Today Mark is talking with Dr. Rahul Jandial(@drjandial).He is a brain surgeon, neuroscientist, and author. His newest book is Life on a Knife’s Edge: A Brain Surgeon’s Reflections on Life, Loss and Survival. Dr. Jandial speaks about many insights and revelations about life from his career in cancer surgery.
- Being “hot” with your mental energy all the time is counterproductive—it will be impossible for you to make good decisions
- There are two types of resilience: systemic resilience and processive resilience—one is built through your life and the other is what you are bringing to the fight
- The brain generates new neurons, but none would grow under no stress or too much stress—it’s the moderate amount of stress that sprouts them
Listen to this episode to get further insight into the brain from a neuroscience expert.
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Hey folks. This is Mark Divine. Welcome to the Unbeatable Mind podcast – thanks so much for joining me.
I’ve got an exciting guest today. Dr Rahul Jandial.
Dr Jandial: Perfectly said.
Mark: (laughing) Brain surgeon, neuroscientist, UCSD guy… dad, author of an incredible book “Life On A Knife’s Edge: A Brain Surgeon’s Reflections On Life, Loss And Survival.”
I’m super-stoked to talk to you. Thank you for being here in person.
Dr Jandial: Thank you for having me. I’m a San Diego almost native… my sons were born here… so it’s a pleasure to be back.
Mark: Welcome. When did you put this out? Just recently?
Dr Jandial: About a month ago, yeah.
Mark: Nice job. Gave it my review yesterday, and I really, really want to go back and read the whole thing, end to end – but it’s your life story basically, right?
Dr Jandial: Yeah, thank you for recognizing that. Basically, it’s a psychological memoir – the evolution of my thoughts and stuff like that through these experiences. So that’s…
Mark: Did you pitch them, or did you bring them a manuscript?
Dr Jandial: Well, the way that worked was, I had a book called “Life Lessons From a Brain Surgeon,” which was a title that they picked. Penguin, UK, not penguin, us – and the us title was “neural fitness.” That felt too much like exercise, and it didn’t have that cachet.
But they changed it. And then it became a bestseller over there. So naturally they wanted to do a second book, and I wanted to do something that sort of crossed several genres – how do you speak about the mind from… the neuroscientists were only using one perspective, right?
We need athlete’s perspective; we need soldier’s perspective… we need parents who are grieving a child perspective…
And so I try to bring all those different stories in – like my performance and moms and parents are going through different things – like, what are the lessons from cancer patients?
Mark: That’s interesting.
Dr Jandial: Yeah. And they were like “this is wild.” I wrote 300 pages they said “210 will be great,” but that’s what they do. They see it with fresh eyes.
Mark: Yeah, that’s true. That’s interesting, so you are both a brain surgeon and a neuroscientist. Those don’t usually conflate into one career. From my perspective, anyways.
Dr Jandial: Yeah, and I did that both in San Diego. The brain surgery training and the PhD right here at Torrey Pines – UCSD Torrey Pines was where I did my lab work and Hillcrest UCSD was where I did my neurosurgical training. I mean, it was an intense eight years in San Diego.
And my wife had three sons. And so it was just a lot of growth.
Mark: I’m curious – how did your understanding of the subjective side of neuroscience – how personality is formed, and how trauma affects a personality and whatnot – how did that play into your work as a brain surgeon?
Where you’re just looking at the physical structure and saying, “oh look, I gotta cut that piece of cancer out. That doesn’t belong there.” How did that affect your thinking?
Dr Jandial: Well, you’re asking me now at age 48 with this book. And it’s partly why I was fortunate and lucky enough to share those thoughts in this book/ but that’s a whole 25-year journey from the first time I saw an incision made and you look at the substance of the brain.
And right away you’re floored. I mean, it gets 20 percent of the blood flow, but it’s shimmering white like an oyster.
So, right away you look at it and you go, “that’s different.” From that to working on it, to caring for patients, to seeing the patient’s journeys before and after brain surgery – that’s when you start to really get into like, “how does this affect their minds? How does it affect my mind? What are the lessons I can learn from somebody who goes on with life after having brain surgery?”
After being diagnosed with the cancer, and showing up every three months to get a scan that might reveal something horrible? Right?
That’s a lot to live with. That’s a lot of trauma to live with, that’s a lot of stress to live with, that’s a lot of -it’s an overused phrase – but it’s a lot of resilience they demonstrate.
So I wanted to take all those words we’re seeing tossed around and go deeper into like what the patients have taught me.
Mark: Right. That’s fascinating. I want to come back to that.
But the book is “Life On A Knife’s Edge,” you said this is your second book.
Dr Jandial: “life lessons from a brain surgeon.”
Mark: That’s interesting.
Dr Jandial: That’s more like brain how it works, smart drugs, stem cells… what you can do to prevent dementia. That’s more brain.
This one is definitely mind – my mind, my patient’s mind…
Mark: Right, well speaking of your mind – I read the introduction and got a little look into your life – but it sounds like you went from basically being a high school dropout right…
Dr Jandial: College dropout.
Mark: Right. So how do you go from a college dropout to suddenly working toward your md and PhD at UCSD.
Dr Jandial: You fall in love, that’s what happened with me, and I thought “I want to do more.”
Mark: Really? That could be motivating…
Dr Jandial: That’s funny… meeting my wife changed my life. And then having my first son changed my life.
So if I were going to be just living the single life, I’m good living on a boat – small place…
Mark: Most guys are, right? Don’t have a heck of a lot of needs…
Dr Jandial: (laughing) I think so. But when I met her, it was not necessarily that I wanted to like have a high power job, but I wanted to pursue my potential, because that’s what she was doing. So we did it together.
Mark: So, is she in the medical profession as well?
Dr Jandial: Wasn’t then. She was 19, I was 20… she was a dorm student I was working as a security guard in her dorms…
And from there, we went to medical school and became surgeons and scientists… and had three babies. And that journey is all here in San Diego, so it’s great to be back.
But that was the turning point – falling in love affects the mind, right? And therefore the brain chemistry. And therefore the brain biology.
And the next one was my son was born. Then I didn’t just want to fulfill my potential – I wanted to leave a legacy – because I love my wife, but when I saw the boy, and I was like “wait a second. There’s a world he’s going to inherit.”
And if he ever looks back when he’s older and says, “what did pops do?” I want to have a good story for him. And he actually drove me here today.
Mark: How old is he now?
Dr Jandial: He’s turning 20 in a few weeks, and he’s going up to Berkeley where I met his mother…. So it’s just so much depth and joy to be back here in San Diego. Thank you for including me.
Mark: Of course.
So why the brain? There’s many paths you can take as a med student, and a doctor. And so why did you choose the brain? What fascinated you about that?
Dr Jandial: Well it’s probably a bit like navy SEALs or astronauts – I know it’s timely with that topic – but I was given the opportunity to become a brain surgeon. I didn’t apply into it; I didn’t have the marks to get into it…
I went into general surgery – I thought I was going to be a heart surgeon or a cancer surgeon – breast oncology maybe – my mom had breast cancer – she survived, she’s doing great. I was going in that direction.
They fired somebody, so I was a battlefield pickup. They’re like “we’re a body short. We only take one per year.” They had seen me for a month. They said, “you want the job?”
And so I jumped ship from general surgery to neurosurgery. And why I did that was because of that thing we were talking about earlier…
When they invited me, I hadn’t even seen brain surgery. I mean, I was a resident… I had finished medical school; I was in first year training… I hadn’t seen brain surgery, because most medical students won’t see a lot of these sort of elite surgical practices, right? That’s not a normal rotation to do.
And so I was like “can I actually see one before I jump ship?” And that’s where they made an incision from sideburn to sideburn – behind the hairline. They flapped the scalp forward, and then they made some pilot holes just like you would in a wall with a pneumatic drill. And then they brought in a little jigsaw, and they sawed it open, and they took some fine chisel – and I was like “is that even possible?”
At that time I had already seen heart surgery and other things and I’m looking at this like “wait a second this is another level.”
And they were like “you’re easily impressed. We’re just getting started.” And then they dissected between the corridors and the vessels of the brain, and I was like, “this is something.”
But while they were doing that, I kept tripping out about it’s white and glistening – the whole time we’ve heard of the brain as like porridge and gray matter. No I mean, it is beautiful. Shimmery, glistening white – bright blue, bright red serpentine vessels on top of that.
And then I thought to myself again, “I’m in surgical training and I feel mislead about the brain.” And that was the first thought that 20 years later…
Mark: Yeah, my image is of the brain in the jar – it’s like Einstein’s brain…
Dr Jandial: Oh my gosh, it’s something to see…
So then I started thinking to myself “this is my opportunity to share with others that there’s a lot of misunderstandings about the brain.” Hence that first book and hence this book…
Mark: I went and talked to neurosurgeons at Harvard about five years ago, and I was impressed with that group too. And one thing I kept hearing from them is just how relentless their work was there. And they were putting in like 130 hours weeks… 140 hour weeks…
Dr Jandial: It’s illegal now, but yeah, we did that back then…
Mark: I was wondering if you experienced that and what effect that had on you? Like, how can you concentrate on hour 110 and you’re in a brain surgery…
Dr Jandial: Yeah, that’s an important question. So first of all – it was too much – it generated a certain type of surgeon also – somebody who goes through that is if they work in a small town, they’ll get up every night for a couple of days and get it done, because they’ve gone through hell – if you will, proverbially…
But now it’s 80 hours, back then it was… we’d go in Monday morning at 4 a.m., come home Tuesday at 7 p.m.…. That’s one shift…
Dr Jandial: But during that time it’s not like in the movies where somebody’s dabbing your forehead and you’re off and on, so you learn to cycle your energy. And there’s these things about like learning that it’s the off period that allows you to actually absorb the information you’re trying to learn. And like off season in sports, off periods when you’re trying to acquire an intellectual skill…
Mark: I see. So you’re not doing surgery for a period of months…
Dr Jandial: No, sometimes you’re sitting, sometimes you’re bored… like in the military. A lot of downtime and then there’s a crisis… and it’s just a mixture of things…
So you realize which gear you need to be in – if it’s to go see somebody who’s talking – you come in, but you’re not really revved up.
If there’s an emergency surgery that needs to be done – then you go into another gear. But you also learn to preserve those gears and not to live under unnecessary stress, because you need to save that capacity…
Mark: Yeah, that reminds me a lot of what we learned in the SEALs. A very similar kind of energy management and also awareness management…
And so one of the models we used was the cooper color system.
Dr Jandial: I’m not familiar with that…
Mark: Well, it’s very simple. Like the basic idea was that a color represents your state of awareness and readiness for action. Which is going to then also have excellent a neurophysiological effect…
Dr Jandial: Yeah, so you’re not hot when there’s no need to be…
Mark: Yeah, you can’t be jacked up and you get all this…
Dr Jandial: Yeah, think about that – vigilance is detrimental, right? Air traffic controllers, soldiers, surgeons… you can’t just be…
Mark: Not a 100% of the time… you have to learn you have to modulate between them, toggle between them…
So white represented just completely ignorant of what’s going on. And you’re taught never to be in white – that would be like the average citizen…
Dr Jandial: Oblivious…
Mark: Just driving down the road clueless to what’s going on… and so we were taught to maintain a state of yellow – which is like passive alertness, where you’re always kind of scanning – you recognize that there might be a threat at any moment. But you’ve modulated your energy, and you’re in a state of parasympathetic and you’re not in sympathetic nervous… kind of like fight or flight. So you’re calm.
And then orange is like you’ve detected a threat – like a ping comes in you’re like “oh shit, I might have to go…”
Dr Jandial: You’re activating…
Mark: Yeah, and that’s when you spool up. But you don’t go to like all systems in red which is like “action, action, action.” But now you’re more focused, so instead of scanning all around you, you’re scanning in a very specific direction. Toward the threat…
Dr Jandial: I like that. Let me jump in there. And I’ll probably borrow that, because it explains it well… but I think what happens there is if you’re always in startle response, you’re not thinking…
So a lot of times people ask you like, “well, how do you perform under pressure?” Well, first of all – it’s not to be jacked up unnecessarily. And not to go to just hot without gradations.
So for example, white in the hospital is never for a surgeon – and especially when you’re driving home after a 40 hour shift. When you lock the door, and you put the latch on then it’s white…
So I always knew that – like, “hold on till you get home.” Not till you leave the hospital, because we drive afterwards.
Hot is the decision to do an emergency surgery. So you walk up to something, you see someone – they don’t look good, they’ve slipped into a coma, the scan shows something that if you jumped in and evacuated that blood clot in 60 minutes, you could save their life. That decision is hot.
Mark: Right, right.
Dr Jandial: And then you’ve made the decision. Then you come back down to orange again. Then you’re moving the patient…
Mark: Your preparation…
Dr Jandial: Right, but you don’t stay hot from the decision point all the way through surgery. And even with the surgery, you get in the room, and you step back a little bit – you let the anesthesiologist, the nurse help you a little bit… you let your team work with you a little bit.
And you step back and then the next time you get hot is “which side have I got to go on.”
Dr Jandial: Because there were some trainees – they operated on the wrong side of the skull – so you have to know “sidedness” on a sphere – that’s when I go hot again.
Okay, then you Mark at the right place… then you get into a ritual – like, incising the scalp and shaving the head – you don’t have to be red on that. You actually want to be somewhere a little bit lower than orange. That’s not operating.
Then even opening the skull is not a challenging thing – it’s opposite of airplanes where takeoff and landing is hard – in surgery it’s the middle part… opening and closing is more routine. That’s where you train people.
But then you get to the part inside and you know, “this vein… oh, that could be…” that could be hot again. So in that like two hour thing, that they show on tv and movies – you’re hot in certain periods… and I’d say for an emergency brain surgery, like for a blood clot – the total amount of time hot is maybe 20 minutes.
Dr Jandial: That lets you be good and hot for those 20 minutes… I love this conversation otherwise people are like, “oh, you must just be…”
Mark: Yeah. We use the acronym PBTA – pause, breathe, think and then act – and the act is what you’re describing as hot. That’s the freaking action – that’s laying down lead – it’s moving your position; it’s jumping out of the airplane…
Dr Jandial: But it’s impossible to be a good decision-maker if you stay hot all the time.
Mark: Right. So let’s talk about that – what specifically does that do? What are the neuropeptides and all the crazy things when you’re in fight or flight – what does it do to your brain?
Dr Jandial: Yeah, I could get deep into that. And I wrote about that here. I think, first of all – let’s go backwards a little bit. I don’t judge… dad hits a grocery cart in front of Albertson’s or navy SEAL is squeezing off lead… wherever you are, that stress or that threat is a personal dimension…
Mark: That’s right.
Dr Jandial: Right? So I think people always think like, “well, how am I going to learn from you. You’re a brain surgeon. I don’t know what…”
I’m doing brain surgery, but the process is the same whether you’re fighting with your lover or your boss or you got a flat tire… that’s the same thing going on for your personal universe inside your skull.
Okay, so that said – number two – what you feel – other than smell – you can tamp down. So there’s five senses – four of them, other than smell, they engage the frontal lobes which is the part that ballooned our foreheads forward. Cognition.
But we still have our emotional brain – the limbic brain – structures you’ve heard about like amygdala and all that, but it’s much more complex than that. It’s not a switch, it’s a tone.
And so, when I first see a snake on the ground, I jump back. I didn’t engage my thoughts, something just made me jump back, okay?
But then I look a little bit more closely, and I see it’s a plastic snake. The next time I see it, I don’t jump back. So there is an ability to take things that affect us viscerally and think them down…
But you can’t do that with smell. You can never stop being disgusted with vomit… you can’t just say “I’m used to that.” So smell is an interesting… olfaction does not engage our cognition… that’s just like visceral… that’s why I smell of an old lover – associative memory, it just takes you, right?
So if we know that not everything, we feel at the emotional level has earned a right to stay inside us…
Mark: It’s interesting in the SEALs, we call that sensitivity training, right? So the more often you can experience something as close to reality as you can, then the more you get desensitized to it and you’re able to modulate yourself out of it.
Dr Jandial: You don’t respond to the plastic snake. I like that.
So, what I do in surgery is, I run through crises the night before. Right? “If I go this way, it’ll be there… if I go around this corner, I might hit this. What do I do? I’d call for this…” I run through my drills, my crisis management by simulating it in my mind.
Mark: Do you do that for specific patients? Or generally for me tomorrow… whatever comes up?
Dr Jandial: Only for cases that have got me losing sleep…
Mark: Okay, I got it.
Dr Jandial: Because not every operation is challenging. Every patient is important, and you can’t get the risk down to zero, but you know when you’re taking on a big case. So I have my own rituals on how to do that.
But just to go back to what I was saying – so emotion and stress and threat – and back to what you were asking about – flight versus fight or sometimes freezing up – there’s more nuance to that – those responses are partly in our control. I’m not going to say I won’t freak out. I’m not asking anybody else to not freak out.
I just want to introduce the concept that we can learn to not be afraid of heights. We can learn to not jump when we see a plastic snake. There’s something cognitive going on where we can learn to tamp down our emotions.
That introduces to me the biology of emotional regulation, stress management… all those things come with the premise that just because I feel it, just because it’s coursing through me… doesn’t mean I have to react to it.
And the last way I would explain that to you is when you do have that sympathetic, fight-flight, whatever… that surge happening. There are measurable things that happen. Between your eyeballs and behind your nose, the pituitary releases things… above your kidneys different things happen… without going into the names – whether it’s cortisol or not…
But there’s a whole cascade of things that happen. There is a type of tumor where the adrenals are kicking out all that juice, all the time…
Mark: No kidding.
Dr Jandial: But because those kids are not under threat, if you check their blood, it says fight or flight, but they’re like, “hey, what’s going on?” Their blood pressure is high, but because the brain has not permitted them to feel stress, the physiological chemicals and hormones are not enough for them to freak out.
So it happens because we let it to… now, it’s largely out of our control, but it is a bit in our control. So if you can get from 1% to 2% control of your emotions and stress…
Mark: It’s almost like cognitive behavioral therapy…
Dr Jandial: Yeah, well that’s what they’re trying to do. Is walk you off that gently.
Mark: Do you think that works? I know you talk about trauma in your book… do you think you can think the emotions down with trauma?
Dr Jandial: Oh, this is a great question. Let’s just back up, because I love explaining… my kids get always get me they’re like, “you can’t just jump into all that technical stuff.”
If you lose memory as a surgical complication, there is no trauma, there is no PTSD. So first of all you got to have memory to feel traumatized…
Mark: So trauma is linked to memory…
Dr Jandial: Yeah, it’s the memory is malleable. It’s not a fixed thing. It’s always tied into emotional context, and smell and senses…
So traumatic memories can be revisited in certain contexts to lose the emotional impact that they’re connected with. You still remember, “gosh that happened to me.”
But it doesn’t grip you. It doesn’t make you stay in bed. It doesn’t make you go to a dark place, right?
So yes, the traumatic memories can be revisited… is it easy? Depends on the trauma, right? I’m not going to tell people like, “hey, yeah, your kid died, and you should work those traumatic memories out.”
No, no, no. I’m just introducing these things that explain what is possible. And I think that’s what people want to know – is it possible or not? And how?
And then they can apply it to their lives whenever they can, you know?
Mark: That’s interesting.
Mark: So gosh… you come to patients, or patients come to you usually after they’ve detected a tumor. In most of your patients, or in your experience, like how long does someone live with a tumor in their brain, before they ever become aware of it?
Dr Jandial: There’s a whole world of cancers of the brain – from non-cancerous tumors that they can have for decades… and it only comes to attention because it’s slowly grown and is knuckling into the brain – to things like senator McCain and President Biden’s son’s brain tumor – that’s the actual flesh just goes bonkers and awry and sprouts a cancer.
That’s a whole range of not deadly to deadly within a year or so. And so that world of cancer brain surgery is what I’m in. But there’s a whole range of things that happen in that sphere.
Mark: And just like any other cancer there’s usually some sort of underlying condition – I mean, it could be genetic – but oftentimes a lifestyle, or a belief, or a fear, or trauma that somehow slowly manifests itself as a cancer.
Dr Jandial: I would respectfully disagree with that. I think stress might cause something, but I don’t know about belief causing… I don’t think that link is there that I’ve seen.
I know stress can cause a lot of problems.
Mark: Totally get that. I don’t know how they would ever study that, right?
Dr Jandial: That’s a great way to describe it. I always say that – how do we show that, right? But we know stress is related to lots of physiologic diseases and inflammation. And inflammation can lead to cancer.
But inflammation is good also. Everything is a dual edge thing, right?
Mark: Yeah. But what about toxins – environmental toxins or exposure to something bad…
Dr Jandial: Yeah, so let’s look at Chernobyl… like I go to Ukraine, and I’ve been on the edge of Chernobyl there with the gowns on and stuff like that. So now we have some experience from that.
Like the wolves have taken over the certain towns and stuff like that. It’s something to see. It’s apocalyptic in the real sense…
But they’re finding a lot of… there weren’t that many differences in certain cancers… but skin and thyroid cancers they found were going up. And that’s partly because skin and thyroid is turning over a lot. It’s shedding and making new stuff. So when that radiation hit it, the DNA was damaged, and it created cancerous cells.
So things with high turnover are the ones that radiation is affecting. So, for most brain cancers radiation can lead to that – they had radiation for some other cause – but it’s not like colon cancer, like your diet’s bad – definitely a higher chance of colon cancer. It’s not like certain hormone-related cancers. Not like smoking and lung cancer, where lifestyle choices increase the chance. They don’t guarantee, but they put you in a more likely bucket to get cancer.
Mark: That’s interesting…
Dr Jandial: With brain cancers, it’s just kind of bad luck unless you’ve had radiation…
Mark: Yeah, I would have thought that lifestyle factors would have had a play in it…
Dr Jandial: Not for brain. But for almost all the other ones.
Mark: When someone has a stroke, is that something that you also deal with? Or are you strictly dealing with cancer?
Dr Jandial: We’re trained in the management of stroke… so stroke is a brain attack, right? Like, we know what a heart attack is now – like the arteries on the surface of the heart, when they get clogged – the thin ones. A heart attack is not blockage from within the chambers of the heart, it’s the vessels that are supplying the muscle of the heart on the surface. And basically you get a clog in the plumbing. And so blood flow can’t get past that clog, and the tissue past that – distal to that – dies.
In the brain, it’s the same thing. Vessels are going up – if you knock off a branch whether it’s through surgery, or a clot… whatever it was irrigating with blood is now not getting that blood. And that swath of brain dies.
In strokes, it can die, or it can die and explode… if that little swath dies and explodes, and there’s fresh blood there, then neurosurgery gets called. Because we might have to remove it.
Otherwise the other doctors take care of it.
Mark: One of the things the guys at Harvard told me was – kind of back to your point, how we know so little about the brain and we’re always learning – is that they’re starting to heal people. Complete recovery from strokes.
And the sooner they can get on it obviously the more effective they are.
Dr Jandial: That’s the key, yeah. The less long the lawn is dead, the more likely you can get it back up watering it.
Mark: Yeah, but apparently that’s kind of relatively new procedure – you would think that that would have been something that someone would have tried in the past.
Dr Jandial: Yeah, I mean they’re breaking clots up with wires and blood thinners and stuff like that. That whole field is expanding.
On the other side, is like neurosurgery going on at UCSF. They have a talented neurosurgeon who is putting electrodes in. And it was in the cover of New York times and other journals, like after lots of training sessions like years and years somebody without the ability to speak after a stroke, with electrodes in could think and the computer would pop up words as communication.
Like to me that’s fascinating… carpentry is great, plumbing is great, I love doing that – I like working with my hands…
Mark: The neuralink. What do you think about that? Where are we going with that technology?
Dr Jandial: I mean, I think super- rich folk are trying to put their name on anything that’s gonna be sexy and forward thinking. So that’s fine. Neuroscience and space exploration, right?
But there’s getting into something, and then there’s getting into something and over-promising, right? So, I don’t know much about spaceships and these guys business’, they hire astronauts, and it seems like they’re doing a good job. I respect that.
But it’s too early for businesspeople to think that they can drill a hole in a skull and put some glue in there, plant a chip and next thing you know, you can look at Instagram on your phone without having to push the buttons with your thumb, right?
Like, I get where they’re going with that. But that’s way farther away than spaceships.
Dr Jandial: And so all I would say is, “I like it, but let’s follow some of the things coming out from people who have been injured…
Mark: Right. Let’s get people walking again first…
Dr Jandial: Exactly. You read my mind. Like, I get that… but let’s demonstrate… there was this ridiculous thing – this bullshit going on a couple years ago – they talked about the head transplant. And they asked me about it.
Mark: (laughing) Yeah, apparently some guy claims he’s done it in China…
Dr Jandial: If it ain’t happening in a prominent city with people from different disciplines looking at it and understanding it – a lot of that is headlines – and it did get it, and we’re still talking about it.
But back to getting people who are paralyzed walking – they asked me – I was like, “well you can connect muscle to muscle, bone to bone, vessels to vessels – but I have yet to see a single case of where you can connect brain to brain and have it grow into each other and function. Or spinal cord to spinal cord.”
Like, you could do all that stitch work for a head transplant, but the spinal cord connected to the head the little stump won’t integrate with the spinal cord that comes with the body.
So it’s a flawed concept – because we haven’t even done it in universities…
So going back to that guy with electrodes at UCSF, that’s nice to see… that plus 20 more of those then maybe neuralink… but bringing up neuralink now when we’re 20 steps away is like bringing up space exploration when you’re talking about the model t. It’s too far away my opinion.
Mark: Is ai playing any role in your field yet?
Dr Jandial: Not mine, but all those things where they look at pictures and stuff like pathology and dermatology… visual analysis. They did try to get into cancer with Watson – remember, the world’s most advanced computer, and trying to sort of standardize what kind of chemotherapy to give patients – it stumbled out the gate.
It’s just too much nuance – because it’s not just cancer, it’s if you had the cancer five years ago, you got treated partially, then you had chemo – maybe you didn’t, maybe you had surgery…
There’s over 200 cancers and then there’s so many different stages of treatment. It’s hard to come up with an algorithm for that.
I’m not against it, but it’s not ready for prime-time yet.
Mark: Right. And one more techy question… what about robotics? Are you using any robotics to like cut the skull open or anything like that?
Dr Jandial: So the way to think about this is the robots are still controlled by our hands on the module. What the robots are great at, is getting into cavities…
Mark: Places your fingers can’t fit…
Dr Jandial: Or two surgeons with two hands… and it’s like we’re gonna both try to work underneath the liver, or in the belly – you’re gonna have to have a big incision to have four hands in there.
So the robots are great, because they’re almost like McDonald’s straws – they’re narrow and they have pincers and little coagulation things, so you can get three or four little working things in there through some ports. And so they get a much smaller incision, they do much better…
Mark: What about nanotech? Is anyone working on that?
Dr Jandial: Nanotech is… the way I try to describe it to my kids is how you can put flavor on candy – you can’t see it, but there’s some element that’s been modified on the structural thing which is candy. And then you can put drugs on metals.
So those heart attacks we were talking about, they put drug eluding stents so it’s bathing blood thinner, so they don’t scab off… nano is actually just a lot more scale microscopic on that. And people are looking at that for like the integration – you get a fracture, you put a screw in there – a lot of times the screw pulls out. Just like you put the screw in a drywall, you hang a painting on it, pulls out.
Nanotechnology is something like that’s good for now – at least in the orthopedic sense or in the spine surgery sense – where the screw is more likely to integrate with the cells of the bone.
So that’s one side and the other is sort of like matrix… delivering things that are going to swim around our brain and fix things and repair things… and that’s much farther off.
Mark: Yeah, yeah. Similar to our discussion on neuralink, that’s way down the road.
Fascinating though to see where that’s going to go.
Dr Jandial: Yeah, we’ve got to take a look at it. We just can’t dupe people with over-promising stuff.
Mark: That’s right. So you tell some amazing stories in your book. Let’s pull out a few of the most impactful ones – where either you saved or did not save a life on the table – and what you learned from it. Like, what lessons you learned about courage and resiliency. And some of the things that really have impacted your life. That made you a different person – a better person.
Dr Jandial: That’s a big question – I guess the first thing I would say at this moment, when you’re talking to me… I’ve been in better psychological places in my life, I’m going through a difficult time…
Mark: Interesting. (laughing) I think everybody in this country is probably on that same…
Dr Jandial: Right. And through other personal things and stuff like that – and what I like to do – first of all – is let’s go to the concepts again, and that way we can back the story into it, right?
Like, so resilience is a word I hear all the time and I just struggle with that word a lot, because I’m seeing it in pop magazines and stuff like that. And I’m starting to see my patients and other people feel like, “oh, I didn’t deal well with that diagnosis. Maybe I’m not resilient.”
It’s not meant to make you feel bad about yourself, first of all but when I when I looked into that I found that there were two types of resilience… engineering is just a stress or strain and then you come back to your natural shape or your vision…
This is different. Psychologically it’s more about… there’s two types in my opinion… systemic resilience you’re battle tested, you’ve gone through a lot, and now there’s a new situation you’re in. You come with a certain resiliency, that you built through your life… you carry it with you, and that lets you handle what’s coming your way.
It does depend on what’s coming your way. Did you get in a car accident? Or did you lose a child? Very different.
Then there’s processive resilience. That’s what you’re gonna bring to the fight that you don’t even know yet. And those definitions leave us completely wide open to however we’re coping right now.
Mark: That’s right.
Dr Jandial: I get horrible news, I’m not doing well – well, I’m developing and potentially growing from this – through these narrows, through these struggles will come strength, right?
And so then you don’t have to feel bad that you’re not doing well. Because this might be something that’s very seismic in your life. Again, losing a loved one, or maybe just psychologically the loss of a pet – I can’t categorize what is stressful or not – it’s an individual experience.
But if you see being resilient as something you carry, but also have the opportunity to demonstrate…
Mark: To deploy…
Dr Jandial: Yeah, to deploy… then it’s a more open and it gives us a reason to keep trying to be better.
And what I’ve seen in my life is that it’s not a linear trajectory we’re on. There’s seasons of our life – of dormancy, of darkness, of winters in our life… or a flourishing. And what I love about that way of thinking about it is that wherever you are, there’s something optimistic.
And it actually follows what happens with neurons at the microscopic level. If you are under no stress -stem cells – discovered here in San Diego by rusty gage he showed the human neural stem cells, that we can actually sprout new brain cells… not a lot, but some. They go to smell, and they go to memory interestingly.
If you’re under no stress, your brain won’t sprout new neurons. It is dormant.
If you’re under a lot of stress it shuts down too, like, “I’m overwhelmed by this.”
But a modest amount of manageable stress is the molecular cue for the little neural stem cells – little seeds to squirt out more neurons. And I think with that sort of thinking at the biological level – seeing your life more as seasons, thinking of resilience as something you carry and cultivate, right?
This way I think people are both inspired, and it’s more accurate.
That said, I think what people misunderstand about surgeons – is that it’s like auto shop or we always fix something the same way. And what they also don’t realize is in complex surgery and a lot of knee transplants – you put the metal in, you make the pilot holes – I can see it gets like that. Even sewing arteries in the heart.
But in cancer surgery, where the tumor is different shape and erodes and invades anatomy in different ways, there’s a lot of judgment going on. And I think that’s the part surgeons don’t get credit for.
Like, “maybe I’ve taken enough. If I go around this way… maybe I use a smaller scissor over here in case, there’s a vessel. Nah, there’s nothing over there – I can save time and lower complications for patients by going fast here.”
There’s a lot of judgment going on. So when you ask old-timers – veteran surgeons – they will say, “yeah good hands – that’s fine. But I’ll take somebody with above average hands and superb judgment.”
And I think surgeons don’t get a lot of credit for that. In some of the cases that I’ve done… there are three allowable good roads forward and you choose one you’ve got it in your head. And then the patient has a complication…
Mark: In your experience, how big a role does intuition play in the final judgment?
Dr Jandial: Great question… in surgery, if you are tackling trauma surgery things are falling apart, you have to make quick decisions… or you’re doing cancer surgery. I do think there are some people that have better intuition.
I don’t know how to explain it, but when you see it and you’re working with them – it’s not like their hands move more swiftly… it’s not robotic, it’s the theater, it’s the ballet of what they’re doing. They took out this bleeding cancer from the liver, and they did it in three hours with 300 steps… and the other person does it in six hours with 800 steps and a lot more blood loss.
The same work done with finesse. You don’t just keep your scissors we part a lot some surgeons, they can they do one and then a wider one and the tissue falls apart and it’s only in two steps. The patient feels it less. Less time, less maneuvers by the surgeon.
Other’s snip, snip, snip, snip, snip, snip… it’s just a different thing… there’s an artistry to it.
And when you see that some people are better at it, it’s not because they’re smarter. There’s something.
Mark: It reminds me just of the idea of mastery – you don’t know how or why you can do it in 300 or 600 steps versus 800 – it just happens. And you can’t even probably go back and know what you did.
Dr Jandial: The quarterbacks were the best example. Like, the ones who can throw the ball through the tire in practice – it’s totally different situation under pressure. Moving pieces, clock timing… some people seem to do better at the end of the game. Clutch performers some people like to call them.
But there are those in surgery as well. And I think that is intuition. It’s not a oh I’m better at processing I know the anatomy more. No, they got something.
And I just want people to remember, surgery is a physical task – and we have our own sort of Olympics of sort where we know this person is talented. Some people can actually do an operation that other surgeons can’t. And then you say, “hey, that’s interesting.” And you refer those patients that need that to them.
Mark: The discussion about resilience reminds me almost on the other end of the spectrum – about the difference between peak performance – which is like gotta train yourself to get in the flow state for an event, or for a surgery. Or for a firefight, in the case of a SEAL…
And sustained optimal performance, right? And there’s certain things that’s where diet, nutrition, sleep – all the recovery, the breath practices can lead to sustained optimal performance from which you can peak without going through these wild cycles of needing major downtime or burning yourself out.
So it’s almost on the flip side of resiliency – what you’re talking about – you have the resilience of being able to bring it in a moment and not having it crush you in return. Plus the resilience of just being able to deal with life’s ups and downs and allowing yourself to stay in that range where the challenges are leading to growth and not breakdown.
Dr Jandial: Stay in that range where the challenges lead to growth… I like that… I think creativity is sometimes similar to that. You don’t just sit down… like, no you got to be learning everything right before you can have that.
Mark: There’s a lot of resistance with creativity…
Dr Jandial: Right.
Mark: Like sometimes as an author, how many times did you look at a blank page and just go like I got nothing here.
Dr Jandial: In the crisis, that came out. And then like later on I was writing this in my garage and like February, March, April when I was sensing the storm coming through. And I was trying to alert people.
I was like, “this is something coming through.”
Mark: You mean the pandemic?
Dr Jandial: Yeah, this exploded out of me. And then a month or two ago I was like, “I think I have maybe at the third book. I try to write down, I was like, “this is shit.” Just hollow.
So I need to be under pressure to – I don’t know what it was – but I think creativity – to be creative you got to know the landscape first. And I think to have peak performance, you got to get in shape first. You got to get all those other things done. And then hope in that moment that you can channel or drift towards a performance that’s better than you expect for yourself or have demonstrated in practice.
You’re not just gonna you’re not gonna turn into Jordan, but if you beat your best under pressure to me that’s peak performance. And I think in the operating room “under pressure” is what differentiates surgeons.
When the pressure comes on you can see the people’s bodies lock up, hands lock up… just freak out. Calling for help… nurses are sometimes say, “hey, calm down.” I mean, it’s not the perfected movements we imagine all surgeons to have.
And how could they? You go to medical school; you get into surgery… they don’t even look to see if you can cut or throw… it’s like going to the NFL without going to the combine.
So you take people into surgery without ever seeing if they have technical skills. And then you put them into the most technically challenging thing with their hands. So you’re gonna get people that aren’t good at it. But yet, they graduate them.
Usually what they do is less difficult operations. So we try to steer them to “change the tires, change the tires…” don’t do engine overhauls.
Mark: And so how do they start getting that experience where they’re going to be able to do the overhaul eventually…?
Dr Jandial: Oh no. You can’t. You can’t be a navy SEAL. Not everybody can. No, you get selected out of that. No, you don’t want that. We’re not going to let you in, and you’re not gonna be good at it. You don’t wanna hurt the patients. You don’t wanna be under that stress. Be happy with tire changes.
Interestingly some of the surgery… you can make more money changing tires than engines often, in our world. And so some of us do it for the glory. And dentists get paid more for root canals than some surgeons do for removing a cancer from a woman’s breast.
Mark: Are you serious? Interesting.
Dr Jandial: It’s not about the money, but the point is why do we go for that? It’s a bit of the glory, the pride that comes with doing certain work.
And we get paid ample. No complaints here, but it’s not like people going to engine overhaul because it pays more. They go into it because they like going into the shop and taking on that project. And forming and demonstrating that craft. There is value in that, as well.
So in our in our hallways it’s not the one who’s making the most money that’s got the cred, it’s all those rooms, you know who’s doing the big cases. No matter what the background, gender, disability – some people have physical disabilities – some people are older, younger… it’s when you demonstrate that skill, all of that stuff doesn’t matter…
And so to me it’s a very egalitarian. (laughing) And we do it in our pajamas, which I love… it’s like you can’t wear a watch and you have to take off your ring. So it’s like you’re bare with your skill…
Mark: That’s interesting. You face and have to inform people of their impending demise. And then you have to deal with them through whatever process they have to go through…
Dr Jandial: I learn from them…
Mark: Yeah, I was going to say, what is one of the biggest or some of the biggest lessons that you’ve learned about death? That helps you live your life or understand your life?
Dr Jandial: Well, it’s a big question again, but I think it’s a quote from Kafka – I was flipping through a bunch of different stuff… and the meaning of life is that it ends. And cancer patients – I would say a great majority have shared with me – that they wish they wouldn’t have waited until a cancer diagnosis to prioritize quality of life. And getting rid of relationships that didn’t work for them. Doing the things they wanted to, loving the people that they had maybe been estranged from…
Those things they do in those last few years, they wish they would have lived like that the whole time.
And for me, I’m benefiting from their challenges, and I don’t carry the real weight… I don’t have a cancer diagnosis, but I see them navigate that. And if we could see that the finish line comes for us all – not in a macabre way, not in a freak out way – but it’s sort of like the time is precious, even when you don’t have a cancer diagnosis.
That we would reprioritize things and we would value different things individually.
For somebody that might be taking up a hobby, somebody that might be giving up a hobby – I’m not trying to tell people here the five things to do, to have a quality life, a great life…
Mark: What did you change? It’s not like one or two things that you changed in an instant – one day you just had that epiphany. It’s probably more likely that you just kind of over time started to reflect upon this. And say, “what do I really value and how do I…?”
Dr Jandial: Exactly right. It’s been glacial – it’s been glacial, because so much in the beginning was learning the craft. Then there was more time to processing and reflecting on the lessons that I had learned from them. And then there was adding in the biology about how our brains handle stuff.
But for me at 48, I think the lesson that I’ve learnt from them is to is to brace and be prepared for challenges, but don’t anticipate them so much so that you live in fear of them. And the way they’ve taught me that, is their brain scans – every three months after the diagnosis they get a scan. They call it “scanxiety.”
And so what they’ve taught me is have a horrible week when that slip comes for a brain MRI or body MRI it’s going to be stressful. It’s better to just have that rough week, because that’s normal – because you’re going through something very difficult. And you might find information that’s completely life-altering.
And you do that every three months. For years. But what they also do is in between, they do their best to save that anxiety for that week. So they compartmentalize. But in a very methodical, structural way.
It’s not just getting rid of anxiety. It’s like you said when we started this conversation, knowing when to get hot. And then not being hot unnecessarily. That is the true approach to equanimity that I think… like, if you look at Buddhist philosophy and they say be the path that doesn’t react too much to negativity and positivity, right? Sort of equipoise.
I would say what cancer patients do is a bit different – the ones that I looked at – so this is amazing – they buffer the pain and the difficulties, but because time is limited, they really celebrate and savor life in between. They are parting, enjoying with reckless abandon in between those weeks where they get their scans.
It’s not just about blunt the highs and lows – it’s actually blunt the lows and relish in the highs. It’s a very unique approach that I’ve seen in cancer patients.
Mark: When someone first learns, let’s say, that they have two year, three years to live – do you see that trigger prior trauma, like childhood trauma? And then have a lot of people go into like a downward spiral as a result of trauma that preceded the cancer?
Dr Jandial: That’s a good question – I’m not in a position to answer that – because I don’t know them from before. So surgeons see you at… sort of, it’s punctuated… the other doctors who follow them throughout their lives might know that – your general practitioner might know that.
But when you see cancer surgeons…
Mark: You’re not privy to that. Like, it would be the therapist who would probably uncover that.
Yeah, because what we found out – I work with vets, trying to help them heal from post-traumatic stress – and what we’re finding is yes, they have that combat trauma, but most of their struggles come from pre-existing trauma. That has been triggered and exacerbated by the combat trauma. Interesting.
So I imagine the same thing could happen…
Dr Jandial: In the book I mentioned there are people who have PTSD, yet they’ve never been combat veterans…
Mark: That’s right.
Dr Jandial: It doesn’t lessen anything. My point is that it’s complex – our relationship with trauma. But it is part of the human experience – to be willing to put ourselves out there, to be willing to be so sensate that… it hurts when your finger is crushed, but it also hurts psychologically when your dreams are crushed. When you have to grieve the life you imagine for yourself. That hurts too.
And I think that mind pain is not recognized enough. Now I’m a brain surgeon saying that, because I get the material, but I also get the people who have gone through these cancer journeys.
And so when people ask me, “what should people do now – in this pandemic,” I say I don’t know. I mean, I’m just explaining the few things that I know. But I do think this is an opportunity to make mental health – preventative mental health – a thing.
Why do we know so much about the heart and cholesterol – I keep telling people- but we don’t know much about the brain. We don’t talk about the brain.
Let every kid build programs not when they’re having mental health issues, but along the way sort of mental health approaches – the systemic resilience. As well as a processive. It’s the mental health approaches they carry with them, and the ones they’ll learn and deploy when trauma comes.
Because we put ourselves out there in life. And that’s also where the exhilaration and the joy and the love come from.
So I wouldn’t trade it, but it can hurt at times. And there’s that children’s book where it says in the first sentence “life is difficult.” And I think trauma is something that can have value – it’s nothing we ever ask for. So if somebody’s listening or some of my patients… like, “you’re saying we should get cancer because there’s value in trauma? Or I’ve been assaulted?”
No, I’m not saying that at all. I’m actually saying it can have value, because it forces you to deal with an aftermath that you never invited upon yourself and don’t want. And I just want people to know that in the cancer center my patients – when I take care of them, it’s a traumatic experience often. Meet them 15 minutes later, they’re signing a paper that says I’m going to open their skull next week.
It’s an intense human interaction – trauma is part of that… yet I don’t see a lot of…
You would think they’re a macabre, sad, despondent bunch. And they’re not. So it’s like “oh my gosh, we’re going to hear from a cancer surgeon. It’s going to be a depressing.”
No, no, no. Wait a second – (laughing) I’ve seen more sort of people struggling – affluent in los Angeles at the mall and at the schools, than at the cancer center. So I tried to pull some of those lessons out in my own personal journey and put it in the book. But I’m inspired by my patients…
Mark: I bet. Well, I think that’s probably a good place to kind of wrap this up. So “Life On A Knife’s Edge: Brain Surgeons’ Reflections On Life Loss And Survival.” And Rahul. And your last name is pronounced johndeeal?
Dr Jandial: Perfect.
Mark: What about social media? Or do you have a place where people can learn more or send you…?
Dr Jandial: @drjandial. It’s more of a creative space I try to show like brain cells and trees and sort of the ways that things connect that people wouldn’t suspect. I think if we think of our brains… you put it under a microscope and you see how beautiful it is.
Mark: I would love to go observe a brain surgery someday…
Dr Jandial: Or just look at the pictures. Seeing the living brain is something – not in a jar – but also just look up like drawings of neurons – I mean, they look like kelp forests. I mean, it’s something to behold.
And when you look at that, you go, “wait a second.” Those trees in Oregon and then this microscopic neuron – if you change the scale, and you start to see like how nature did it… nature – it doesn’t constrain us but understanding the nature inside our minds and our bodies can also inform us to what is possible, and how to approach things.
So that’s my next journey, is to spend some time and try to think about human nature, but actually down to how we… just a riff – I know we’re going to wrap up…
Mark: What’s the brain of mother earth?
Dr Jandial: There you go. I like that, and I’ll just finish with this – why is it like cosmic dust – lithium, li plus or minus – I don’t remember it from Berkeley, but on the periodic table. That little element is given to treat bipolar disorder. It can blunt mania and improve depression. And it pops off of a comet.
Like to me, if I could try to understand how the human mind connects to elements to stardust.
Nobody’s going to read that, but I’m going to love learning about that…
Mark: I think that’s… that is a new frontier of thinking, like looking at kind of the meta-mind. We’re going there anyways, with this idea of like all minds connected to the internet someday.
What does that mean? Singularity, what does that mean? But also, I think everything is alive, and we’re connected to everything. So it’s possible that everything is mind.
Dr Jandial: Yeah.
Mark: And we’re just experiencing a little separate aspect of it.
Dr Jandial: Yeah.
Mark: That’s a very eastern perspective…
Dr Jandial: But an important one to… these perspectives – people don’t have to drink the Kool-Aid, but they should know about it…
Mark: They should reflect on it. Thanks again for your time I really appreciate it. Awesome.
Dr Jandial: I’m going to enjoy the day in San Diego.
Mark: Yeah, please do.
All right folks, that’s it for this podcast. Dr Rahul Jandial – go check him out at his Instagram or wherever you can find him and read his book. Excellent book. “Life On A Knife’s Edge.”
Thanks so much for your time. Stay focused. Until next time, be unbeatable.