116. Abraham Verghese Thinks Medicine Can Do Better

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Thanks so much.

My guest today, Abraham Verghese, is a professor of medicine at Stanford University.

But as you'll hear today, he's also so much more.

He's been a leading voice in the medical profession, calling for a greater focus on bedside manner and attention to patients' emotional needs.

Most physicians I know share these same sentiments, but we are trapped.

We are actually prisoners in what has become the healthcare business.

Welcome to People I Mostly Admire with Steve Levitt.

Well, that's his day job.

He also writes novels, blockbuster award-winning bestsellers like Cutting for Stone and more recently, The Covenant of Water.

How in the world can one person do all that?

Yet, Abraham's own story is as compelling as the ones he writes.

He was born and raised in Ethiopia, his life thrown into chaos when the Ethiopian Civil War broke out in the 1970s.

So Abraham, you've built a remarkable life for yourself.

You're both a superstar physician at Stanford University and a best-selling novelist.

But I'm personally so curious to hear about your early life.

You grew up in Ethiopia.

You were born to Indian parents who were Christian.

Before I read your books, I didn't even realize there was a long Christian tradition in India.

Could you talk about that?

Sure.

My parents come from a small, by Indian standards, Christian community who trace their origins to St.

Thomas the Apostle landing in 52 A.D.

and converting some of the Hindus there in Kerala on the western coast of India, the southern tip.

And our religion is very much like Orthodox, Armenian, or Greek, and yet it has little traces of Hindu customs and rituals that are very much a part of it too.

I became aware early on that we were part of this community, but I had no idea of its size because the Emperor of Ethiopia, also a Christian nation in a sea of other religions, he hired many of his teachers from this Christian state in the south of India where he happened to do a state visit.

And so we actually had enough of a mass of teachers in Addis Ababa to have our own church and priests who were also teaching in the theological college.

So I think I was aware very early on of our faith.

You talked about the emperor of Ethiopia.

So that must be highly slassy.

So Ethiopia is Christian and he came to India.

And that's how your parents ended up in Ethiopia?

Well, my parents individually saw an advertisement for teaching positions in Ethiopia.

And this was just about the time of independence.

And both of them had physics degrees, didn't know each other.

answered the ad and I especially marveled at my mother, a lone woman in a sari, going to Aden by steamship or something.

But I found out later that the emperor made a state visit to India, and they wanted to take him to see the Taj Mahal and the Ellora Caves.

And he said, no, I also want to see the churches of St.

Thomas in southern India, because he was very well aware of this tradition.

And so he did, and he was struck by the sight of all these school kids in uniform washed and their hair parted, heading to school.

And I think that sight, so it's said, moved him to hire the bulk of his teachers from there.

And we actually worshipped in the cathedral that he worshipped in after his service in the early morning.

That was when we had our Sunday service.

So you grew up in Ethiopia, and I suppose everything changed for everyone when there was a revolution, early 1970s.

Haile Selassie was overthrown by the military.

Were they were called the Derg or something like that?

That's right.

Yeah, they were called the Derg.

And my parents had seen the writing on the wall and had left, which I resented because I really felt very much a part of the country and had an Ethiopian girlfriend and really could see myself doing very well there.

And all of a sudden, this harsh military regime took over and they imprisoned the emperor.

And the first thing they did was close the universities in this get the intellectuals out of town.

thing that the Khmer Rouge had done.

So the same story, all the university students were asked to go to the countryside and educate the masses and expatriates were asked to fend for themselves.

So I came to America and joined my parents, but I was stuck.

I didn't have an undergraduate degree.

Most parts of the world, you go from high school to pre-med to med school.

And so I had pretty much given up the medicine dream and I began to work as a hospital orderly or nursing assistant.

which I look back on now as the best training I ever had.

I really saw what happens to patients in the 23 hours and 57 minutes that doctors are not in the room and gave me a real solidarity with the nursing profession, which I think I still retain.

So just to go back, you were in medical school in Ethiopia when everything was shut down.

I was in the third year.

You went from training to be the most powerful and respected member of the hospital community to doing one of the lowest status jobs there is in medicine.

Was that not difficult for you?

Maybe especially in light of how Indian culture is organized?

Yeah, it was difficult.

It really was difficult.

On the other hand, it took me a while to extricate myself from Ethiopia.

During that time, I saw some real horrors taking place.

And of my thirty odd classmates, maybe ten or so defected and joined the Eritrean Liberation Front fighting for Eritrean independence.

A couple of others took up the royalist cause, a couple of them were tortured and murdered.

So I was so happy to be in America, a place that in a sense we've all been brought up on, even if we're not living here, brought up on the books, the culture, the music.

So I had a sense of arriving strangely in the place I was meant to be perhaps.

And that kind of offset the great disappointment that I might not ever finish medicine.

Did you speak English?

Oh, yeah.

So the education in Ethiopia all along was English.

And because we lived in a sort of multicultural community, my parents made no effort to have us us speak in Malayalam.

And so we spoke to our parents in English and understood what they were saying in Malayalam.

But English was really my first language.

Now, when you came to the U.S., I know you worked as an orderly in some tough neighborhoods in Newark and Trenton.

Were you like a refugee, or did your parents were able to maintain some of their wealth when they left?

Or were you literally starting over from scratch?

My parents have actually both separately come on short sabbaticals.

My mother got a master's from teacher's college in in Columbia and then came back to Ethiopia.

But eventually, when they left Ethiopia, my mom got a job right away as a junior high school teacher in Springfield, New Jersey, in Asari, a beloved teacher.

I taught for many years.

And my father did teaching jobs in colleges.

And so they were settled.

I wouldn't say they were well off by any means.

So I came as an immigrant and I just felt like I've gotten a second chance.

I'm better off than most of my classmates who were really struggling or disappeared.

I'm still thinking about you as an orderly.

I have a feeling, without knowing you, never having met you, that there was some kind of destiny around you that you would do something special.

And maybe that's completely ex post based on what's happened.

Did you have that feeling?

And how did being an orderly fit in with that?

No, Stephen, I had no sense of destiny.

I was a very troubled sort of guy because I went from this prestige, such as it is, of being a medical student and going to be a doctor and the cachet that gives you at least least with the girls that I was dating at the time.

I went from that to being nobody, to being just this person on the night shift.

I was terribly young, keep this in mind.

In its own way, it was exciting.

My parents would come back from their teaching jobs and at night I would take their car and show up for my work and I was pals with the whole third shift crew and they're a very special sort.

They have their own bars that they go to and places for breakfast in the morning.

And I thought, this is my life, a blue-collar life.

And you know what?

It's not bad.

But a part of me was missing medicine.

I was also just shocked at what I was seeing.

My first job was in a nursing home, and I really got to see the warehousing of the elderly, which was an eye-opener to someone who's never seen such a thing.

But there was a moment about nine months into this where a medical student at Raritan Valley Hospital, he or she, I don't know, left their textbook, Harrison's textbook of medicine, on one of the ward counters, the nursing station.

And I saw that book and I had this cathartic sense that, God, all the stuff I studied, all those long nights of memorizing Gray's anatomy and Harrison's textbook of medicine, I couldn't let that go.

And about that time, my aunt in India said, if you come here to Delhi, we'll petition the government and you'll be registered as a displaced person and maybe we can get a transfer into an Indian medical school.

And that is what happened.

When I went back to medicine in Madras, Boy, I went back with a passion.

I knew how much I loved this and I gave it my all.

And I think I was a very good student.

On a very tiny scale, I had the same experience.

I left college and I went and worked in management consulting.

And I couldn't believe how much I hated doing it.

And when I went back to get my PhD in economics, unlike all of my other classmates who were forlorn because getting a PhD was so much less fun than being an undergrad, every day I woke up and I said, thank God I'm doing a PhD.

This is such a breath of fresh air compared to doing consulting.

It's a strange kind of gift to work at something so that when you go back to education, you understand that it is an incredible privilege and blessing to be able to do it, even if it's not as much fun as being an undergrad.

I completely agree.

I mean, I actually think there should be some sort of a national service or a requirement that you take a year or two doing something else before you...

come back to academia rather than just sail all the way through and then wake up one day and say, what the hell am I doing?

we'll be right back with more of my conversation with physician and author abraham virghese after this short break

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Flu shots subject to availability and applicable state law.

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So you got your medical degree in India and you came back to the USA and you decided to specialize in infectious diseases, which turned out to be an incredibly fateful decision because this was just before the AIDS epidemic and you had no idea that you'd soon find yourself on the front lines of that AIDS epidemic in rural Tennessee of all places.

And your first book entitled My Own Country is a memoir of that time.

And wow, it captures some of the most heart-wrenching experiences imaginable.

Can you paint just a sliver of the picture of the lives of your patients and your own life in those incredibly painful years?

Life is ironic, isn't it, Stephen?

Because I went into infectious disease thinking it's the one specialty that's all about cure, cure, you know, unlike cardiology and oncology, where, you know, it's rare that someone just

back to where they were necessarily.

And here I could make an astute diagnosis on someone coming back with fever from the Congo and they would rise like Lazarus.

That was my fantasy.

And ironically, this incurable disease landed up in the laps of people like me caught up in what I call the conceit of cure.

But like so many things in life, like the earlier experience we talked about, it turned turned out to be the best thing that could have ever happened to me.

I was humbled.

I discovered the difference between curing and healing.

I left Boston after my infectious disease training in the height of the HIV epidemic, its early years, 83 to 85,

and landed in Tennessee where everyone said you can see maybe one HIV patient every other year because this is an urban condition.

To my surprise, in a fairly short time, I was following 100 people with HIV infection.

an extraordinary statistic for that population size, 50,000.

And it turned out to be a story that I'd stumbled onto, a very American story playing out in every small town.

A young man grows up and leaves town for all the reasons that you and I leave small towns, jobs, education, opportunity.

But in their case, they were also leaving because they were gay and didn't want to live that lifestyle under the close scrutiny of their friends and relatives.

And so they went to the big city, they found themselves, and decades later the virus had found them.

And now, after their partners had died and they'd nursed them, they were coming back to their hometowns.

The story was surprising in so many ways.

These men were received so well, which goes against the stereotype of the Deep South, and they were so wise.

I felt like I was humbled and I learned so much from them.

But it was painful watching them die slowly under my care.

And I think it gave real meaning and purpose to my life, certainly.

People who are less old than you and I don't probably know the whole story of the early time with HIV.

I mean, the first piece is that there was so little understanding and so much fear because people in general, even the medical profession, didn't understand what was happening.

And it was unprecedented.

The prejudice against these men must have been tremendous.

Oh, it was huge.

It was huge.

And sometimes when I try to describe to medical students now what it was like to look at an x-ray with a radiologist to get their opinion, have them turn to you and say, why do you take care of these f ⁇ ks?

I mean, they would say that to you.

They should just die.

It's hard for current students to even imagine that.

I actually thought that the disease was bad enough, but what was bigger than the disease and what sometimes killed them was the metaphor that traveled with the disease.

And the metaphor of HIV was one of shame and one of secrecy.

And I had a young man that I had the misfortune to have to break the news that his HIV test was positive.

I was so worried about his reaction that I asked him to come back the next day so we could talk some more.

I tried to give him some hope at a time when we didn't have any medications.

Instead of which he went to a nightclub and engineered a shootout with the police, pulled a gun.

Suicide by police, I think is the term now.

But I always felt that he hadn't been killed by the disease.

He'd been killed by the metaphor, by what it meant.

And even within the medical profession, the fear,

I imagine that when these patients came for care, doctors treated these patients like they were poison, like they were toxic.

I just can't imagine what that must have felt like to these young men who were already dying of such a horrible disease.

The rejection and the stigmatization was just awful.

And when the disease first manifested, when I was seeing it in Boston City Hospital, we were scared.

I was scared.

I had a needle stick one time and, you know, really worried for a long time after that in the absence of a test, in the absence of a known cause for this.

But once we realized that this was spread like hepatitis B, namely body fluids, blood products, and so on, we were more comfortable.

But overall, I would say HIV was a litmus test for the medical profession.

And there were so many heroic figures who quietly rolled up their sleeves and just did what they needed to do, taking the appropriate precautions.

And there were others who just stepped back metaphorically or just physically.

They basically had nothing to do with these patients.

And I think some of us will look back and feel happy about our reaction.

Others won't be too proud of it.

You had no tools, essentially, for helping these patients.

But your approach was maybe love is too strong a word, maybe it isn't, but you embraced these patients in a way that

is really, really beautiful to read about.

Were you scared or fear was too far back because everything else was so pressing?

I wasn't really scared anymore, although I would have nightmares where in my nightmare I'd been infected and I'd suddenly realized what a divide it was to be infected versus not.

But I felt helpless.

There was really nothing I could offer.

And one time one of my patients, who I really got to know well, he'd moved back from San Francisco, just a delightful man as most of them were and he was too weak to come to clinic but not sick enough to be in the hospital and for my own sense of completion I decided to drive out to where he lived and visit with him and my arrival was just profound it unexpectedly had a great calming effect on the family helped him to come to terms with this inevitable thing and maybe gave him a sense that I was not abandoning him.

I would be there.

I still remember the image of washing my hands in their sink and then drying it and walking out and I thought wow this is what the horse and buggy doctor of 200 years ago did.

They didn't have any cures the way we might have now for diphtheria and this and that but they were able to heal even when they couldn't cure by which I mean just helping the patient the family come to terms with this and the sense of you're going to make this journey with them, you know, and I think we in Western medicine have gotten really good about addressing the physical problem,

but we're not doing as good a job as we can with that sense of spiritual violation.

And that is really the time-honored function of this profession.

It used to be called the Ministry of Healing.

Those words resonate to me.

Life is a terminal condition where all our days are going to end, and some people are facing much sooner than others.

And they just want to know that you're there and you empathize and you are going to do your best to make it as comfortable as you can make it.

The way you're talking about patients is so different than virtually every doctor I've ever encountered.

Do you think that you are typical of the modern medical system or do you think you're an outlier?

How do you appraise what we do right now in modern medicine?

I think I'm not alone.

I think I'm far from exceptional.

Most physicians I know know share these same sentiments, but we are trapped.

We are actually prisoners in what has become the healthcare business.

We are in this multi-trillion, maybe more than a trillion-dollar industry, a big rich trough that everybody's feeding on.

Like swine, we're all gobbling from the same big giant trough, suppliers, hospitals, instrument makers, doctors, specialty groups.

And anybody trying to reduce the portions in that trough is going to get attacked.

It's a terribly dysfunctional system.

I feel sometimes we are the highest paid clerical workers in the hospital, spending so much time on an electronic medical record that doesn't serve us.

It has its uses, but it's not user-friendly the way the Boeing cockpit is.

It's actually designed solely to capture every billing possibility there is.

for the system.

Perhaps you could tell me, Stephen, but I always thought that if we get to 15 to 18% of the GDP GDP going to healthcare, then the system has to self-destruct and will correct.

Well, we've gone past that.

It's only getting more.

You've coined this term, the eye patient.

Could you talk about that?

Because I think it captures so well the extent to which the medical system no longer sees the patient as a person, but rather as something a little bit removed from that.

I always feel sad when I talk about it because in a way it's our fault, meaning my generation of physicians allowed this sort of creeping cancer to take over where our residents and interns are forced.

It's not their choice, but they're spending much more time on the computer because that's the nexus for everything you want to do for your patients.

You can't be around that long without coming to the sense that the patient is an afterthought almost.

And so I wrote it a New England Journal of Medicine article, for which I got a fair amount of pushback from the sources you can imagine, for using the term,

I said that the patient in the bed has become a mere icon for the real patient in the computer, and I gave that entity the term the eye patient, which in Silicon Valley is a loaded term to appropriate.

The fact is the eye patient gets beautiful care.

Meanwhile, the real patient wonders where is everyone, what's going on.

My particular interest in medicine has always been the bedside and reading the body for clues that are so obvious so we can spare people the unnecessary tests or ask better questions of the test.

It's embarrassing how little we seem to address the physical body.

Can you give me an example of something you do physically on the body that allows you to circumvent invasive procedures and has a real impact on patients?

Well, I don't want to say that I'm doing something that is unique.

And actually, I'm only doing the things that we all claim to be doing on the charts.

Oftentimes we underestimate the power of examining the patient.

So what I do is even when I'm called on a consult where the question isn't one that requires me to do anything but weigh in on some theoretical aspect of a bacteria or the treatment, I will, as a matter of routine, do a quick exam, maybe even a very limited exam.

But I'm struck by how often that's meaningful in the physical exam.

We're participating in a very interesting ritual.

You take a stranger, put them in a room, and one member of this dyad is wearing a white coat and tools in the pocket, and the other is in a paper gown that no one knows how to tie or untie.

And then, amazingly, one member of the dyad disrobes and allows touch, which in any other segment of society is assault.

But the great privilege, and it comes with its fiduciary responsibility of being a physician, is we are allowed skill touch to extract phenotypic information

because of this wonderful tradition we have.

I see so many different patients from all kinds of cultures in this area and they all have different beliefs and traditions and whatnot, but they all understand ritual.

And I tell my residents that ritual is important and if you do this well with skill and pride yourself on doing it well, you get a kind of buy-in.

you can't get if you just walk in the room with one foot out the door, one foot in the door, and opine

on something, on an image or a biopsy result or a chemical result.

You have to help people localize their illnesses on their body symbolically.

And I think the exam does that.

I still remember being a child, watching my father, who's a doctor, when a friend or a neighbor would come to him with an ailment of some kind.

And he was gently physical with the area of concern.

Say it was a hand.

He would press in many places, ask if it hurt.

He'd gently bend it.

He'd cup the wrist and the forearm.

And all the while he would ask dozens of questions, seeking some kind of a clue or lead.

And it would go on for some time.

And almost always it would conclude with him saying, well, I think all of this will just take a few days of healing and then you'll be fine.

And I believe, like you just said, that all of the touching and the asking questions made that diagnosis or non-diagnosis reassuring and acceptable, exactly what you just talked about.

And I asked my father about that, knowing I was going to talk to you.

And he said he learned it from his father, who was a doctor who I guess must have gotten his MD in the 1920s.

It's really a hearkening back to a different generation that you're talking about.

And it's easy to see how that got lost in the quote professionalization, in the striving for efficiency that really, I think, has dominated the last 50 years of medicine.

I'd love to meet your father and your grandfather because you point out something very important in describing them.

They had behavior modeled for them.

And the trouble with shortchanging our bedside rounds is the interns and residents don't necessarily get to see you model the kind of human interaction that is just as important as the sodium level or the differential diagnosis of low platelets or whatever.

It's timeless since antiquity.

This is a human-to-human interaction.

AI is going to hopefully greatly help us with both diagnosis and taking away some of the drudgery of being chained to the computer.

But we need this human-to-human interaction.

And the subtext of even the most educated person interacting with you is needing to hear what your father said to your neighbors, whoever came by.

This is all right, it's going to get better, or I got you.

Or if it's not going to be all right, to be able to say, this must be really hard.

And I can only imagine what it's like.

But listen, we're going to do these things and we'll be with you every step of the way.

That is timeless.

And to the degree we believe that, it's tragic.

It's a great failure of our contract with society.

I think there's a reputation among doctors for an immense amount of hubris.

Do you think there's something in the training of doctors or in the selection of people who become doctors who make that reality?

No, I mean, as I said, I think that there are a lot of misconceptions about doctors.

Most physicians I know and talk to in practice and out of academia, they're pretty much like me.

And we are having an epidemic of physician dysfunctional health.

We are unwell as a profession because of the stresses, because of the pressures being put on us by the bean counters who have the strings to their purse.

I think what's interpreted as hubris is often people under pressure and unwell in a very dysfunctional system.

There is hubris, but for every horror story story I hear, many more stories about incredible moments with physicians who made such a difference to people.

I think economists are equally self-confident and equally arrogant as some doctors appear.

But somehow it's just more pointed when a doctor is dismissive.

of my perceptions and insights about my own body and my own pain compared to what I'm sure I do all the time, which is I'll be at a cocktail party and a doctor will have a pet theory about economic growth.

And I'll be very quick to dismiss it.

I will treat that doctor's theory the way I felt I've been treated by doctors about my own pet theories about my body.

It's not a difference in character.

It's just that we all hold our own body to be so precious and so important that there's this extra need for compassion and consideration around it, perhaps.

Yeah, I think you're absolutely right.

But I think what's often interpreted as hubris is sometimes we just don't know.

That's what makes us human.

We're complex.

We're wedded to our theories, maybe just as economists are too,

and resistant to all suggestions about our own bodies.

Aaron Powell, you have spent over a decade proselytizing about the need

for this change in medicine, perhaps to be more humanistic might be one way of putting it.

Have you seen any progress in that dimension?

Obviously, you're fighting a many-headed hydra in trying to do it.

Are you optimistic?

I'm an optimist by nature, so I'm optimistic about this.

I wouldn't say that I'm proselytizing.

What I do try to do is I love speaking to physicians in groups, to trainees.

I want to remind them of why we're in this, to remind them that this is a calling.

I'm optimistic for a perverse reason because the physician wellness problem has become so huge, the burnout, despite our best efforts, so big that there's been great recognition that this system is untenable and they need to be easier on us.

What we need is really large systemic changes.

So what I proselytize for, Stephen, is just keep the faith.

I love what we do.

We're in a difficult situation now, but we have lots going for us.

We still have the most...

advanced care for certain things.

I would pick our country over any other.

It is expensive, it's dysfunctional, it's taxing us, but it's still a beautiful thing to be in.

You're listening to People I Mostly Admire with Steve Levitt and his conversation with physician and author Abraham Verghese.

After this short break, they'll return to talk about Abraham's extraordinary success as a writer.

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Why, what's happening?

The Walmart wellness event.

Flu shots, health screenings, free samples from those brands you like.

All that at Walmart.

We can just walk right in.

No appointment needed.

Who knew we could cover our health and wellness needs at Walmart?

Check the calendar Saturday, September 13th.

Walmart Wellness Event.

You knew.

I knew.

Check in on your health at the same place you already shop.

Visit Walmart Saturday, September 13th for our semi-annual wellness event.

Flu shots subject to availability and applicable state law.

Age restrictions apply.

Free samples while supplies last.

I obviously can't let Abraham Briggies get out of here without talking about his amazing side gig as a best-selling novelist.

So let's dive into that now.

So, as if what you've done as a doctor isn't enough, in your spare time, you write books, both memoirs and novels.

And these just aren't any old books.

Your first book was chosen by Time magazine as one of the five best books of the year in 1994.

And then your second book was ranked by Slate as one of the 50 greatest nonfiction books of the last 25 years.

Your third book and your first novel was called Cutting for Stone.

Two years on the New York Times bestseller list.

It was one of the five books that Barack Obama put in his summer reading list.

And then your most recent book is called The Covenant of Water.

And it's again a huge bestseller.

And Oprah Winfrey, who's probably the most powerful player in the publishing industry, she has said it is one of her three favorite books of all time.

I mean, what the hell?

That's not fair to all the people who write for a living instead of doing it.

It's a hobby.

What's going on?

Well, I wouldn't say it's a hobby.

I never intended to be a writer.

And I push back at this notion that I'm wearing two hats, physician hat and a writer hat.

Honestly, I'm all physician.

This is how I see the world.

I became a writer to tell the story of HIV in that small small town.

It allows me to give voice to sentiments that many of us in the profession have and feel.

It so happens that I'm a big believer in fiction.

I've always loved reading.

I think fiction has the capacity to really capture young minds and launch them on a path.

And that was certainly true for me.

We think that Uncle Tom's cabin is really more responsible for ending slavery than any other thing because the thought of slavery became untenable.

In the UK, the National Health Service, people say, was born out of this one book, The Citadel, about a Welsh mining town and the medical conditions.

So I'm a great believer that fiction is the great lie that tells the truth about how the world lives.

Trevor Burrus, Jr.: I've written non-fiction books, of course, and I understand how to do that.

Honestly, it's pretty straightforward.

You pretty much know what you're trying to say when you start.

There's obviously some artistry in how one does the storytelling, the order of the argument, etc.

It all feels intuitive to me.

But writing a good novel, that seems next to impossible.

I can't begin to think about how one constructs the fictional world, which is filled with made-up characters.

Would you be willing to walk us through your process for creating a novel?

What comes first?

Where do you even start?

My process is going to disappoint your listeners because unlike many novelists I know who actually spend a lot of time and and know the whole arc of the story, know the first line and the last line, I don't really know.

I mean I have a general idea.

With the second novel I had a whiteboard mapped out with this story as I saw it and within a short time the whiteboard had no resemblance to where the story was going.

But what I do begin with is typically an image, a period of time, a sense of one character or a family.

My previous book, Cutting for Stone, began with an image of a nun, a very dutiful nun giving birth to twins in Africa, unexpectedly.

So I throw the ball up in the air and then I have to make it real, so to speak.

But once you're in it, it's just like in medicine.

Sometimes someone presents with one symptom, but then you just fish and hunt.

And all these disparate facts at some moment, if you're lucky, will all come together into one cogent explanation.

Occam's razor personified in that cognitive moment.

And there's something similar that happens in a novel.

Do you start at the beginning and type out the first sentence and then just keep on going to the end?

Or do you take a more circuitous approach?

Very circuitous route.

To the point where my editors have despaired.

And in Cutting for Stone, it was just marching along.

And usually people sell novels when they're complete.

But I really felt like I wanted to work with an editor and would send pieces at a time.

And at some point, my editor said, Abraham, at this point, you need to know the rest of the story.

And I was so perturbed that I flew to New York, and we sat in her office and hammered out what was going to happen.

And I came back to Texas at the time so relieved because I now could focus on the writing.

I knew what was going to happen.

But even dramatic things happened that neither of us discussed in that room because the characters dictated it, because God knows the muse spoke, the right brain kicked in.

It's something about that act of writing, the commitment to the process.

That's when the muse speaks.

You aren't a writer by chance.

You took the time to go to the Iowa Writers Workshop, which is maybe the best known place to learn how to write.

Did you actually quit medicine to do that or did you do it in parallel to practicing medicine?

No, I quit medicine.

So when I had lived through that story for five years in a small town with HIV, one of the lessons that my patients were teaching me was don't postpone those things that you really feel a burning desire to do because life's too short.

And I wanted to tell their story.

I had written a scientific paper about this paradigm of migration of gay men back to their hometowns.

And I felt that it left out all the human things that had made those five years so poignant for me.

It had left out the tragedy, the heartbreak, the joy,

the brilliance of these men.

And so I wanted to write that story.

and I decided I'm going to take what they said to heart.

So I was going to moonlight for a year, but write this thing.

And on a whim, I also applied to the Iowa Writers Workshop.

So when they took me, I cashed in my 401k plan.

I gave up my tenured academic position and drove across with my wife and young children to Iowa.

It forces you to take yourself seriously as a writer, if nothing else.

I was lucky enough that the faculty at the medical school in Iowa, they understood what the workshop meant.

And they let me work in the HIV clinic once a week for in-state tuition.

But otherwise, basically, I was not a physician for two years to get my MFA.

I want to talk to you about that research paper you wrote, because when you were in Middle Tennessee State and you had experienced all of these HIV patients, you took the time to do a data-driven analysis that shed light that I don't think anyone else could see.

Maybe you could describe that paper first, and then I want to tell you what I find so fascinating about that paper.

Yeah, sure.

I'm not sure it's the highest standards of data-driven, but you know, I knew my patients so well.

Each of them was like little stories in my head.

So I had index cards on almost all my patients.

Great violation of HIPAA.

And this paradigm wasn't evident initially, but I was beginning to have a hunch that this is the story.

There wasn't much HIV acquired in that little town.

And so one night I took all those index cards and I plotted on a map where my patients lived.

And it turned out that there were quite a few who were driving more than 100 miles, sometimes much more, to see me, mostly because of the anonymity it offered to come far away from their hometown.

And then I plotted on a second map of the United States where they had lived when, by their best estimate and mine, they contracted infection.

And it was a different map, Steven.

These port cities of America just lit up New York and Miami and San Francisco and Los Angeles.

And it was basically an epiphany for me.

I could just see how they had happened to be in these thriving gay communities in the Castro and Greenwich Village.

And the tragedy was when HIV was recognized, almost all the people in those communities, those tight-knit communities, were already infected.

Whereas I did a study in the gay bar at Johnson City, Tennessee, and in four successive weeks we tested people and nobody was positive.

So it was a real window in time where the urban gay men had been infected and now they were coming back to their homes.

That was the methodology of that study, but it was all based on story.

It was all based on vivid memories of what I'd seen.

But that's what I love about it, because I think people get completely the wrong idea about what the word data means.

This idea that data means you have thousands or hundreds of thousands of data points and that somehow it's been created by some rigorous system.

But to me, the greatest insights come when people recognize that things that we don't usually call data are data.

And that's what I love about what you did.

You embedded yourself into the lives of these patients and you took those insights that other doctors wouldn't have had because other doctors would have been more at arm's length.

And then you had the insight to put these observations together in just the right way using the prop of the maps to consolidate something that was growing in your mind.

And so I want to bring attention to this because to me, that's what great data analysis is.

That is really what I strive for in my own life, what I admire in people.

Well, Stephen, coming from you, that is really high praise.

But I do think, and I hope you agree, that this sort of quantitative analysis is the only way to get at some things.

And, you know, I think too many of the quote-unquote hardcore scientists stop when you say the word qualitative research.

If interviewing fellow human beings and coming up with a cogent explanation for things is a bad thing, well, you know, tough.

I don't think it is.

I think it's the only way to understand human beings.

Yeah, I couldn't agree more.

So your books are populated by good people who are trying to do the best they can.

They're often virtuous.

And yet I cannot tell you how many bad things happen to the characters in your book.

Do you feel pain in inflicting these sorts of things on your characters?

It's interesting that you should say that because one of the critiques in an otherwise good review for the most part in the New York Times was that my characters are all good.

And I like to think that most of us don't surround ourselves in our lives with anything but largely good people.

But these are all people.

They're all people like me who have made terrible mistakes and have great remorse about that.

And most of us are at some level looking for redemption for some of those things that we've done that we don't feel good about.

To me, those are the kind of human beings I'm around.

That is how I see the world around me.

Lots of good people, lots of people struggling, even people who are doing things that are evil to me, so to speak.

It might be that they haven't quite evolved.

Their moment hasn't come.

They haven't been humbled or set back.

And I don't think I ever make things happen to my beloved characters gratuitously.

I actually

would weep when I would get to the sections in the book where one or other character had died and I was revising it again and again.

But the moment that I had suddenly realized that, you know what, they're going to pass away, it came organically and it felt right.

And it wasn't something I was subjecting them to.

Perhaps as a physician, I'm more aware that we live lives of illusion a lot of the time.

There's a lot of death and tragedy and illness and abrupt endings all around us.

I get to see and hear of a disproportionate amount of it.

And I think that colors my work, certainly.

If you want more of Abraham Bergees, you've got a lot to choose from.

You might want to pick up his latest novel, The Covenant of Water.

It's been on the New York Times bestseller list for more than 20 weeks.

My own personal favorite is his first book, a memoir entitled, My Own Country, A Doctor's Story.

Now is the time of the show where we take a listener question.

And as always, I welcome our producer, Morgan, to join me.

Hi, Steve.

A listener named David wrote, he asked, do we have any data on the traits and skills of people who will make good data scientists?

Or maybe do you just have an opinion on the traits and skills necessary for someone to be a good data scientist?

So I definitely have opinions about what makes a good data scientist.

I don't have a lot of data.

I really only have anecdotes.

It is ironic that we have very little data about what makes good data scientists.

We even, I have to admit, have a lot of disagreement within the field about what data science really is and what makes someone a data scientist.

What I call a data scientist is somebody who can take a pile of data, even messy, dirty data that's not in the form that a computer can easily read it, and can entice the computer to read in those data and to then analyze them in a way which sheds light on the world.

And my definition of a data scientist doesn't involve anything complicated.

You don't have to be really teched up and be able to do fancy stuff.

For me, most good data science is really, really simple.

You do need to understand the difference between correlation and causality.

You do need to understand some basics of statistics.

But when people talk about, do you need to know a lot of math to do data science, my own opinion is not so much.

You don't need to understand so much of the why of how things work, as long as you have an intuitive sense for what you're doing and what the right interpretation is of the techniques that you're using with the data.

And that view of the world is why I have been pushing to teach data science, not just in college, but in high school and even in grade school, because I think data science is as much art as it is science.

And you can introduce it very early and get kids thinking about data before they have a whole lot of really technical tools.

But Steve, if you don't think that data science requires a lot of math, and why in your efforts to revamp the curriculum, are you focusing so much on math appreciation?

That's just expediency.

I really don't think data science should be embedded into math courses, but that really seems right now to be the easiest path.

What I think we should do with data science is I think it should be sprinkled in everywhere.

I think the social sciences should have a bunch of data science built into it.

I think the humanities should have data science built into it.

I think science should have data science integrated.

I hope in the short run that we're successful in changing the math curriculum to build in more data science.

But I hope in the long run, what we really see is that data science is everywhere.

David, thanks so much for writing.

If you have a question or comment, our email is pima at freakonomics.com.

That's p-im-a at freakonomics.com.

We read every email that's sent.

We look forward to reading yours.

In two weeks, we're back with a brand new episode featuring data scientist Nate Silver.

She's the founder of the website 538 and the author of the best-selling book, The Signal and the Noise.

Any country that can elect both Obama and Donald Trump back to back is a complicated country.

It's kind of been interesting having a front row seat at this very confusing time in some ways to be an American.

As always, thanks for listening.

We'll see you back soon.

People I Mostly Admire is part of the Freakonomics Radio Network, which also includes Freakonomics Radio, No Stupid Questions, and the Economics of Everyday Things.

All our shows are produced by Stitcher and Renbud Radio.

This episode was produced by Julie Julie Canfer and Morgan Levy with help from Lyric Boutich and mixed by Jasmine Klinger.

Our theme music was composed by Louise Garra.

We can be reached at Pima at freakonomics.com.

That's P-I-M-A at Friconomics.com.

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