was not the science. yeah bentsen great journalism. he was surprised me the most was the outpouring from the characters in this book, the raw candor and honesty. i want to say something in particular from the windows of the men, you know, this book on some level is built on grief. what they open up to me, what the hunters, if you go, the prosecutors and victims' advocates open up to me, stories of their own lives of abuse, domestic abuse, sexual abuse, those are not ancillary to this, not irrelevant to because they plan to the question of attention. what do you pay attention to ? what in your life, and your

history dictates how you attend to the world? and in this case, in 2006, reggies story was on the rages -- razor's edge of morality, and the way people attended to it depended upon the places that they came from. and so, i think, what surprised me the most, gratified me the most, i feel truly honored to have been a vessel for the outpouring of candor, emotion, ron energy from people. i mean, it is just, i think it was once in a lifetime. >> host: and i think that to understand this issue we need to look carefully at all the difference spectrums and layers of it. again and again technology throughout history has not been a matter of just what the inventors say or how you use it that moment or what it was when it was first in your pocket. it is a very dicey,

changeable, shape shifting, powerful aspect of what would you hope -- and we have a few more minutes. how do you hope that we've often respect to their evolve mince? >> guest: of of the question. i think there is an analogy in the book that its it home for me and i hope will answer it. in the end i tried to add up with this means. scientists gave me an analogy, technology of today compared to the industrialization of food. you know, when we industrialized food, a lot of amazing things happened like less expensive food giving calories to more of people, a survival mechanism but when it got in the extreme, not the right word -- it gave us the vending

machine. and what a vending machine is as competitive cocotte, it up but, and as -- and get a bag of chips that has all the sugar and fat you ever needed. but you had to walk halfway through the jungle, kill the bear, fight off. by the time you were eating it, you desperately needed it. now it makes you obese and diabetic. this survival thing turns into a problem. the same thing is true today with our devices. they are incredible. make no mistake. but, look, this technology is amazing. its utility is incredible. we should not lose sight of that fact. it is tantamount to the industrialization of food. it has the potential to short circuit us by providing an ease, like going right to our nerve

centers with primitive, social rewards that can hijack us. that is a word they used. so i hope that we become critical of this the way we become critical of froude. i think that we have -- it is a metaphor that has been used before, i diet. that is what i talk about in the book. disconnect enough to find a real diet, but it really does take a concerted effort because we are just at the beginning of understanding what is fat, what is sugar, what assault. >> host: right. we are out of time, but i think that, you know, you have left us with so much to think about and so much to be skeptical about and so many ways in which we can think about this issue in new ways, as a thank you very much. >> guest: it was a real pleasure. thank you.

>> on the next washington journal susan b. anthony. ♪ sixth issa, and in it, didn't on the voting procedures across the u.s. washington journal begins live at 7:00 a.m. eastern on c-span. >> that c-span cities to work takes book tv and american history tv on the road traveling to u.s. cities to learn about their history and literary life. this weekend we partnered with comcast for a visit to colorado springs, colorado. >> montgomery pike was sent into the american southwest to explore the region. very similar to lewis and clark, who were sent to the northwestern part of the newly acquired in louisiana territory. pike was sent to the southwest part of the territory, and from his perspective.

when pike first seized the grand peak, he thinks he will reach the top of it in a few days. it really takes weeks to approach. they reached what we believe is a lower mountain on the flanks of pikes peak called mount rose up. at that point he wrote in his journals that given the conditions, given the equipment that they had at the time, no one could have cemented the peak. pikes peak inspired the poem that became america the beautiful. the view down to the planes from the top of the mountains inspired the poetry and inspired the images that are captured.

>> watch all of our events from colorado springs saturday at noon eastern on c-span book tv and sunday afternoon on american history tv. >> next on "after words", dr. atul gawanda talking about his book "being mortal" about end of life medical care. he is interviewed by a surgeon and health policy professor marty makary. this is an hour. >> host: great to see you again. congratulations, again, on the book, "being mortal". >> guest: thank-you. >> host: the cover, i love it. it has a piece of grass on the cover, and it has so much potential, symbolism. i immediately thought of walt whitman and his book, leaves of grass. his famous ," i bequeath myself to the dirt, to grow from the grass that i love. what does that mean to you,

and why did you decide to put it on the cover? >> guest: it is up biblical reference actually. all flesh is grass and refers to the idea that on the one hand we all come from something fertile but also the idea that grass is mortal, grass is temporary. >> host: in the process of writing this book, "being mortal" -- which i think it's terrific, by the way. we can have an honest discussion about our mortality and end of life issues. tweeted you and strike you, hey, i will not be around here forever? what impact did it writing this book in doing their research for this book have on your own practice? >> guest: a lot. [laughter] it was kind of a story of an impact that it was having to just dart. ♪

gasol a successful job of dealing with mortality. we have reached a place where 17 percent of the population died in the home and 803% in institutions, often hooked up on machines unaware of what is happening, and a chance of saying goodbye, and a chance to preserve some quality of life as they came near the end, and it was clear that this is not what people wanted, and i was not being successful at it. and began interviewing patients, family members, over 200 patients about their experiences with aging and the end of life or just dealing with serious illness i interviewed scores of physicians, hospice workers, nursing-home workers, and i learned a lot. i learned about what some of them do that is successful, the process of changing care , and i began trying

that. and then my father was diagnosed with a brain tumor in his brain stem and spinal cord. unexpectedly he needed to you -- unexpectedly i needed to use some of what i was learning as a sign, instead of as a doctor. >> host: was that a tough time for you personally? >> guest: yes, it was. having the chance to understand what people who are more effective, whether as family members or as clinicians, what they do, made it less tough, though. it was very interesting. people have priorities. beside just living longer that medicine does not recognize. i was never taught to articulate all recognize that. the second part was that the most reliable method of learning what people's priorities are is to ask. i was not asking.

i've was also not asking even my own dad. so when his condition began to deteriorate, and this is a tumor that was going to make him a quadriplegic, gradually took his life, and he said his options of surgery, radiation, chemotherapy. i started asking the questions that people talk about asking. what are your priorities and what are the tradeoffs are willing to make and not willing to make. hard questions to ask and yet it changes every step of his care along the way. >> host: you describe your grandfather, he lived to be 110 years old. [laughter] a village in india. some the a little bit about what you learn from his life . >> guest: he is fascinating because he is the kind of old is that we think we want.

last 20 years of life he needed 24-hour care, and yet he did not have to check into a nursing home like you would be here. he was surrounded by family, could sit at the head at his dinner table health, still the head of the family. people came to him for business advice, advice about who they should marry. he was respected and venerated. he really was able to live as good a life as possible all the way to the very end. now, what made that possible, and why did we lose that? that was the lesson to me that came out of this. >> host: as a society, you mean? >> guest: as a society. it is what the world had during the 19th century. the breakup of the extended family taking care is occurring because that worked only by enslaving the young. young women to provide the care. on top of it, imagine

reaching your 80's still waiting to inherit your land , your economic future still dependent upon your dad. and economic progress of the world occurs because it can give young people freedom not. the move to the city's often, take different lines of work, often leave the elders behind, and we did not have a plan in the 19th century for what happens to people left behind. india, china don't either. and what we have decided, madison will take care of it . >> host: turn it over to the medical field and it will fix and treat. >> guest: trouble with memory or falls in the home. taken to the doctor and a fix that. you take them to the doctor and say, we have a procedure that we can do, therapy we can offer.

sometimes you can't fix. some of these, you cannot make them go away. well, i can try extra like ozzie argosy and other specialists that is the failure of our understandings. living longer are trying to repair unrepairable problems . >> host: when we go through school, it seems like medical school attracts good people. the type of high school student that wants to be a nurse is a remarkable person and this sort of person of interviews for medical school is a remarkable person. they come out in this dilemma. is this confusion or preparedness, a sense of this is out of my lead. better things go wrong when you have such great people

going to their profession. faced with dealing with a problem that many feel is out of their lead. >> guest: a few things happened. the geriatric -- generate accurate cost us our clinic and for years i would walk by and did not know what they did in there. they did not teach geriatric skills. i went down and said, let me hang out for a day. among the thing that he did was recognize the most life-threatening thing for this patience was that they might fall and if they fell and broke their have they had only six months on average and were miserable more important than getting a mammogram, the colonoscopy was preventing a fall, and he knew how to do that, examine the feed for the ways that toenails and callouses could make someone and steady.

>> host: see if they could reach their feet. >> guest: yes. he would make them take off and observe and make them struggle to take off their shoes because it told them something about their abilities and whether there was care that they could have at home. he went further and recognize that people who are at a much higher risk of falling and would reduce of drug so that there was not trouble was dizziness and dehydration. >> host: and he could do that because they were just not really necessary drugs? >> guest: they were not addressing the priorities. the priority was not survival. the priority was having as good a life as possible for as long as possible. when you understood it that way you were making different choices are trade-offs. it mattered that she was alive to do the things she wanted to do, and what she said was the difference in priority was keeping her own and so if you ask -- if i ask you, you know that there

are four risk factors were someone -- for the likelihood of falling and the three most important things that we can do. i didn't know that. and so we did not teach people all along the way in the residency, and medical school before that, what is the science of the aging body? what are the skills required to help people achieve the best possible outcomes? it actually is often something that requires the implement of medical technology, but for different goals. and i think that what has happened is, our medical values are fundamentally about health, safety, survival. we are recognizing that well-being is bigger. the second force, the whole -- who are the lowest paid people in our profession? not of the surgeons, the geriatricians, psychiatrists

, primary-care doctors, primary care physicians, and it is because these professions really take time to talk to people, but having the payment, allow people to have the time to talk and make -- get an understanding of what matters in people's lives and then make plans accordingly, you know, it just does not remotely pay as well as deciding to i you know what, we can do an operation and that colonoscopy. >> host: i did not even know there was a field called geriatrics in medical school, did you? basically, it really grew, like pediatrics crew, were both worse still specialized like infectious diseases or primary care, but they did that for older patients. and as i think about these issues you are talking about, i wonder, what is happening to geriatrics today? >> guest: is in decline at

a time when we have more elderly people than ever. we are training fewer people today than we did a decade ago. it has reached the point that the profession itself says, we are so far behind, the country has been ignoring the fact that we do not train pediatricians, pay pediatricians, that we have to give up on the idea that there will be enough and we have to train these basic skills to internists, medical students are residence, and they are right. we have to make these basic skills, you know, the checklists for -- that have to be executed on, the most important ones for people who are facing aging and address their particular health risks. but also stepping back even higher than that, being able to ask the questions and get some skills and improvement

along the way in how to ask people about their priorities in life effectively while helping them understand they used to care. just because you are talking about the worst-case scenario does not mean that you are saying, you know, i am giving up on you. >> host: medical school seems to be -- and i may be overly reducing it, but it seems to be the equivalent of learning so many foreign languages the only way that you can memorize things is to pare thanks, diagnosis and treatment, diagnosis treatment, and it is almost as if we can come out with this reflex. their is a diagnosis, i know the treatment. diagnosis, treatment. you can learn all of this knowledge command there is plenty out there to learn, but what is concerning his you can miss out on a sense of what is appropriate, appropriateness. and that really seems to be one of the focuses of the issues around the end of

life, as you described, the sense of, when is it appropriate? why are we treating high cholesterol and somebody who has the expectancy of two years. >> guest: the medication makes him dizzy and likely to fall. >> host: and then they confuse it with an important medication a speech to a core point which is, how do we deal with it. the great fear that people have is that it, even if appropriateness means it is no longer about my choice about what is appropriate -- and that think what we are seeing is a revolution about what it means to be a doctor fifty years ago it was a paternalistic doctor knows best to my doctor would tell you what you are going to get to my door might not tell you what is really going on with you, never would go through the options . >> host: yes, doctor, whenever you say kind of thing. >> guest: bright.

we've rebels in the 70's, 80's, and 90's about that. by the time you and i were trained we were taught to be dr. informative, i call it. you go through all of the options, talk about the pros and cons and risks and benefits and make the menu of options and then go, what would you like to do? which one do you want? and invariably you find this. they say, well, i don't know, what would you do, doctor? what do we get taught to say it is not my decision. this is your decision to make. i am not deciding for me. you have to. and what is evolving is the recognition, i began to see it when i followed geriatricians. they play a role of counselor, and the counselor says, well, here are the options, but i need to ask you a few questions to understand your life. >> host: to give guidance. people what options, but they want guidance. >> guest: and the guidance must come from your understanding of their priorities in life and you

have to be good at listening during short conversations. >> twenty minute conversations where they ask, what is your understanding of your health to my fears and worries of the futures, the goals that you have if your health worsened, the outcomes that would be unacceptable to you and based upon that -- well, option eight, that doesn't work. option b does not work. options he might be the way to go, or, you know what, none of them work. a woman who said, my priority is a wedding now want to get to this weekend on saturday. will we focus on is how we get to that wedding. hughes medical technology not to put her in the icy your surgery but get her to the wedding.

that is what -- cool again to be a doctor. >> host: the first time you have to break bad news to a patients, do you remember that time? >> guest: i remember it as an intern he would be asked to go and get the informed consent and he would invariably be taking this operation and talking about the risks and benefits. the have this risk of death. this risk of durable leading . they raise their eyebrows and say, no one said anything about that. these are just forms. sorry about it.

how can we possibly even know what the conversations are like. the fascinating thing is, when i met the people who are really good at walking through a conversation about whether you want a do not resuscitate order or not, they treat it as, that conversation, the same way that people treated teaching us how to do an operation. from a broken down, study the component parts and recognize there were certain questions more effective than others. you need to use questions. need to check yourself. and you should be talking less than 50 percent of the time that you are in the room with the question -- patient. ninety plus percent of the time the patient would not and you get to the end and say, do you understand?