Atul Gawande has written four books and countless articles for The New Yorker.
When you think about doctors who write well, he's gonna be the first person who comes to mind.
What's unique about him is that this isn't something that came naturally to him.
The work of research writing editing, shaping sentences, telling stories.
Those are all things that he taught himself.
He's a surgeon, so intense, so demanding, and he's still been able to write as much as he has.
How has he done it?
What has the discipline of writing for him been?
That's what this episode is all about.
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All right, let's get to the episode you gotta tell me.
So how describe your sort of as Tyler Cowen would call it, the Atul Gawande production function?
Like you have just done so many things.
It might've been the thing that surprised me the most in the prep is all the different sorts of things that you've done and how have you persistently marched forward as a writer.
Um, but then also in building your career, there's just a sense of discipline and dedication over many decades.
Well um, a friend of mine said uh, that the advice he often gives is uh, and I realized this is what I've done all my whole life.
Um, say yes to everything before you're 40 and say no to everything after you're 40.
So by that he meant, um, before you're 40, you don't know what you're good at.
You don't know what you're energized by.
And the world is changing.
Like when I graduated from college, there wasn't, you know, the internet wasn't a thing.
Um, and like, like it would become the, you know, fortunes made, uh, it and jobs that many people have today are you know simply don't didn't exist it's not like you train for them so trying lots of things that you know you're curious about or potentially interested in allows you to figure out if you pay attention oh here's what you know the parts of it I'm energized by here the parts of it that exhaust me and and so I and then just maximize for your energy and that's what i was doing so i worked on the hill i had a band i worked in some labs i um you know started writing for my friends you know his his internet magazine i went into an operating room and was blown away and uh and i pieced it together and i found there were three things i ended up doing that did not make any sense um i was learning how to do surgery.
I had this longstanding interest in policy and public affairs that ended up focusing on advancing health for the overall population public health and health systems.
And I found writing and the theme that emerged.
So by the time you're 40, you should know those things.
What are those things for you?
And that you say no to everything else, because Now the bet you can make is I can work at these things for a long time and know that I care about them.
And so, now that I'm 60, I've had three decades of a fascination, and I'd say, an obsession, with Seeing the, seeing humanity through the eye, through the eye of health, the science, the art, the practice, the expertise, the experience of being a person in the world where we've discovered how to double human lifespan but we haven't learned how to make it available to everybody, how to deliver it reliably, how to make it affordable to societies, how to help people navigate their way through getting the pieces of it you need and dealing with its complications and its impact.
You know it might be different things I've been doing, but they're all.
They're all illuminating something new, at least for me, Whether it was a surgery practice, the work I did in government and public health.
You know I started 25 years ago researching how can we improve outcomes at population scale and surgery, got this work with checklists and systems to replace Systems that were mainly about improving through punishment and training to now how do we build for systems that can make it easier for people to do the right thing and harder for people to do the wrong thing?
And so the net result has been it can look like I've been all over the place.
I got to ask, why would a surgeon write?
It seems so separate and it probably doesn't seem like the most financially prudent way to spend your time, but there's definitely something deeper.
You take this craft very seriously.
Well, I came to medicine very naturally.
I did not come to writing very naturally.
I wasn't born a writer by any means.
So it was after I was in surgery.
A friend of mine started an internet magazine, and it was Slate Magazine.
At that time,
Slate, okay.
So it was 1996, Netscape Navigator Days.
And he was not getting paid journalists to come and write for something that was a shot in the dark.
And so he'd ask his friends, could you write?
And so I started writing small pieces for him.
These were like diaries, right?
Yeah, the very first thing I did was just a, just a diary, you know, like um he'd gotten, they'd gotten Beck to do one.
And so that, uh, and he did an amazing one.
And I thought, and then he asked me if I'd do one from just being on on surgery duty as a uh, as a second year resident uh in surgical training.
And, um, and so that was, you know, almost stream of consciousness.
Um, just taking notes at the end of the day, firing it off.
You know We didn't have a word for what it was then.
It was essentially a blog.
And then he asked me to do some more pieces.
And that became an outlet for me.
What I noticed about it was that I was getting home from you know my day in residency and making time, making an hour and a half, a couple of hours to be researching a piece or to be writing.
And that was just a signal to me that it was that was finding energy instead of exhaustion from doing it.
I, you know, my first pieces were not that good.
There's lots embarrassing about them.
The metaphors were overwrought and clashed and all of those kinds of things.
But I was, but I learned every step of the way like um, you know, my friend uh, his name's Jake Weisberg um would tell me all right, this is what you're doing well.
This is what you're not doing well.
He was like an editor of sorts.
He was being an editor.
Cool.
Yeah.
And so, yeah.
And, and then would say, you know, do more of the first, do less of the second.
And then he'd hand it back to me and I'd say, what's this for?
He said, you know, to, to rewrite.
I'd never rewritten a thing in college.
Like, I never heard of it.
Like who rewrites anything?
And that's, you know, was the opening into you know, when I got, a couple of years later, a chance to write for the New Yorker, that was 22 rewrites.
And, you know, I, I had to, I built up some tolerance for the process.
22 rewrites was the first New Yorker post that you wrote.
Yeah.
For the first New Yorker piece about 4000 words was uh had 22 back and forths, five complete rewrites.
I thought it would be a couple-month thing.
It ended up being nine months.
But, you know, it just kept getting better.
Did you want to slap the editor in the face or were you like, I respect this?
So every time filled me with anxiety because I was like, okay, I'm done.
I've got my surgical training to do.
And so this is great.
And then he'd come back and say, well, there's a little more of this or a little more of that.
How about adding –
You know, I want to see.
I got to see.
But every time I was learning something new that was making it significantly better.
So I couldn't really object.
You know, I wanted to tear my hair out, but it was more that he kept finding stuff that could make it better.
You know, it's crazy.
And this is going to be one of the themes of the conversation, is when you talk to people who run companies, who are doctors, whatever it is the most –.
The most common excuse might be I don't have time to write.
You have blown that excuse out of the freaking water.
Like four books, who knows how many New Yorker articles.
How are you able to do that?
Like you got – you don't just have a nine to five.
Like you got a serious job that doesn't just take a lot of time but demands a kind of cognitive awareness and intensity, and you're still able to do it.
I look back on my residency and I wonder how I did it, because it was – and I really think it was just as simple, as the basic principle I followed is if it gives me energy, I want to do more of it.
And if it exhausts me, I do less of it.
And the writing gave me energy and surgery does and some of the research stuff I did.
And so I just kept – moving each ball a little bit forward along the way.
I wasn't trying to write insane amounts.
I set a goal of 30 hours a month.
And most of what I was writing was putting in 30 hours a month, like an average of an hour a day.
That felt doable.
When you say average of an hour a day, was the median an hour or was there high variance?
High variance, right?
So getting an initial draft down on paper would be just whatever time I could grab to do some basic research.
In those days, there was a lot of turnover time in the operating room.
You could wait an hour, hour and a half between cases sometimes.
And so I could get a slug of just reading stuff, get some weekend time and put a few hours into just getting it down.
And those initial days was writing and 800 word piece for slate, my first piece for the New Yorker.
I was doing like one or two a year for the first couple years and as I was getting to the end of my surgical training and then I had more control over my time and as I entered into practice I started reserving time for it, you know, and I'd be able to chunk out bigger blocks and and try to make that, make that happen.
But you know my First book was 2002.
So it's about a year before I finished the training.
And that was a collection of essays.
Two thirds of them had appeared in the New Yorker.
I had to finish out one, you know, one third more.
And when I signed the contract I remember I laid down on my living room carpet and just I had to, had just breathing heavy, saying like what the hell did I just do?
Because I don't know that I can get that. chunk of those extra essays written in that time.
But we made it.
My agent talked me off the ledge and just pushed through.
And then with writing for The New Yorker, how does it work with The New Yorker voice?
Because The New Yorker voice.
I can't think of a magazine that has a more distinct voice and style.
But then you're a tool, right?
So how do you think about the similarities, the differences, the reconciliation of those two things?
Well, you know, I always felt like I was simply using my voice and I didn't feel like I was needing to.
I think I either just had read so much New Yorker than I had imbibed it.
But but you know, trying to be very crisp, very clear, not really long sentences be as vivid, visual as I can.
But also, it's all about the argument.
Like how I'm, how, you know, do I have a sound argument?
I'm making and a story I'm telling that illuminates that case.
So, um you know, the editors definitely uh, and my editor there, Henry Fender, who's amazing, um you know, is definitely sort of raised me and coached me in my writing.
So I'm sure I imbibed a lot of the way that, that they're right.
But how?
What would you describe as the New Yorker uh style that is different from what you see elsewhere?
I always think there's going to be a flair.
I don't know why that's the word, but there's a flair.
There's a pizzazz.
There's kind of a swagger to the New York style or the New Yorker style.
It's, you know, you're talking about clear sentences aren't too long.
And a lot of times you get a kind of dryness from that.
And I do not think of the New Yorker as being dry.
I almost think of the kind of walk that, like a West Village girl, kind of like struts through New York City and the kind of energy that's sort of embodied within the Within that, while also having a sense of direction.
Somehow the New Yorker has that with like a little touch of like the cartoonish New Yorker humor that goes back to the very early New Yorker covers.
Well, what you're getting at is I was allowed to have a voice in a way that I wouldn't have if I was writing for The New York Times or writing writing elsewhere, so I could tell jokes in the middle of it.
You know, like I always I a little gold, especially if it's one i'm telling about a surgical case or a.
You know something.
You know i wrote a piece about the called the itch, about a woman who had a uh, an itch so severe uh on her forehead that she scratched through her skull and injured her own brain.
What and the whole goal was tell this macabre story, have it, illuminate something about the brain and how it works and sensation and what philosophically that meant.
And make you itchy.
Like, well, that was one of my goals.
I wanted to make you itchy.
And like, I wouldn't have had that opportunity somewhere else, right?
I'm trying to use techniques that are typically associated with fiction writers in a reporting piece that is telling a story.
And, you know, that is... that may be a kind of New Yorker style, right?
That I'm, I'm trying to tell a well-written story.
I'm trying to grab you often around subjects that are, that one's really sensational, right?
I could be writing about washing hands.
Like one of my.
One of my earliest pieces was about, you know, 2 million people who get infected in hospitals because someone doesn't wash their hands.
And just the, the prosaic story of hand washing and the.
You know those are interesting examples because I want to get into the idea of entry points right.
Like that first one is something that makes your eyebrows go up like, whoa.
And then the second one makes me want to read it because it's very important.
It's super simple.
And then the question that I was thinking about is why don't I wash my hands sometimes, even though it's obviously so – proven to improve my own health outcomes and other people's too?
Yeah.
And then you get to the behavior.
It's like important, you know?
Well, and if you're in a bathroom, you know at the airport, if someone is standing there, you are more than double more likely to actually wash your hands, as opposed to if no one is standing there.
That's true for me.
Also, you know it's true for me, as I'll look at other people and I'll be like you didn't wash your hands.
What the heck is wrong with you?
And I will literally not wash my hands after going to the bathroom.
Like, 45 seconds later, probably TMI, you know?
Exactly.
Don't come anywhere close to me.
But you know, I think about this a lot because I don't know why I'll sometimes get annoyed with washing my hands, but then I'll read the numbers on it.
It's like, what are you doing, dude?
It's such low-hanging fruit.
Yeah.
Yeah.
Well, it's the problem of an action now for the sake of an invisible delayed gain later that is – you know, low likelihood, but significant.
So you know your likelihood you will get a cold or a flu when you're traveling through the airport or when we finish.
You know, from shaking hands with each other today is, you know, not insignificant.
So washing your hands a few times a day.
I washed my hands 25 minutes ago.
No, there you go.
Because someone else was watching, you know.
Okay, tell me about the entry points.
Tell me about the entry points, of how you think about.
Okay, you have the core argument and that's the thrust of the piece.
I could say
And then you have the, almost the framing of the piece.
Is that how you think about it?
Well, I mean, I keep a list of, uh, potential ideas for articles.
It's the same list that is about um, could be about research, but also is about uh, story ideas for the New Yorker, or might even be book ideas.
And, um, and I've kept that running list for, for years.
It's, it's past 400.
So like an Apple note?
Yeah.
An Apple note.
And uh, many of them sit there and don't have any legs because it has the.
It's either a cool story with no larger frame of meaning.
You know, like you see lots of dramatic things.
Someone died, someone had you know uh, a really interesting article that signed something you know, the woman who had, who had the itch.
I read that as a case report and that went down in my my notebook, as that is a.
That's a cool story.
But, I didn't have anything like, okay, why is that interesting?
What makes that work?
And when I then either think of or read something that connects up with that, now that goes into it, and now I have it right.
I need both.
I need the meaningful narrative, the story, the meaning, the philosophy, the abstract concept, the mental model or idea, the vehicle.
That's the story that can Make that, make that move.
And then what?
Then it can be an opening that starts with the idea.
You know Two million people picking up infections in hospitals per year, back when I was writing that article I think it's down, but it's still a lot of people and and then I had the.
The vehicle was a following, along with the woman in my hospital who leads infection control and her whole job is trying to keep people washing their hands.
And she's like I don't want to be the hand-washing police, like I didn't go to medical school to be the hand-washing police.
And, And you know, following her in her job, Purell was just coming out.
You know, alcohol-based hand rubs.
So it was like changing her life and so I
There are several turns to the story now that made it really compelling.
And the opening could be her.
It could be a confrontation.
The temptation is always to start with a very dramatic story case.
And then it becomes a very predictable.
Well, it's funny, right?
Because this is one role of the writers.
You could say that humans have a against boring bias in terms of.
What we're inclined to do and not to do, what we're inclined to think about and not think about.
And there are so many Things in the world probably in health more than anywhere that are kind of boring to talk about, boring to think about, But if you actually get people to change their behavior, to talk about it, huge improvements to society.
Yes, the thing is is we also have a bias not only for not boring but also for not predictable.
And If you read, you know in a book I write every chapter opening with a.
You know he was in the emergency room.
You're going to notice the mechanics at work.
And so sometimes you start with a surprising idea.
Sometimes you start with setting a scene.
And I had to learn that.
You know it took a lot of time my editor would talk about, like he'd literally talk about.
You know, this one is an O, meaning we're starting.
It's where it ends.
It's gonna start where it ends.
And you know, this one's more like a W.
We got three peaks and we're gonna work our way through and we're gonna advance from left to right.
One of the things like in surgery in an operating room, you're trying to do as much as possible.
The same thing every time.
You're not trying to be creative.
You're trying to be like you're at the free throw line and you're trying to make every move so you're sinking.
99 out of 100, 100 out of 100.
I'm not making, I don't want to change the game.
And in writing.
Part of what's attractive about it is that's the space where I'm constantly trying to do something new every time.
And it gets harder and harder as time goes on, in some ways because you use up your tricks and you've got to figure out.
How am I going to make this time different?
Do you ever think about being a full-time writer and leaving medicine or was your calculus always –
No, I can write better stories and have more impact if I stay in medicine, you know, if I keep the blade in my hand, so to speak.
I think it's a reflection of my lack of confidence, that I'm afraid of giving up anything else and just relying on you.
Know what's what?
The experiences I've had?
I mean, amazing writers are, you know, drawing on almost no added experience outside of their writing.
But I sort of feel like the well will dry up.
What will I have to say if I'm not out there trying to do something in surgery and public health and research and something that gets me out of my comfort zone?
Trying to challenge learn, do new things?
The biggest lie that writers will tell themselves is, ah, I'll remember that later.
No, I mean, There's so many times when I'm listening to a podcast that want to save something and I just never end up saving it, because typing it into the phone is just too much work, you know.
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All right, let's get to the interview.
And then when you're writing for The New Yorker, how do you think about integrating the timeliness of a piece?
This is in the June 2022 edition with the timelessness of a piece you know i go back and i i would actually say the median new yorker piece i read is like 10 years old you know there's probably the oldest of any magazine publication and there's a sense with the new yorker that the pieces will age well but also there's got to be a reason for why now right yeah i mean i think there's really two different kinds of pieces in the new yorker because you know they have the cy hirsch abu grabe story and they have the you know there's they are breaking news all the time.
Um, and that is not one of my roles, right?
Um, which rarely the case.
I was doing a lot of writing around when Obamacare was happening.
I'm doing a lot of writing now around the dismantling of public health at home and abroad and the damage that's doing.
And so that's meant much more timeliness than I'm and deadline driven than I'm used to.
Um, for the most part, I'm thinking about in my writing for, whether it's the New Yorker or for a book or other outlets.
Um, can I write something that uh, people will still want to read five or 10 years from now?
That's my, my Holy grail is five or 10 years there.
Okay.
And of course now I'm older and, and then I think, okay, can it be even longer than that?
But but um uh, you know the pieces I'm writing they'll land and then they'll sit on them, sometimes for two three, four months, because um Many of the deadline-driven ones are getting first priority for space.
If I'm writing really long pieces, 8,000, 10,000 word, then that's their quote-unquote cover story.
And so they'll only do one really big piece generally in a magazine.
And so that might wait a while.
And the beauty of it is picking topics that feel evergreen, like the itch that we were just talking about.
Um, that could, that could go at any time.
Yeah.
The books are very different though, right?
The books, I mean, being mortal, that doesn't really have an expiration date.
If I'm doing it right, it doesn't.
I hope, I hope it doesn't.
Um, being mortal is 12 years old now.
And, uh, and it's been, uh, it's been amazing.
It's like putting a child out in the world and seeing it grow up and um and hearing back good things about how he's doing.
Um uh, being mortal was, you know, written out of.
Often my books come from things I don't Understand and I'm and I'm either distressed or uncomfortable about, and so you know, by that point, in my practice I was middle of my practice as a surgeon.
I was primarily doing cancer surgery I'd reach past the stage, you know complications.
My first book was about discomfort from being imperfect and Still being on a learning curve, doing my first operations, you know, and how do I get permission to do that?
Making mistakes By the time I'm writ writing being mortal.
I'm comfortable with the errors I make.
I I'm confident in my ability to fix things and also that, even when things go wrong, that That I'm doing the best I can.
By contrast, in a cancer practice.
You're also seeing people who you can't fix, and I was not comfortable that I was being competent at being able to take care of people whose problems I could not fix.
I didn't know what it meant to be great at what I was doing.
I'd had cases where we clearly were, I was making people worse off and and harming their quality of life without helping with their quantity of life, and that me to start using the chance to be a writer to say let me, let me write about this dilemma and first to started, this New Yorker piece and about a you know, a woman in her mid-30s who was pregnant with her first child and diagnosed with stage 4 lung cancer and then had a second cancer that I was called in to treat and navigating a pathway where just was not offering her the support I felt I should know how to give, and so I interviewed lots of patients about their experiences, many of them pretty grim and disturbing, about how they felt in the medical machine, and then interviewed people who were palliative care doctors and nurses, nursing home workers, geriatric specialists, and learned by the end after 200 interviews, a kind of duh.
People have goals in their life besides just living longer.
Priorities that really matter to them.
Those priorities are different from person to person.
They will change over time.
And the most effective way to know what people's priorities are is to ask them.
And we don't ask.
We ask less than a quarter of the time.
And the result of that is your care.
If you don't ask, your care is often out of alignment with their priorities.
And the result of that is suffering.
And so it was walking through getting to write about now walking through the experience of changing the way I talk to people, the questions I asked, how I practiced, and then finding that it that when my dad had a terminal illness um it made a huge difference there too let's just walk back real quick to the part of this that says i need to write about that there was you sort of used the word confusion grappling with tell me more about the felt sense that you have when it's like all right i'm i'm really going to commit to a book here well a lot of the things that i write down in my list of things to write about are things that that that calm bring me up short and i feel like bring me up short meaning that it's either an idea that surprises me or a problem that i don't have a good answer to um and i'd at various point written about people coming to the end of life I wrote about a case in my first book complications.
I came back again and better.
And each time, um, my conclusion was very unsatisfactory.
I didn't.
I didn't have a way to, to offer, I didn't know what my role was, you know, with people and what I would should be offering, doing or saying to them and understanding.
And so reaching the point that I could.
Writing is my way of grappling with the problems that confuse me.
They are often where the science and the art and the humanity of medicine collide.
And sorting it out is what I can do on the page.
I'm often doing that in a journal or other things, and then that can start to become something when I feel like I'm seeing a way through and I can write my way through it.
Yeah.
Tell me about this.
This is something you wrote.
Sure.
Our ultimate goal, after all, is not a good death, but a good life to the very end.
Really embracing that, that's from being mortal.
Really understanding what that meant changed my practice.
So I would have said that the goal of medicine was to save people's lives and help them live independently and ably as possible.
But when you can't do that, then what is the goal?
And and what I came to realize is it's understanding what people's priorities are besides just living longer for their life.
And, and so I, as an example, that one well, two things.
Number one was meeting a palliative care clinician who could walk me through.
Here's what I do when I'm talking to people about their very serious illness.
They ask some key questions.
What's your understanding of where you are with your illness?
What are your hopes and what are your fears if this gets worse?
What are you willing to sacrifice?
What are you not willing to sacrifice for the sake of more time and why?
What's the minimum quality of life you'd find acceptable?
And that gives you the answers people give you.
People can't if you just say, what are your priorities besides living longer?
People often can't give you a clear answer, but they can answer those questions that I just asked you.
And that can tell you.
So, for example, one person I write about said, hmm, minimal quality of life.
Well, if I can watch football on television and eat chocolate ice cream, that'd be good enough for me.
Like that's the best living will ever.
That's the instructions you need, right?
If you can, you know?
Will this operation, will this medicine help me still eat chocolate, ice cream and watch football on television?
Yes.
Give it to me.
Keep me going.
No, let me go.
And then I said to my father who had a brain tumor uh, that was advancing, and um said so.
You know, this guy said chocolate, ice cream and football on television.
He said, no way is that good enough for me.
And we were off to the races.
It's okay.
What is.
And then that guided us to the things and to change over time.
You know, in the beginning he was a surgeon and it was uh, you know his answer.
His story was I am a surgeon.
My priority is to keep on doing surgery.
And so that's what we prioritize.
And then when he couldn't do it anymore, He was lost and didn't know what there was to do.
And then he realized what he loved about surgery was connecting with people and being able to do something good for them.
And even with this tumor, he ran for district governor of the Rotary Club in southeastern Ohio and visited 66 clubs in the course of a year, visiting them, helping them figure out how they're going to, What charitable work they're going to do, and building community.
And, you know, it was one thing, you know, what was most important?
What would give him a good day?
What made life worth living evolved as his capacities declined?
But he found something at each step, even when he was becoming quadriplegic.
Wow.
You know, I love talking to surgeons because y'all are intense, like real intense.
You know, this is a regular thing on your show.
What surgeons?
Yeah.
How surgeons, right?
Well, how surgeons, right?
Well, I was going to ask you, why aren't there more Atul Gawande's in the world?
And then I was just like I think the job it might just be too intense to make it easy for people to write.
There's lots of doctor writers, actually.
Really?
Yeah.
In fact, there's, you know, one of my good friends is Sid Mukherjee, who is a surgeon.
He's an oncologist, not a surgical oncologist.
And, you know, he wrote about cancer.
He wrote a book called Emperor of All Maladies, which won the Pulitzer.
My heroes included Sherwin-Nuland, a surgeon who wrote How We Die in 1980.
Oliver Sacks, of course.
What I was getting at with the surgery point is that surgeons seem to me like the professional athletes of the world of medicine in terms of the intensity, the commitment to improvement.
I'm sure you see it all over the place, but every surgeon I've met has that about them.
We have a certain amount of ego.
Yep.
We believe we are the kings of the hill, but that's also—
Partly show and partly what I'm interested in probing, because the character of surgeons was a part of what drew me to the specialty.
I was a public health and policy person.
Primary care was a logical way to go.
Yeah, you worked for Clinton in the 90s.
I worked for Clinton in the 90s.
And the best surgeons I knew and got to see were people who had confidence and humility.
Confidence and humility.
At the same time.
And understanding what that was.
You know, you never want a surgeon who is not a little bit afraid, and you don't want a surgeon who's paralyzed.
Yeah.
And that made them incredibly interesting.
I was a guy you know my favorite New Yorker cartoon was the gravestone that said he kept his options open.
And that was me.
And I did it as much.
I went into the field as much to shape my own ability to make decisions and character is anything else.
Oh, wow.
Yeah.
What is this thing that you do around reading drafts of books in a house where you buy dinner?
Um, when you're, you're at a point that you're, you know, for me it's about three quarters of the way through, or maybe even getting the first draft when you've got enough of it down but you're not totally committed to it.
You're willing to tear it up.
So sometimes you can get so far you don't actually want to hear any feedback.
Right.
The clay is still a little wet here.
And instead of sending it out to everybody like, give me feedback and then you're going to hear from nobody,
It's I'm going to buy you Chinese dinner.
We're going to have some wine and we're going to talk about the book.
It gives them a deadline.
Time boxes it.
Time boxes it.
And then get five six – friends who would come together writers, and ask them what they think about the book.
So like Being Mortal is an example.
I had that rough draft book club and I had all this history of nursing homes that I found completely fascinating.
And there's a fair amount in there.
And half of a chapter I had mentioning my dad's tumor and that process sort of towards the end.
And the feet.
Universal feedback came, came back that um, cut the nursing home history by half.
Give us a lot more of your dad.
And I felt like it was.
It was.
It was too indulgent telling my family story and like people don't want to hear that.
Let me tell you, let me teach you something about, and of course it's the opposite.
And it required me being a little more vulnerable than I've normally been in print.
Um, uh, About family and stuff like that.
So the it was like it was fantastic.
It was exactly what I needed.
And, you know, didn't need to be line by line.
It's, you know, help me understand where the emotional heart of a book is, where the what's what's grabbing people, what's not grabbing people.
Let's see if this question works.
How do you think about sort of the different hearts of a piece?
Like you're talking about the emotional heart.
We've talked about the idea heart, maybe the story heart.
Like what are the different hearts of a piece?
Almost.
If you had to think of a checklist for lack of a better word of things to get, what would those things be?
Well, I'm in the middle of my next book now.
And I'm about just got to the point, about two thirds of the way through, and I'm grappling with exactly this.
Wait, is this before Pizza Night or after?
This is still before Pizza Night.
Okay, cool.
So the book is about how minds change.
That's the working title.
It won't be the title.
And it's about experiences in medicine and public health with individual behavior change.
And so I know the technical story I'm telling.
And by the end I've learned.
You know, we got the surgical checklist adopted in 75 of the operating rooms in the world within about a decade.
And And what what our strategy was for making that happen etc.
So there's there's an intellectual heart to the story I needed the narrative that would make it compelling to go all the way through that and So I needed the story arc that would work and then the final part that that I'm only just Starting to feel my way towards now is where is the emotional heart?
Why?
Why will this be grip anybody?
Um, and that i'm finding is somewhere around why do we even want other people to change right?
Why do we care?
Right and what, what is?
Are we just bossy?
Do we just want the power trip right, like what the hell is going on with that?
And and, of course, in this moment in time, with trump and the administration and uh, and a certain amount of change being being forced, you know, happening by coercion, there's also the conflict of, you know, the stakes are much higher than when I first started the book four years ago.
So it's fitting those pieces together that makes it more, that starts to make it live and breathe more and get there.
So as you're now working through that, you're working through those problems.
What are you doing to work through them?
Are you just kind of, ah, I need button seat.
I just need to hammer away at the keyboard.
Get away from me.
I need the 30 hours a month.
That's how I'm going to do it.
Are you in conversation?
Are you already working with an editor?
You have this problem.
What are you doing to solve it and give yourself some clarity there?
Yeah, I'm avoiding getting in too much conversation about it.
The conversation is mainly with myself and my wife, who has to deal with my frustration on a daily basis.
Um, the and I'm writing a lot more than 30 hours a month to get it done because I'm uh, it's due in in early 2026 and I'd taken three years in government.
So I couldn't write then.
But, um, but it's a math problem to me.
It's going to be somewhere around math problem.
Yeah.
Like it's 90 to a hundred thousand words.
I broke it down.
It means I got average about 2000 words a week.
So I have to get enough time to do the research.
Um, then write and and I'm just trying to go start to finish as much as possible and get 2000 words down, and You know, I chunk it out even into 30 minute increments.
It drives my wife crazy.
But, like you know, I'm doing 30 minute increments and, just you know, by 9 o'clock I want to have gotten to 30 minute increments in and then I.
Once I can get that, I can get it going.
I try to have eight of those 30-minute increments at a minimum in a day.
And some days, you know, there's other stuff going on, so I have to miss it.
And it's just math.
Just keep on going.
Some things aren't working, and you'll work it out later.
And then, you know, I see problems, and inevitably I go back and I do some revising.
But I'm trying to keep forward momentum going so that i'm just getting it down on paper research writing editing, those are the three phases.
Talk to me about those.
Yeah, and they're not quite as neat.
You know, like it isn't just start with research, then write, then edit.
It sounds like it's more fused.
Yeah yeah there's, there's a lot of, there is a lot of upfront research that gets it going.
And then, as i'm going, i find oh, i'd really love to know more about this.
I have, you know this is i did lots of research over there and nursing home stuff.
Okay, that was interesting, more interesting than I expected, but way too much.
Right, you know, I need to do more development of this story, or more interviewing with people or, or I've hit a wall where I have to unpack things more.
But in general, that's right a lot of research, getting a first draft down and then revising revising, revising and and i hated revising, but now it's the part i look forward to.
Like i can't wait to get this done.
The the first draft is always painful and um uh, but the revisions, i know that will make it better.
What is it that you love so much about it?
Um, it is less dicey.
I mean by that point i, i have more confidence that it's good time spent.
Right.
Like I can, this thing's actually going to be out in the world.
Yeah.
Or that or that I'm.
I actually have something and with tweaking and revising and rewriting it will be.
I can make it better.
And, and it, and it'll, it'll be by that, by that point, I've become convinced it's worth telling the story and writing it.
Yeah.
Well, I want you to read this quote from the way we age now, an article in the New Yorker.
And it's, It's a little bit long, so I'm just going to ask people to stick with us.
But I think that it gets to where I want to go, which is style and how you think about the pragmatic conveying of information, to doing it in a way that has some elegant and some spunk.
All right.
The hardest substance in the human body is the white enamel of the teeth.
With age, it wears away nonetheless, allowing the softer, darker layers underneath to show through.
Meanwhile, the blood supply to the pulp and the roots of the teeth atrophies and the flow of saliva diminishes.
The gums tend to become inflamed and pull away from the teeth, exposing the base, making them unstable and elongating their appearance, especially the lower ones.
Experts say they can gauge a person's age to within five years from the examination of a single tooth, if the person has any teeth left to examine.
I mean...
There's a few things that stand out to me here.
One thing that I see in medicine all the time is what I love about medical writing is it's like a new language for me, because I don't know the first thing about medicine, but I learn all these new words, like even white enamel the teeth.
It gives me new images that I don't usually get, but it's a balance between the medical language and also using language that everybody would know.
That's one thing that I was thinking about as you were reading that.
Yeah, I generally use the language we use rather than – I really dislike it when someone – when it feels like I'm reading someone who's talking down to me and not giving me the terms that they use.
And you can define them for me.
You can make me understand it.
And so I try as much as possible to – not use the kiddie words, but to use the actual words.
And, but then use them in such a way that I don't have to.
That I can trust you to be able to understand it.
So, as I read one of your sentences, one of your paragraphs, how should I think about what kind of editing has been done?
What kind of revision do you do?
What it is that you're going for?
Yeah, like like with this the, when I'm talking about something complex, I'm trying to make the sentences shorter.
So each idea is crisp and I'm not running complex ideas together.
Um now, this is great because I can this is a subject I can make very visual and that can make it easier.
The white enamel of the teeth.
Yeah.
And the, you know the blood supply to the pulp and the roots of the teeth.
Uh, those atrophy, um the flow of saliva diminishes.
Those are, those are all things that you can picture happening.
And certainly at my age now, I'm, I'm 60 this week.
Uh, you know, I feel it happening, right?
I know what long in the tooth actually means now, as the gums pull away and uh, and and those kinds of sayings come to be.
And, um, uh, and so the, constructing it as number one, can I make it visual?
Am I conveying a new piece of information with each sentence?
And then also, is each sentence necessary?
Does it add up to an accumulating picture?
I'll bet you I started this and it was twice as long.
Oh, really?
Yeah.
And it had more run-on sentences.
And then I shortened it.
And then... sharpened the imagery, tried to make sure I'm using action verbs.
All of that's going into compressing, condensing, distilling as much as possible.
And of those things, what do you think you least understood in those slate days when you were like ah, this is not my best writing.
All of that.
All of that.
I didn't understand like I would use a metaphor in one sentence that made no sense to use in the next sentence.
The teeth could say the story by themselves.
I didn't need to say, you know, it was like a picket fence of teeth in the mouth, right?
I can people have all these metaphors for a tooth falling out and you know it's like gravestones with a with, with a great, with a headstone popped over.
Like all of those are in, are commonly used.
And I, and I, undoubtedly threw some of those in there and then needed to pair them away.
Um, because you could see it.
How do you feel like your storytelling has evolved over the years?
Um, when I first started writing, especially for the New Yorker and Henry Finder, my editor, I remember one of the things that we had to revise was um, He said imagine you're giving me the Steadicam.
The person has a GoPro.
You're telling the story with a GoPro attached to your head.
And you need to show what's happening.
And so that first piece was about automation in medicine.
One, a computer program that could diagnose heart attacks from an EKG.
And the other, a factory in Canada that did hernia operations.
And so one was a person as a machine, one was the EKG.
And the EKG study had compelling data, but I wasn't showing you what's an EKG look like.
How can you begin to see it?
And then what's the difference between what you see and what a doctor is seeing?
A cardiologist might be seeing in the little spikes that are there.
And then what's a machine seeing that might be different from what the cardiologist is seeing.
And so, you know, I had to learn in that first piece and it was great.
I had, you know, I had a teacher who was it was like a writing writing class.
Um, walking me through like okay, you got to do more of this can now make the sense.
You know that it took a ton and I and the good news is I, I do learn and, and can you know, begin to apply that.
So now you know my.
My typical New Yorker piece is um going to need three or four revisions, but not 22, you know, before we're done.
How much do you think about your audience when you're writing in terms of over explaining, under explaining, word choice, the kind of people who you're trying to reach and persuade?
Books versus the New Yorker?
How conscious are you about those things?
I'm very conscious because everything I'm writing, I'm thinking about who is the audience for it.
It could be a scientific journal.
It could be for The New Yorker.
It could be for the book.
You know, for the most part, I'm trying to get to readers.
And that is a subset of the American audience who is going to be willing to sit with something.
A decreasing subset of the American audience.
And are going to be willing to sit with it forever.
10000 words.
You know that that 10000 words a long time to sit and read.
It's probably 20, 30 minutes, Maybe longer, that's an hour or two.
I think about it and and then a book.
You know it's gonna be 80000 words or more, and And so people really have to be.
Those people are people like my friends, people.
You know, I'm thinking about the people who, What they will find that compelling.
For the most part, I'm trusting, however, whether I would find it compelling.
I'm sort of imagining it's people like me more than anything.
And so the surprise to me is that the books have done well, assuming people are like me, which I don't think I would have guessed.
Do you feel like you had to get over a certain kind of ego that leads to posturing?
Because it does seem like you know if I think of a medical journal or an economics journal.
Oh my goodness, the writing is so bleh.
It's totally turgid.
Oh, turgid.
Thank you.
Good word.
Even the.
You know, when writing for a journal, a scientific journal, I'm constantly forcing my co-authors we're not going to use the passive voice.
Like, you know, the statistical analysis was done.
Like why do we like make this worth reading?
And Getting people to be really clear, like what's the headline here?
Don't give me, we have all these 10 different results.
What's the meaning behind it?
How do we apply the meaning?
Yes, we've got to lay it out.
Other people may come to a different meaning behind it, but we have to give what we think the meaning.
We've lived with this for however many months or years we might have been trying to make sense of it, of a trial or a study.
And so every...
Every profession gets its terminology, and often that terminology becomes a way of not being able to articulate what you're doing.
And it can be that people themselves are not really understanding the words they're using and are obscuring whatever concepts behind that.
Yeah, terminology at its best opens up these new vectors of sight.
You begin to see things, think things that you wouldn't be able to see and think otherwise, and the world becomes more precise.
You know, there's reasons why we say these things.
Yes, if that's the way the terminology— But at its worst, it does exactly the opposite.
It almost becomes a private club of people basically saying, we're going to gatekeep people by using these words, and then they won't understand what—if we're talking about business—
ROIC means.
I don't know what the equivalent is in medicine.
And yeah, there's good things about things about this.
Yes.
Obviously, AI has been a big topic of conversation in the healthcare industry.
Now that you've looked at that, how might you think about AI differently in terms of the world of writing, in terms of the rate of improvement?
Should we use it?
Should we not use it?
Like putting on your medicine hat, looking at the world of writing, where does your mind go?
Yeah.
I mean, I
AI and health people waste too much time on.
Like you know, Your phone is gonna replace your doctor.
Like you, we won't need you anymore.
Who needs you like That's just.
People don't understand what what medicine is.
It's not just get a diagnosis and get a treatment.
You know Oncology and cardiology.
You're starting with the diagnosis.
All the hard stuff comes from there and it's navigating different trade-offs, different goals.
People have the ups and downs of outcomes, the navigating the system and your own suffering and things like that.
But AI is a valuable tool along the way.
And in writing, I'm just using it as another tool.
You know, there's a lot of research that goes into my books.
And I'm finding it's shortening the amount of time it takes to do research.
Like there's a whole section on the in my current book about AI.
You know how did anesthesia spread within two months in a world in the mid 19th century, in a world where there was no internet getting I deployed two or three different models.
You know, get me to 19th century, firsthand accounts of surgeons and tell me, you know, what they're finding.
And Uh, and of course it's wrong.
Like I found, it found great stuff, but made up the quotes.
Um, but quotes are always made up.
Never trust.
Exactly.
But with my research assistant, you know, we went from three months of library research to two weeks to find, you know, getting down to.
Oh, here are 10 surgical accounts from the 19th century that are actually gold.
And, you know, not quite as neat and clean as the quotes that they gave me, but allowed me to allow us to work from there.
Um, A second thing is copy editing.
I find it incredibly valuable helping me, you know, uh, find where is the fat.
Um, and another one was I was giving a giving a talk, and my first draft was 4000 words, which was way too long.
It needed to be about a 15, 20 minute talk, which is like 2000 words.
And I'd say, cut this to 2000 words.
And I again, I used three different uh uh platforms and just to see how they differently cut it.
And then, of course, chat.
GPT gives me a 500 word version, like no no no, give me a 2000 word right.
Like sorry, and it's a sorry sorry, sorry gives me a thousand word version, like that is not what I wanted.
I wanted 200 word, 2000 words, and it never gave me a 2000 word.
But I ended up with like six different versions.
Everyone killed my opening anecdote and you know, and I was like and I had to confess I had to concede I all right, it was a cute story, but it wasn't really working or necessary for it.
And so that was good guidance.
But getting it to draft stuff or not useful or fruitful, I found at this point.
Last question.
Is there a book that you feel like you want to write, that you feel called to write, that maybe you?
Think you're going to end up writing later because you need more life experience or you need more skill as a writer in order to write that.
I can't say that that's the case at this point.
Like I have topics I want to write about.
I haven't figured out how to bring them alive yet.
Like there are things that are that I think are really important but but may not be interesting as a book.
Just just feel like important policy to me, but may not be there.
I do think I'm you know. tempted by fiction or memoir.
Um, and, uh, fiction is totally intimidating.
Um, and also I'm not clear.
I haven't felt the need for fiction, like at any given moment, the stories that I want to tell, um, it's been more like, you know, how do I chisel from the clay of what, what the actual facts and story are, but I love reading a lot of fiction and I'm you know, I puzzle over what's the, what's the fiction that would really matter for the time that we are.
I just don't know that I would be able to write that.
Yeah.
That's all.
Thank you very much.
Thank you.
It's good to meet you.
Pleasure to meet you.
