Atul Gawande: How to Use Writing to Improve Your Thinking | How I Write

Atul Gawande has written four books and countless articles for The New Yorker. When you think about doctors who write well, he's going to 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 is the discipline of writing for him been? That's what this episode is all about. Okay, let me show you this new tool that I've been using to write called Sublime. and they're the sponsor of this episode. What I'm going to do is I'm going to show you how I use Sublime to write this post on X, which got almost a million impressions.

So it started off with the basic note-taking stuff. I was just throwing notes in, but it's the stuff that came after that was really unique. That's what makes Sublime special. You'll see here that I had this mind map. And that allowed me to begin to see connections that weren't even there. And I was blown away by this. And then...

It didn't just end there. Sublime has the save one, discover 100 feature where you can just put in a piece of information and all of a sudden it just starts recommending things. It's like having a research assistant that actually has good taste. and these are put in there by actual human beings and so now i had the mind map i had all the related ideas and i really started to think about how am i actually going to structure this piece and sublime helped me

see parts of my structure that I didn't even realize were there to see how ideas were actually connected. See, Sublime is built by people who care about creativity and beauty and not just productivity and efficiency. And you can feel that as you use the app. So if you want to use Sublime in your own writing, well, you can go to sublime.app and use the promo code Perel, and they'll give you 20% off. All right, let's get to the episode. You got to 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 have 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 but then also in building your career? There's just a sense of discipline and dedication over many decades.

A friend of mine said that the advice he often gives is, and I realize this is what I've done all my whole life, Say yes to everything before you're 40 and say no to everything after you're 40. So by that he meant 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. Like it would become, you know, fortunes made.

over it and jobs that many people have today simply didn't exist. It's not like you trained for them. So trying lots of things that 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 are the parts of it that exhaust me. 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.

you know, started writing for my friend, you know, his internet magazine. I went into an operating room and was blown away. And I pieced it together and I found there were three things I ended up doing that did not make any sense. I was learning how to do surgery. I had this long-standing 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 after 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'd 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 humanity 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 can't. 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 illuminating something new, at least for me, whether it was my 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 in 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 help. 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, like, why would a surgeon write? You know, 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. 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.

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 to... just a diary you know like um he'd gotten they'd gotten back 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 second-year resident in surgical training. And so that was, you know, almost stream of consciousness. 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 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 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 learned every step of the way.

his name's Jake Weisberg, 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, and then would say, you know, do more of the first. do less of a second and then he'd hand it back to me and i'd say what's this for he said you know it's to to rewrite i'd never rewritten a thing in college

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 4 000 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 I, 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 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. I couldn't really object. I wanted to tear my hair out but it was more that he kept finding stuff that could make it better. It's crazy and this is going to be one of the themes of the conversation.

When you talk to people who run companies, who are doctors, whatever it is, 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 – 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 like the median an hour or was there high variance? High variance, right?

You know, getting an initial draft down on paper would be just whatever time I could grab to do some basic research, you know, in those days. There was a lot of turnover time in the operating room. Like you could wait an hour, hour and a half between cases sometimes. And so I could get a slug of just reading stuff, you know, get some weekend time. put a few hours into just getting it down and you know those initial days was writing an 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. I'd be able to chunk out bigger blocks and try to make that happen. book was uh 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 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 that I had imbibed it. Washed over you. 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, do I have a sound? case I'm making and a story I'm telling that illuminates that case. So, you know, the editors definitely, and my editor there, Henry Fender, who's amazing.

you know, has definitely sort of raised me and coached me in my writing, so I'm sure I imbibed a lot of the way that they write. But what would you describe as the New Yorker 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. West Village girl kind of like struts through New York City and the kind of energy that's sort of embodied 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 elsewhere. So I could tell jokes in the middle of it. You know, like I always... had a little goal, especially if it's one I'm telling about a surgical case or something. I wrote a piece called The Itch about a woman who had a

an itch so severe 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 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 may be a kind of New Yorker style, right, that I'm trying to tell. 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 about you know

2 million people who get infected in hospitals because someone doesn't wash their hands. And just the prosaic story of hand washing and the problems. 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 you're 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 what's true for me is 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.

TMI. Don't come anywhere close to me. But 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 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. Oh, there you go. Because someone else was watching, you know. So, 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 potential ideas for articles. It's the same list that is about – could be about research but also is about story ideas for The New Yorker or it might even be book ideas.

And I've kept that running list for years. It's past 400. So like an Apple Note? Yeah, an Apple Note. And 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.

a really interesting article that signs something, you know, the woman who had the itch. I read that as a case report and that went down in 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... the meaningful narrative, the story, the meaning, the philosophy, the abstract concept, the mental model or idea, and the vehicle. That's the story that can make that move. And 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 then I had the vehicle was... 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, 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 there are several turns to the story now that made it really compelling. And the opening could be... It could be a confrontation. The temptation is always to start with a very dramatic case. And then it becomes a very predictable crash. Well, it's funny, right? Because this is one role of the writers.

You could say that humans have an 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, in. A book I write, every chapter opening with a, you know, he was in the emergency room. You're just going to notice the mechanics at work. Yeah. And so sometimes you start with a surprising idea. Sometimes you start with setting a scene. And I had to learn that, you know, 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. Is where it ends. It's going to start where it ends. And, you know, this one's more like a W. We got three peaks, and we're going to work our way through, and we're going to 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 syncing. 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? 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, if I keep the blade in my hands, 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 the experiences I've had. 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?

Well, I found a great solution to that problem. It's called Podcast Magic, and they're the sponsor of this episode. So what you do, super easy. Say you're listening on Apple or on Spotify, if you find a bit... in this conversation that you really like just take a screenshot of it and then email it to podcastmagic at sublime.app if you email it like a minute later you'll get an email back with the transcript the context all the information that you need

And then that way, you don't need to write down all the information. So if you find something in the conversation that you really like, well, check out Podcast Magic. 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. I go back and – I would actually say the median New Yorker piece I read is like 10 years old. 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 Ghraib story and they have the, you know, there's... they are breaking news all the time. And that is not one of my rules, right?

It's 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 and deadline-driven than I'm used to. 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.

Can I write something that people will still want to read five or ten years from now? My holy grail is five or ten years from now. Of course, now I'm older, and then I think, okay, can it be even longer than that? Yeah.

You know, the pieces I'm writing, they'll land and then they'll sit on them sometimes for two, three, four months because many of the deadline-driven ones are… Getting first priority for space if I'm writing really long pieces eight ten thousand word then that's their 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. 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. Being Mortal is 12 years old now and it's been amazing. It's like putting a child out in the world and seeing it grow up and hearing back good things about how he's doing.

Being Mortal was, you know, written out of often my books come from things I don't understand and I'm either distressed or uncomfortable about. 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 reached 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 writing Being Mortal, I'm comfortable with the errors I make. I'm confident in my ability to fix things and also that even when things go wrong 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 harming their quality of life without helping with their quantity of life. And that prompted me to start using the chance to be a writer to say, let me... Let me write about this dilemma. And first it 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 state 4 lung cancer, and then had a second cancer that I was called in to treat. And navigating a pathway where... I 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, you know, 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 talked to people the questions i asked how i practiced and then finding that 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. 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 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 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. And I'd... at various points 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 My conclusion was very unsatisfactory. I didn't have a way to offer – I didn't know what my role was, you know, with people.

what I 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 as independently and ably as possible. But when you can't do that, then what is the goal? And what I came to realize is it's understanding what people's priorities are besides just living longer. for their life. And so as an example, 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. You know, they ask some key questions. What's your understanding of where you are with your illness? What are you willing... to 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, 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? 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 that was advancing, and 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 it changed over time. You know, in the beginning, he was a surgeon and it was, 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.

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, house surgeons, right? Well, house 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... 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 an oncologist, not a surgical oncologist. You know, he wrote about cancer. He wrote a book called Emperor of All Maladies, which won the Pulitzer. My heroes included Sherwin Newlin, 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, you know, 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. 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 me i i was a guy you know my favorite new yorker cartoon was uh 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 as anything else. Oh wow. Yeah. What is this thing that you do around reading drafts of books in a house where you buy dinner? When you're at a point that you're... 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 hear from nobody. I'm gonna buy you Chinese dinner. We're gonna have some wine and... 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.

Ask them what they think about, you know, 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... 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 universal feedback came.

came back that cut the nursing home history by half. Give us a lot more of your dad. And I felt like it was too indulgent telling my... you know, family story and like people don't want to hear that. Let me tell you, let me teach you something about, you know, and of course it's the opposite and it required me being a little more vulnerable than I've normally been in print.

about family and stuff like that. So it was fantastic. It was exactly what I needed. And, you know, it didn't need to be line by line. It's, you know, helped me understand. where the emotional heart of a book is, 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. Oh, cool. 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 Pizza Night? 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. 75 percent of the operating rooms in the world within about a decade, and what our strategy was for making that happen, etc. So 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 I'm only just... starting to feel my way towards now is where is the emotional heart? Why will this grip anybody? 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 a certain amount of change 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 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 – 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. And I'm writing a lot more than 30 hours a month to get it done because it's due in early 2026. And I'd taken three years in government, so I couldn't write then. But it's a math problem to me.

It's going to be somewhere around… It's a math problem. Yeah. Like it's 90 to 100,000 words. I broke it down. It means I got average about 2,000 words a week. So I have to get enough time to do the research and then write and… I'm just trying to go start to finish as much as possible and get 2,000 words down. And I chunk it out even into 30-minute increments. It drives my wife crazy.

You know, I'm doing 30 minute increments and just, you know, by nine o'clock, I want to have gotten two 30 minute increments in. And then once I can get that, I can get it going. I try to have. 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 um and then you know i see problems and inevitably i go back and i do some revising but i'm trying to keep the 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 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 did lots of research over there.

That nursing home stuff, okay, that was interesting, more interesting than I expected, but way too much. You know, I need to do more development of this story or more interviewing with people 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 I hated revising, but now it's the part I look forward to. I can't wait to get this done. The first draft is always painful.

But the revisions, I know that will make it better. What is it that you love so much about it? It is less dicey. I mean, by that point... 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 I actually have something and with... tweaking and revising and rewriting, it will be – I can make it better and it'll be – 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 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...

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. 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 with this... 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.

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, those atrophy, the flow of saliva diminishes. Those are all things you can picture happening. Certainly at my age now, I'm 60 this week. I feel it happening, right? I know it 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 you know constructing it is number one can i make it visual am i conveying a new piece of information with each sentence and then also does it is it ness is each sentence necessary does it add up to an accumulating picture can you know

A lot of 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, this, 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? People have all these metaphors for a tooth falling out. It's like gravestones with a headstone popped over. All of those are commonly used.

undoubtedly threw some of those in there and then needed to pare them away because you could see it. How do you feel like your storytelling has evolved over the years? When I first started writing, especially for The New Yorker and Henry Fender, my editor, I remember one of the things that we had to revise was... He said, imagine you're giving me the Steadicam. You know, 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, you know, that first piece was about automation in medicine. 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.

Okay, now make the sentence, you know, it took a ton. And the good news is I do learn and can, you know, begin to apply that. So now, you know, my... typical New Yorker piece is 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 for... 10,000 words. 10,000 words is a long time to sit and read. It's probably 20, 30 minutes. Maybe longer. It's an hour or two now that I think about it. And then a book. It's going to be 80,000 words or more and so people really have to be – those people are people like my friends, people – I'm thinking about the people who…

what they will find 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 um 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 – if I think of a medical journal or an economics journal, oh my goodness, the writing is so – It's totally turgid. Oh, turgid. Thank you. Good word. Even the – 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. You know getting people to be really clear like what's the headline here?

What, you know, don't give me, we have all these 10 different results. What's the meaning behind it? How do we apply them? You know, yes, we 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 or we've lived with this.

however many months or years we might have been trying to make sense of it and of a trial or a study. And so 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 the 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. The world becomes more precise. There's reasons why we say these things. Yes. If that's the way the term – 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, what ROIC means. I don't know what the equivalent is in medicine. And yeah, there's good things about things about this.

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, AI and health.

People waste too much time on like, you know, your phone is going to replace your doctor. Like, we won't need you anymore. Who needs you? Like, that's just people don't understand 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.

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.

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 what they're finding. And that's like Google on steroids. It's Google on steroids. And of course it's wrong. Like I found, it found great stuff, but made up the quotes. Oh, wow.

Quotes are always made up. Never trust AI quotes. But with my research assistant, we went from three months of library research to two weeks to find 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, allowed us to work from there. A second thing is copy editing.

I find it incredibly valuable helping me, you know, find where is the fat. And another one was I was giving a talk. my first draft was 4 000 words which was way too long it needed to be about a 15 20 minute talk which is like 2 000 words and i'd say cut this to 2 000 words and i again i used three different 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

2,000 word version. Right. Like, sorry. And it says, sorry, sorry, sorry. Gives me a thousand word version. Like, that is not what I wanted. I wanted 200 words, 2,000 words. And it never gave me a 2,000 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 all right it's a 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 they're things that are –

that I think are really important, but may not be interesting as a book, just feel like important policy to me, but may not be there. I do think I'm tempted by... fiction or memoir. And fiction is totally intimidating. 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, 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 puzzle over 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. Thank you very much. Thank you. It's good to meet you. Pleasure to meet you.