone you care plus has my back Come visit us at qcare.com.

We'll see you next time Convenient labs and medication delivered discreetly Get in line behind plane change She's gonna be the first one at the clinic Get your prep and doxy pep at qcareplus.com