#37 – Zubin Damania, M.D.: Revolutionizing healthcare one hilariously inspiring video at a time

KEYPOINTS

• 01

  Burnout is better described as moral injury

  Damania, a Stanford-trained internist known online as ZDoggMD, says that by his third year of residency his humour had turned from a coping mechanism into a wall. He used 'gomer' ('get out of my ER', from the novel The House of God) in every possible form for patients. Underneath was a feeling that he was a bad person doing work that often harmed people or was 'half-baked'. His program director told him he was a bad influence on the interns, which pushed him to become a committed teacher instead.

• 02

  Money couldn't replace the doctor–patient relationship

  After residency Damania told his program director he would not do a fellowship or practise, and spent a year at Silicon Valley startups. He says he wanted to get rich, but learned that without deep relationships with patients, money 'was never gonna cut it'. He returned as a Stanford hospitalist with a side career in comedy and music. Zappos CEO Tony Hsieh saw that work and recruited him to Las Vegas.

• 03

  Attia's wife framed his choice: fix the 12 problems or leave

  In summer 2005, about a year into their marriage and with two years left in surgical residency, Attia gave his wife 12 reasons he was miserable. After a few days she told him there were only two ways he'd get better: fix all 12 or leave. He loved operating but couldn't stand the system. He had just spent two years in a lab at the NIH, and considered a PhD, another specialty or quitting medicine before leaving.

• 04

  Hierarchy works only when you respect the person above you

  Attia says he loved hierarchy in residency when the people above him were exceptional, and struggled when he didn't think a superior was good enough. Damania observes that some personalities can't sit in the middle of a hierarchy. They either dominate the people below them or treat them as equals before they're ready, when those juniors actually need training and support.

• 05

  'My diet's better than SAD' is the real result of most diet wars

  Attia's framework starts from the standard American diet (SAD), engineered for palatability, shelf life, cost and profit rather than deliberately to harm. Keto, paleo, Mediterranean, vegan and vegetarian diets are all one approach, dietary restriction, which removes something from SAD while still eating freely. Caloric restriction and time-restricted feeding are separate levers. Since every camp compares itself with SAD, 'paleo or vegan?' is often the wrong question; stay on whichever keeps you off SAD.

• 06

  Attia's goal: live longer and better on three fronts

  His stated objective is to delay the onset of whatever would otherwise kill him and to improve quality of life, which he defines with three legs. The first is cognition. The second is the body's 'exoskeleton': muscle mass, mobility and especially stability, which he thinks gets no attention, plus freedom from pain and sexual function. Can you still drop into a goblet squat to pick up a 30-pound grandchild? The third, which he calls the hardest for a doctor to influence, is happiness or distress tolerance, a term he borrows from Paul Conti. For that he sees meditation as the key tool, along with social support and purpose.

• 07

  Fasting is a drug whose right dose nobody knows

  Metformin activates the nutrient sensor AMPK and rapamycin inhibits mTOR, the central amino-acid sensor; both partly mimic caloric restriction. Treating fasting like a drug raises open questions of calorie amount, composition, duration and frequency, plus what you eat in between, which Attia calls an unsolvable search. His professional obsession is funding ways to measure the effects, especially autophagy. That would let him tell patients, for example, that a gentler plan gets 50% of the benefit.

• 08

  Attia uses metformin in patients but not rapamycin, yet

  Attia says rapamycin, a transplant-rejection drug, is safer than its reputation. At the right dose and frequency, which is nothing like transplant dosing, he would worry less about it than ciprofloxacin. He calls his own fasting routine improvised and says his measurement tools are too blunt to draw firm conclusions.

• 09

  Healthcare costs explode when the decision-makers don't pay

  Attia says it took his McKinsey skills to map US healthcare's money flows: the people driving costs don't bear them. He compares it to a Saudi friend who left his air conditioning on all summer because energy cost him about $2 a month, and to buying a Lexus while paying only 9% of the price. He adds that cost, access and quality move together, so Canada, for example, has optimised for cost.