[00:00:00.000] - Gary Isaac Wolf

Don't start with the tool. Don't start with how can I use this complicated tool and get the most out of it? Start with what you care about. And once you have a focus on what you care about, you're going to find out probably that there are a number of different paths to learn more and to increase your agency around finding the answers that you need.

[00:00:23.030] - Dr. Lemanne

You have found your way to the Lemanne-Gordon Podcast, where docs talk shop.

[00:00:31.190] - Dr. Gordon

Happy eavesdropping!

[00:00:38.610] - Dr. Lemanne

I'm Dr. Dawn Lemanne. I treat cancer patients.

[00:00:41.830] - Dr. Gordon

I'm Dr. Deborah Gordon. I work with aging patients.

[00:00:45.630] - Dr. Lemanne

We've been in practice a long time.

[00:00:47.990] - Dr. Gordon

A very long time.

[00:00:49.600] - Dr. Lemanne

We learn so much talking to each other.

[00:00:51.640] - Dr. Gordon

We do. What if we let people listen in? Today, we're talking with Gary Isaac Wolfe, co-founder of the Quantified Self movement and author of the new book, The Quantified Self: Learning to Observe. Gary has spent nearly 2 decades developing ways for people to test whether the changes they make in daily life are actually helping them or not. Suppose you change something, A medication, a supplement, what you eat, when you exercise, and you feel noticeably better. Did it work? Or was it coincidence, expectation, a good night's sleep, or something else completely different? Randomized trials are very good at telling us what happens on average across groups, but many of our listeners are dealing with a different problem— advanced cancer, cognitive changes, chronic symptoms, aging, situations where the question is often not just what works in general, but what is working or not working for me?

[00:02:07.430] - Dr. Lemanne

And that distinction matters a lot in oncology. In oncology circles especially, single-subject research or N-of-1 trials, those terms are used almost pejoratively to silence someone who brings up an unusual response or recovery. But decades of large randomized trials in oncology have produced cures in the early stages of the most common cancers. But in the advanced stages of cancers of the breast, the lung, colon, prostate, pancreas, esophagus, and others, large randomized controlled trials have failed to produce cures. But there has been a deep culture in medicine of ignoring the individual in research, and so I think it's worth asking whether we've neglected the individual for too long in chronic disease, and in this episode, I describe hearing a research funding agency challenge oncologists to begin thinking of every cancer patient as a single-subject trial or as an N of 1. Gary Wolf is unusually well positioned to explore that question, He was part of the early editorial team at Wired Magazine, became the first executive producer of Wired Digital, wrote the landmark New York Times Magazine story that brought self-tracking to a broad public, and his TED Talk has been viewed more than a million times.

[00:03:37.030] - Dr. Lemanne

He's a Kavli Science Journalism Award winner and a former Knight Fellow at Stanford University. His new book is a guide to doing something we have often done, but done poorly, learning systematically from one person over time, often ourselves.

[00:03:55.770] - Dr. Gordon

Some of the most surprising ideas in his work are remarkably simple. One is to stop asking sick people to constantly record how bad they feel and instead track feel-good time. Another comes from Gary's own heart arrhythmia, which he'll discuss with us. He compared his subjective sense of what was happening with data from a medical-grade Holter monitor and found that his simple observations tracked the medical measurements closely enough to become genuinely useful in his own management of his condition. Yes.

[00:04:37.960] - Dr. Lemanne

Yes, something that his cardiologist would absolutely have missed without Gary Wolf's own observations. And so this episode is about how you can turn observation into evidence, how to separate signal from noise, and how to learn from yourself, the person actually living inside and through your treatments. Because if a treatment works only for some people, The question that matters most is, am I one of the people it is working for? Enjoy this episode. Why don't you start by telling us why you wrote this book?

[00:05:20.480] - Gary Isaac Wolf

I wrote the book because I think the topic is really important, and I think that it could be better understood. And if it were better understood, it would help people a lot. And what I mean is that everybody at some point in their life has to troubleshoot something that really matters to them where they can't just look up the answer. And often that's related to health. And when you need to do that troubleshooting, you almost automatically, habitually, you turn to our number one method of troubleshooting, which is trial and error, right? You hear something, somebody tells you something, maybe your practitioner tells you something, you try it and either it works or it doesn't, and then you try the next thing. And trial and error, it's a great method. Even animals use it. But I think we can do better than trial and error. And we have science. We have 500 years of modern science. It's one of our great cultural legacies. And everybody can practice with a scientific mindset the troubleshooting they have to do in their daily life. So, so for me, that was the motivation, was to try to bring that knowledge to the public.

[00:06:29.390] - Gary Isaac Wolf

Of course, I have some background that I also enjoy bringing to the table, which is that I've been part of what we call the Quantified Self community for almost, well, 18 years, I guess. And I've seen a lot of people troubleshooting their health issues using a scientific mindset. So I had a lot in my background to base the book on, and that's what I tried to do.

[00:06:54.830] - Dr. Lemanne

Well, one of the things that my colleagues and I were, you know, we're both physicians, Debra and I, and we talk about anecdata, and I am really curious to hear your definition of an anecdote versus a true N-of-1 study, and are N-of-1 studies what are happening in your book? So this book is Wonderful, lists so many different scenarios and people who have tracked various things and come up with really interesting insights, both positive and negative, you know, what works and what doesn't. But I'd love to hear your take on how you're moving this way of thinking from an anecdote into an actual scientific experiment for physicians who have patients who come in with data they've tracked.

[00:07:46.950] - Dr. Gordon

Right.

[00:07:47.800] - Dr. Lemanne

This might be really helpful.

[00:07:49.970] - Gary Isaac Wolf

Great question. And I think we should just talk about it, go back and forth a little bit, because it's quite a deep question. The word anecdote is used a lot in biomedicine, and maybe that just helps to introduce the word biomedicine because it's a mouthful to say clinical and academic research and practice, right? So by biomedicine, I mean the whole package where You know, you have studies going on, you have interventions being developed, whether those are drugs or devices or just practices, right? And then those research results are being translated and physicians are being trained. And then if you are a patient and you come into your doctor's office, you're going to get the benefit of that biomedical research.

[00:08:41.280] - Dr. Lemanne

You know, anecdote is used Rather pejoratively by doctors. And I think those days need to end very quickly, which is really a lot of the work that you do.

[00:08:53.950] - Dr. Gordon

Before we go on, may I ask you a quick favor? Hit the subscribe button. Your hitting that subscribe button really, really matters. You're making sure cutting-edge ideas that matter to you move to the center of medical discourse where they belong.

[00:09:09.250] - Dr. Lemanne

Thank you.

[00:09:12.060] - Dr. Gordon

I have to follow this little chain you started, Dawn, on anecdote because I realized— so I did something different yesterday with one of the medications I take, and I felt great, and I thought, oh, I should do that every day. In other words, I was turning a single episode anecdote into a conclusion And although some of the data gathering in your book where people are doing the same thing is daunting in its complexity, some of it is just brilliantly simple. And if I just decide I'm going to make this change every day for 2 weeks and just do a scribble— great day, another great day— you know, even that step, which is a tiny step compared to some of the accomplishments of the examples in your book, is—

[00:10:04.980] - Gary Isaac Wolf

Yeah.

[00:10:08.160] - Dr. Gordon

It would be a very adult thing for me to do that might actually be really helpful. The first case that came to mind for me reading your book with a patient, and Dawn, I'm not sure what you're referring to because this just came to me yesterday when I was reading his book. In your section about cognition, you distinguish our ability to overestimate our abilities or underestimate them. I have a patient recently who performs in one way. You know, he's about my age, so older than the two of you, not put together, but older than the two of you. And, but he just said, my brain's not working so well. And luckily, I have access to a really good online cognitive test, and he was comfortable doing that. And he aced everything. So there's still a question to be pursued. What is it that he's noticing that's subjective? But it was just wonderful to say, you are not estimating your abilities actually correctly, but you're— you know, his cognition was perfectly intact. So he had competence without confidence in it, and of course, many people go the other way. There's nothing wrong with me. Why do I have to come see the doctor?

[00:11:33.010] - Gary Isaac Wolf

Right.

[00:11:33.380] - Dr. Gordon

Well, because you failed your cognitive test, and you give a third example of how cognition can be confusing, which is blindness to automatic behavior. Can you say something more about that? Because that's the part of it I didn't get so clearly as the distinction between confidence and competence.

[00:11:55.900] - Gary Isaac Wolf

Okay, these are great questions, and you've plunged All the way in. And so I will not forget to answer your question about blindness to automatic behavior. But before I do, I just want to distinguish between the way we think about evidence in biomedicine and the way we think about evidence in what I call personal science, in a personal context. Because the role of evidence in biomedicine is to explain investigate and justify interventions that will be applied to many people. And that's extremely important, right? If you're going to market a product or put a drug, you know, into dispensaries, right, you have to really know something about how that drug is going to affect the population of people who may be using it. So you need a certain kind of evidence, right? And We have a whole system of developing that evidence. Sometimes people spend literally hundreds of millions of dollars to make that evidence good enough to satisfy regulators, right? But in personal science, we use evidence in a different way. We are not trying to find out what works for people in general, or even necessarily what will work for us. for all time.

[00:13:18.430] - Gary Isaac Wolf

What is the absolute answer to our question? What we're trying to do is improve our reasoning power in the moment so that we know a little more tomorrow than we knew today. And even if we don't get to the kind of level of certainty where you would feel comfortable standing up in front of a room and say, hey, if you doubt your cognition, you should do this particular test, and then you'll either know that you're doing well or know that you're doing poorly for sure.

[00:13:44.020] - Dr. Lemanne

Right.

[00:13:44.260] - Gary Isaac Wolf

Because you'd have to be— you'd have to have a good evidentiary basis to really get up there in front of a group of people and make that claim. But if you just want to know a little more tomorrow than you know today about yourself, then you can do some simple tests and think about what they show you and what you've learned. So for me, anecdote is a very loaded term, right? Anecdote is often used to say, hey, your evidence is not good enough. to make a claim about something that people should follow and believe. Okay, fair enough. And, you know, you're— maybe the claim is not good enough to tell other people what to do, but maybe it nonetheless gives you insight into what will help you. And that kind of evidence, I don't think we should really even call it an anecdote anymore. I think we should call it Like good empirical evidence that aids your own reasoning power. So I like to make that distinction really clear, right? Because otherwise people get confused and they say like, oh, I did this, but I'm not sure I really learned anything because I didn't do a double-blind placebo-controlled trial, right?

[00:14:56.170] - Gary Isaac Wolf

And then I have to try to explain as best I can that for learning something for yourself, you may not have to do the same kind of evidentiary labor that you would have to do if you were trying to practice on somebody else.

[00:15:09.820] - Dr. Gordon

But the message I took away first, you know, like a deer-in-the-headlights kind of thing, is I can't— I considered what I did yesterday an anecdote. I did one thing one day, and I hung my hat on it. Oh, wait a second. I should at least do it a week, and I can make any little observation I want, and then that turns it into From anecdote to experience or somewhere that would be more logical.

[00:15:37.480] - Gary Isaac Wolf

Right. So one way you could think about that is you got a little tiny clue, a little tiny hint, but you're not that certain about how much reliance you should place on that little hint. Still, a hint is important, right? Like something happened and, and it kind of steers your attention in this direction. I made this change. And while it didn't make things worse, it seemed to make things better. Then you can ask, okay, how do I get some more certainty? How do I, how do I really build my knowledge based on the tiny step I just took today? Is there a second step I can take tomorrow? And that's where the technique comes in.

[00:16:17.760] - Dr. Gordon

Yeah.

[00:16:18.510] - Gary Isaac Wolf

I think of scientific thinking as basically skilled practice. It's a skill. It's like all the other skills we have. We can get better at cooking, we can get better at playing music, right? We can get better at a sport. But the way you get better is you, you do it, and then you think about how to improve, and then you do it again. So for instance, when you think you see an effect, of course, the logical next thing is to do the same thing again the next day.

[00:16:47.710] - Dr. Gordon

Mm-hmm.

[00:16:48.520] - Gary Isaac Wolf

And to see if the effect continues. Now you build some confidence. If it's not too risky, maybe you say, well, what if I stopped doing that thing? And then you stop for a certain period of time and see, wait, does the effect that I thought I saw go away? That is a structured way of thinking. And if you also at the same time keep some good records, and I don't mean complicated records, right?

[00:17:13.530] - Dr. Gordon

And that's the key, is to not just be winging it, but it's— I could have a page in a notebook. No big deal.

[00:17:21.480] - Gary Isaac Wolf

Exactly. And, you know, I've noticed in working with lots and lots of people that once you start to use these techniques, you sort of take them for granted and they seem obvious and it seems like I always knew that, but actually everybody has to learn it. That's so— yeah. One of the things that's really useful is to have a dated notebook with the date and the time that you did what you want to explore. Because after a week or 2 weeks or 3 weeks, all that stuff is going to become fuzzy in your memory. And once you have a dated record, there's a lot you can do with that record that will help you learn. For instance, let's say you see the effects some days and not on other days. Now you can go back and look at your record. You're thinking to yourself, I don't think it always works. Seems to work sometimes, but it's not a sure thing. Okay, let's look at my record. Do I notice anything about the days that it worked and the days that it didn't work? Is there a difference between morning and night? Is there a difference between weekday and weekend, right?

[00:18:27.170] - Dr. Gordon

Mm-hmm.

[00:18:27.600] - Gary Isaac Wolf

Is there a difference between when I'm at home and when I'm at work? All of these things really can turn out to be wonderful clues, and they build on each other. So over time, you end up with a much more solid way of thinking about your question than you had at the start.

[00:18:45.270] - Dr. Gordon

That's, uh, well, I always love a good dated notebook, but I love the idea. And I can just imagine, you know, I'll write in blue pen all the notes about this, but if I decide, because I'm very inspired now, to start observing some other things, one of the— that I'll have to do a different color pen in the notebook for a different observation. But One of the observations that one of the people shared was— so the book is interestingly laid out in that there's a lot of explanation of your principles, but you also have shared the records of many individuals who've done their own personal trials, quantified their self. And one of them, the question just knocked my socks off, which is, What— how many concentrated work episodes, and maybe he said a certain duration, do I do in a given day? I'm sure it's less when the dog is home and my wife's at work. And he found it was exactly the opposite, which I had to share with my wife yesterday because, okay, I should be able to work when the dog's home and you're not.

[00:19:54.980] - Gary Isaac Wolf

Yes. Yeah, I think that is a great example of You know, you try something once and you think you found the explanation, and then you turn the dial back to where it was before and you discover it doesn't work as well as you thought it did. And I think even one— we call those ABA trials. A is the first condition, B is the second condition, and A is going back to the first condition again, right? It's like, turn it on, turn it off again.

[00:20:24.980] - Dr. Lemanne

Right.

[00:20:25.240] - Gary Isaac Wolf

Turn it on again. Does it happen every time? It's just a 3-phase research design, and yet it is so powerful. It's like learning the 3 chords, right, of, you know, a musical piece that you want to play, and you're thinking, well, those are only 3 chords, but it actually sounds like a song, and I can do a lot musically with 3 chords, a lot more than I thought.

[00:20:50.620] - Dr. Gordon

Yeah.

[00:20:51.210] - Gary Isaac Wolf

I think the ABA research design is very similar to that. You can learn so much from it.

[00:20:58.710] - Dr. Lemanne

Well, one of the things that I am really interested in is the idea that we can start to make much more concrete how we look at the edges of medicine, which is the single patient. And I was at a meeting in 2017, I think it was about the time I was involved in the quantified self movement a lot, and somebody from some large government research agency, maybe the FDA or the NCI or something like that, stood up and said, hey, all of you oncologists, I'm paraphrasing, of course. You've been doing large randomized controlled trials in advanced metastatic cancers of late adulthood, like breast cancer, lung cancer, colon cancer, and You've been doing these for decades. They cost billions of dollars per decade, and they take 5, 10 years to get results, and you've gotten zero cures.

[00:21:57.030] - Gary Isaac Wolf

Zero.

[00:21:57.980] - Dr. Lemanne

Out of this, all of this work for several decades, 3 or 4 decades, and the next thing he said was, in the next 10 years, what I'd like to see is that every cancer patient becomes an N-of-1.

[00:22:11.440] - Gary Isaac Wolf

Wow.

[00:22:11.940] - Dr. Lemanne

And so that was 2017, so we have one more year to get there, but it shows that the thinking is moving and that we can, you know, and Gary, one of the things that you've done is help in the quantified self movement, help move this to a more designer place. You're learning how to do the numbers and the math and the statistics With single patients, and every patient already is, in my realm, in cancer, every patient already is, in some sense, and I don't mean this formally, but they are an N of 1, in that I don't know if the treatment that is prescribed for them by the standard protocols is going to work for them. It generally works in a minority of patients. If we get a 3% improvement in survival in, for instance, certain types of breast cancer, we consider that a win in oncology.

[00:23:08.680] - Dr. Gordon

Right.

[00:23:09.120] - Dr. Lemanne

And so one of the things that I am really interested in, and so you mentioned the ABA design, which is, you know, we can't do, I guess we could do randomized controlled trials within a single person. That's kind of what, you know, if you're using an ABA design, that's kind of using yourself as a control, I guess. Can you talk a little bit about the things that you've learned in terms of, you know, this book is so rich in The types of data that people collect and the way that they organize it. And so for cancer patients, I think that's going to be really helpful to have these different ways of collecting data and looking at them. And they'll probably figure out things that we don't know. And in fact, I think that's what's going to happen. But I wonder what you think about the field of oncology, especially where I—

[00:24:04.200] - Dr. Gordon

Yeah.

[00:24:04.860] - Dr. Lemanne

live, I generally work with patients who have a diagnosis that is considered incurable with current treatments, and they're looking to, of course, improve quality of life, but a lot of patients are actually looking for ways to extend their survival. And are there any ways that you might counsel patients to look at things? So, for instance, And me, I would use circulating tumor DNA, which is a biomarker that is useful in a lot of cases. PSA, prostate-specific antigen, is something that we use a lot in oncology and other bloodborne tumor markers and imaging, things like that. But what have you seen in the field of quantified self that gives you some, you know, some new ideas about how we can approach each cancer patient? That's kind of a loaded question.

[00:24:59.130] - Gary Isaac Wolf

No, it's not. Also, it's loaded, yes, but also, you know a lot more about cancer therapies than I do. So I wouldn't presume to lecture you on cancer therapies, but I would say that when it comes to the individual, of course, I know many people who have had cancer and been treated for cancer. And so when it comes to the experience of dealing with cancer. I know, as I know you know, that many parts of that experience are not accounted for in the traditional therapeutic context, right? So for instance, a practitioner will say, you know, you're going to do a course of chemotherapy, and I know you're frightened about the effects that that's going to have on your life, and we're going to watch how you handle it.

[00:25:55.550] - Dr. Lemanne

Right.

[00:25:56.240] - Gary Isaac Wolf

And we're going to adjust as well as we can to make it something that you can tolerate and get through because we think there's a chance it could help you and that the suffering is going to be worth it along the way. But in that little conversation about we're going to watch and see how you do and see how you tolerate it, there are 100 questions that people have. And those questions are not necessarily well answered just by asking, as you know, how are you doing?

[00:26:26.860] - Dr. Lemanne

Right? Exactly.

[00:26:28.130] - Gary Isaac Wolf

Yes. You actually need to be able to make some observations and to work with your clinician, right, to incorporate those observations into the course of therapy. And I think that's probably where the biggest impact from Quantified Self and personal science techniques can be felt just immediately in cancer therapies. When you ask about what are some markers, how do we, you know, find ways to truly extend longevity under, you know, the more serious diagnoses for which our therapies aren't as useful as we very much wish they would be, then I get very deeply out of my depth.

[00:27:08.040] - Dr. Lemanne

Yeah. Well, how would you help one of— a person with that kind of an issue? You know, how could you find one question that might be worth investigating? And so you don't, you know, chase every single, you know, you have an unmanageable spreadsheet that, you know, you can't control. And, you know, do you like to, for those patients, have you found that they will do well with like a symptom-directed intervention or, you know, biomarkers or trackers? Are there anything?

[00:27:40.740] - Gary Isaac Wolf

Well, let's talk about symptoms for a moment. I mean, symptoms are very important. to all of us when we get sick. So by symptoms, I mean the noticeable effects on your life, either of the disease or of the therapies, right? The what we call side effects. So those are symptoms, right? Symptom tracking is extremely useful for people, but it also has some traps. And I've seen both of those in Quantified Self practice. The one probably most important trap for people with serious and/or chronic conditions is paying attention to debilitating symptoms or just really, you know, unpleasant symptoms is discouraging. And asking yourself constantly, Mm-hmm. You know, how bad is this symptom? This is not something that is good for your mind, right, as you're trying to gather and maintain your resources. So for people with really serious symptoms and chronic conditions, a couple of tricks that seem to work. One is people just turn the question around and they track things For instance, what my friend Sarah Regari, who's had Parkinson's for several decades, calls feel-good time. So instead of tracking off time, in a sense, you track on time. And when you experience a period where you're doing well, that's what you make a note of instead of a period where you're doing poorly.

[00:29:25.040] - Gary Isaac Wolf

So that's one trick of tracking. It seems kind of obvious, but once people start doing it, it makes the tracking a lot easier.

[00:29:32.820] - Dr. Lemanne

Oh, that's brilliant. Yeah.

[00:29:34.180] - Gary Isaac Wolf

Yeah. That's really nice for people, right? Or it's much nicer. I think Sarah picked it up, actually, now that I'm thinking about the last time she told me about it. She picked it up from another person with Parkinson's in her community whose name I can't bring to mind right now, but just to credit it properly. But tracking feel-good time is a good trick. Another really good trick is to identify a proxy symptom. So to identify one thing that kind of stands in for your overall state. It might not even be the most important thing, but it's something that's relatively easy to track and you have confidence in it, right? So that can be a very common, easily measured thing like time I woke up. So for instance, somebody suffering from pain as one of their symptoms may experience a lot of early awakening because the pain builds up in the morning and then it wakes them up from sleep and then they can't, you know, go back to sleep, right? So that might not be the most important symptom of their disease, but it's something that kind of stands in for their overall state.

[00:30:46.920] - Dr. Gordon

Mm-hmm.

[00:30:47.370] - Gary Isaac Wolf

And it's just one thing. And it's very easy to track. You can do it manually. What time is it, say, on the clock this morning? It's just once a day. Or of course, there's a lot of devices now that will give you your wake-up time. So finding a proxy symptom is also a really good way to kind of handle the more serious symptom tracking. A third trick, just to say, is what I call a General daily assessment. And that's a single score you give yourself before you go to sleep. So you just look back on your day. I prefer a 3-point scale because it's really easy to use, right? And you just look back on your day and you say a 1 is a— I did poorly today. A 2 is I did about the same as I do on most days. And a 3 is I did a lot better today than I usually do. And that retrospective general daily assessment is also very easy to handle and very meaningful to people. So those are, those are 3 tips I can give you.

[00:31:51.810] - Dr. Lemanne

Oh, that's, that's brilliant. And, um, uh, so, so, uh, I think that gives people a place to start. One of the things that, that kind of follows on this is that throughout the book, one of the themes is how to simplify what could be a very burdensome And can you tell us one of, maybe one of your favorite cases from this, from your book, that where someone, you know, started off with maybe too ambitious or too complicated a protocol and had to simplify, and once they simplified things, things just came into view for them in terms of what they were, what was actually affecting their issue? Yeah.

[00:32:33.080] - Gary Isaac Wolf

Sure. There's a lot of stories like that in the book because it is one of the most important skills. And it's a skill that professional scientists use too, by the way, right? You can't track everything.

[00:32:42.300] - Dr. Gordon

Yes.

[00:32:42.700] - Gary Isaac Wolf

You can't study everything. You have to identify what is the phenomenon that you think is really going to give me insight into the big question I have here. And to just pick one story, perhaps my colleague and co-author Jacob Eglarson, who's Danish, had headaches for many years. And there's hundreds of headache trackers and headache tracking apps out there. And he tried the headache tracking apps and they didn't work that well for him. And the reason was a headache is not that simple a phenomenon, right? Like, okay, I'm going to track my headaches, but does that mean if I have a headache and then it gets kind of better and I don't notice it for a while, but then I realize, oh, now my headache is kind of there again 10 minutes later. Is that 2 headaches, or is it 1 headache? Or I've got my 10-point scale, which is a typical pain rating scale, and I've given my headaches a bunch of 7s, but now I think it might be an 8. Like, how confident am I that the difference between a 5 and a 6 is the same as the difference between, you know, a 6 and a 7, or a 7 and an 8?

[00:33:51.060] - Gary Isaac Wolf

Those seem like minor problems, but one of the things we've learned is If you have a measurement protocol or you're looking at some kind of phenomenon that's fuzzy and it causes you a little cognitive dissonance every single time you do it— oh, I'm not sure I'm doing this right, don't really know the difference between a 6 and a 7, or, you know, I don't really know if I should count this as 1 or 2— over time, you're going to stop tracking.

[00:34:16.080] - Dr. Lemanne

Right.

[00:34:16.350] - Gary Isaac Wolf

That little bit of friction just ruins it, actually, for people. Data that you never collect is much worse than data that is a little bit fuzzy or, you know, has some noise in it. You really need to have the data in order to think about it. So if your method leads to you dropping the process, you've kind of lost before you've started.

[00:34:38.340] - Dr. Gordon

Hmm.

[00:34:39.030] - Gary Isaac Wolf

So Jacob, what he ended up doing was tracking the aspirins that he took. Now, that's not perfect. Because sometimes an aspirin isn't handy, right? You have a headache and you don't take an aspirin, and now you've got sort of a false negative, right? Your record says you didn't have a headache, but probably you did have one and you just couldn't get to an aspirin. So you've got a little bit of inaccuracy in your record. But nonetheless, over time, the number of aspirins that you take is more or less how bad your headaches are. And he found that That simplification of using a proxy measure, how many aspirins I'm taking, instead of trying to tune into whether he had a headache or not, unlocked his entire project.

[00:35:28.320] - Dr. Lemanne

Well, you know, how can you tell whether something's actually meaningful? I mean, that's very, very helpful. So counting the aspirins, there's a little bit of error in there, but it's better than the opposite. How have people determined whether there's a meaningful baseline and it's distinguishing a pattern from an ordinary fluctuation, signal versus noise? Is that something that people can work out themselves, or are they going to have some trouble with that?

[00:36:04.470] - Gary Isaac Wolf

That is something that people will learn Step by step. So the most important thing is to take the first step, to use your intuition, use your creativity, use your ability to reflect on your own situation, use your conversations with your clinicians if you're lucky enough to have a good kind of experimentally minded, you know, sensitive clinician, which many people do. Use that to just start to say like, okay, I think I'm going to track something. I'm going to track my headaches, right? Jacob started tracking his headaches and he got a headache tracking app.

[00:36:37.070] - Dr. Lemanne

Right.

[00:36:38.480] - Gary Isaac Wolf

It was only through doing that that he learned that that wasn't really going to work for him, and he had to think again. He had to go back and say, hey, I don't really like having to rate my headaches. Is there something else I can track? And by taking that step-by-step approach, you will learn what's meaningful. It's almost like any kind of research, and if you've done any research, you know the most important thing is just to ask the question and to Go and try to look up the answer. And if you're not happy with the answer you get, which you probably won't be the first time, you kind of take the next step from there. And before you know it, you've learned more and your skills have developed and your kind of capacity to reflect on your own situation has just grown enough that the next thing you try is going to be better. So you asked another question in there, which was, what about kind of noise? This distinguishing what's the real signal. There are some very good techniques that people have used in the quantified self that are adapted from scientific practice to answer questions like that.

[00:37:44.560] - Gary Isaac Wolf

But before you can use them, you actually have to have some data, right? So you have to have picked out a phenomenon, you have to play with it a little while, see if you can track it in your daily life. Once you get there, you're going to have set of measurements, right? They might be instant records. They might be, this happened at this time. That might be all there is. Or maybe there's a value, right? Like, this is my blood pressure, right? So I have a number associated with that, and I can watch the number go up and down. So then you can use some of the techniques that are in the book or really easily findable to ask questions like, well, what's the typical range?

[00:38:23.910] - Dr. Gordon

Right.

[00:38:24.460] - Gary Isaac Wolf

I have 60 measurements. Can I look at my measurements and say most of them are between here and here, but a couple of them are especially high? Now you're able to kind of zone— zoom in on those high measurements, say, and ask what was different about those times. And, you know, those techniques, they bleed over into statistical techniques.

[00:38:52.630] - Dr. Gordon

Yeah.

[00:38:53.680] - Gary Isaac Wolf

But for most quantified self-practice, you don't need to go very far in that direction. You can sometimes simply like look at your timeline and take a magic marker and like run it through the typical range, right? And see like, oh, most of them are right within this range. And I can see some are higher and some are lower.

[00:39:14.540] - Dr. Gordon

That kind of observation suggests to me that in this daily journal tracker that now I'm obsessed with and I'm going to run home and start creating, It would be good for me not to put in some data that I may not consider would be helpful. So for instance, I do my medication alteration, today is an equally good day, but it was a different day than, you know, some comment about the day so that when you go back and look at your magic marker line and you see those 2 days are high and there's no obvious one's a workday, one's a weekend day.

[00:39:49.730] - Gary Isaac Wolf

Right.

[00:39:50.520] - Dr. Gordon

One was raining, one wasn't. Is there a commentary sort of little section in your note-taking or record-keeping where you put in some seemingly meaningless but perhaps in the future contributory observations?

[00:40:08.200] - Gary Isaac Wolf

That's a great idea, and it matches what many people have done and learned a lot from. In fact, so many people have done something like that that we formalize that a little bit in the method we teach. But this is just a formalization, right, of a practice that's out there. And, you know, your mileage may vary, but we call it foreground and background data. And the foreground data is exactly what you're focused on. It's the thing you're tracking. It's the thing you care about most. It's your pain level. It's whether you have a headache, you know, It's, you know, what makes some people— they're concerned about, say, gaining weight after a surgery where they've lost a lot of weight. Right. So there, then their weight would be, you know, their foreground data. And the background data is all the things you use to explain what might be in the foreground.

[00:41:00.010] - Dr. Gordon

Oh.

[00:41:00.400] - Gary Isaac Wolf

And one of the most useful things to have as background data is just a little short daily note, like a diary note about anything unusual that happened that day. Background data, by the way, is also where a lot of the wearables data lives.

[00:41:14.870] - Dr. Gordon

Mm-hmm.

[00:41:15.270] - Gary Isaac Wolf

People think they're gonna use the wearables data to answer their questions, but a lot of the wearables data is pretty generic, right? It tells you, was I— you were active that day, how many steps you took. It tells you maybe a sleep score. Did I sleep well or did I sleep poorly? You know, it provides some background, that you might find really useful, but typically your core questions are not just going to be packaged up in that wearable data. You still need a foreground observation, and that foreground observation is kind of truly your own. It's what you've decided counts.

[00:41:54.110] - Dr. Lemanne

Well, this— I've just got to put this in. One of the things that's, you know, has been— was really pivotal in my entire career was Watching the quantified self movement, and correct me if I'm wrong about this, Gary, but watching the quantified self movement aid and push and really develop the artificial pancreas, which is, you know, it sounds a little bit funny, but it's basically a continuous glucose monitor connected to an insulin pump.

[00:42:24.430] - Dr. Gordon

Okay.

[00:42:24.920] - Dr. Lemanne

Via usually your iPhone, and it was, you know, questionably, it was a legally murky area, but patients were doing this literally in their garages, And they would have quantified self-meetings in San Diego about how they did this. And so the wearables, which the CGM is one that I use a lot with my patients, has turned out for me to help patients. It's turned out to be very, very important. And I also— and the Oura Rings and the Whoops monitors and all those with the sleep scores.

[00:43:01.320] - Dr. Gordon

Yeah.

[00:43:01.670] - Dr. Lemanne

Beautiful. And one of the things that really, really touched me, moved me, stirred me about your book, Gary, was the fact that a lot of people made huge discoveries with a pen and a notebook and maybe a little pocket clicker. If you want to talk about these high-tech interventions—

[00:43:24.020] - Dr. Gordon

Stress.

[00:43:24.710] - Gary Isaac Wolf

Stress.

[00:43:25.690] - Dr. Gordon

A stress button. I wanted one of those.

[00:43:28.660] - Dr. Lemanne

The question embedded in all of this is, how do people flip between these? I think you're already onto that somewhat, but I think if you want to talk a little bit of how you see people flipping between these things and how that advances their ability to ask really fantastic questions. I guess I think that's the crux of this frontier. You get to the edges, you measure what you can, and in the beginning of your book, you mentioned if you have new tools, you can make new discoveries. So you do that, and then there are very simple tools that you can use to answer the bigger question, like, okay, my glucose is changing. How do I feel when that happens?

[00:44:12.700] - Gary Isaac Wolf

Yeah.

[00:44:14.660] - Dr. Lemanne

So— I just want to hear how your mind works when you think about these.

[00:44:17.370] - Gary Isaac Wolf

Yeah. And the open-source Automated Pancreas System, incredible tool, right? I mean, they really advanced Not just technically, but also, if I can say, epistemologically, how we think about data and how it can be used in daily life. And just to, you know, get the history right, when Dana Lewis and Ben West and the other people who were really moving the DIY glucose measurement world forward were developing that automated pancreas system. So that was for sure not us, although we were on the scene and learning as much as we possibly could. And Dana presented many times as part of the Quantified Self community, so we do have a right to kind of claim her. But that work really came out of the Type 1 community, right? Because they are dealing with daily measurement under conditions of life and death.

[00:45:26.060] - Dr. Lemanne

Mm-hmm.

[00:45:26.770] - Gary Isaac Wolf

And I think overall, the quantified self movement learned a lot from what people were— who were dealing with Type 1 diabetes were doing. And why is that world so technologized? It's so technologized because it's actually very difficult what they're trying to do. I mean, they're trying to replace the function of a human organ so that these really serious risks and symptoms can be ameliorated or avoided, you know, completely. Right. So, so that takes some heavy-duty technological development, technological work. Most of what happens in the quantified self community does not require that kind of technological daring-do. Thank goodness, right? Because you really have to be in a special place to be able to create a DIY automatic pancreas system in terms of your training, right? And your networks and your also experience and understanding. Most of what happens in the quantified self community requires some willingness to tinker with the tools you have, but at a much simpler level where you ask, what do I need to do in order to observe the thing that I care about most? And in order to answer that question, you actually have to reflect on what you care about most.

[00:46:57.200] - Gary Isaac Wolf

So, for instance, I do want to get back to the question you asked earlier about blindness to automatic behavior. Because the world of cognition tracking is a really good example where people sometimes get confused by the complexity of the tools.

[00:47:12.930] - Dr. Gordon

Mm-hmm.

[00:47:13.560] - Gary Isaac Wolf

And so they take cognitive assessments and then they start to mistake the scores they get on the assessments for, you know, the kind of goals that they have. But really those scores, you know, they They require some expertise to interpret, some sensitivity, and some context that often goes missing when you just do online versions.

[00:47:37.700] - Dr. Gordon

Mm-hmm.

[00:47:38.300] - Gary Isaac Wolf

So what's the most important thing when you're doing a self-experiment or pursuing a personal science question? It's to really reflect on what you care about. What is it that matters to you? Don't start with the tool. Don't start with, how can I use this complicated tool and get the most out of it? Start with what you care about. And once you have a focus on what you care about, you're going to find out probably that there are a number of different paths to learn more and to increase your agency around finding the answers that you need. Sometimes those tools will be very technically demanding. There are cases where you need technical skills And then you either have to develop them yourselves or hopefully partner up with a clinician or somebody else who has access to advanced-level tools. But often, even in that, you can then dial back once you learn a bit of what you want to know. And I'll give you an example from my own self-tracking. I was very concerned about a cardiac arrhythmia that I have. It's very annoying. It's debilitating at its worst. So I, you know, have to go lie down and stop work.

[00:49:02.110] - Gary Isaac Wolf

And so of course I saw a cardiologist. And the cardiologist, ton of knowledge, ton of techniques, technologies. I got complete workup. I got a really good diagnosis, which is that I have—

[00:49:15.320] - Dr. Lemanne

Atrial fibrillation.

[00:49:16.890] - Gary Isaac Wolf

PVCs, which is a common arrhythmia, not super dangerous, but, you know, it's annoying and, you know, at the margins it can be dangerous. And there were probably some things I could do about it, including some medications I could take. All right. So that's where the cardiologist got me. Pretty far. Pretty great. Right. But now I have to titrate my medications. I have to choose between medications. I have to balance the side effects.

[00:49:43.950] - Dr. Lemanne

Right.

[00:49:44.490] - Gary Isaac Wolf

Right. And to do all of that, I had to do some measurement. I had to know, okay, how bad are my PVCs?

[00:49:51.300] - Dr. Gordon

And how bad does the medicine make me feel?

[00:49:53.700] - Gary Isaac Wolf

Or— Exactly. Exactly. So my focus, my foreground observation is how many PVCs do I have? Okay. What's the rate of PVCs? Cardiologists find that really easy to answer because they put a Holter monitor on. And they can tell exactly how many PVCs I'm having. However, that cost me $300 for 2 weeks, and I don't get the data, right? The data just goes to the cardiologist and I get a PDF. I can't really do my year-long personal science project using this complicated medical measurement technology. But what I could do is use my 2 weeks with that technology to see how closely does it match my own self-recorded sense.

[00:50:38.580] - Dr. Gordon

Right.

[00:50:39.350] - Gary Isaac Wolf

of my PVCs, right? So I tracked for myself using a really simple method. Do I notice a PVC episode right now? Of course, I'm only tracking in the daytime, right? So the numbers don't match, right? The Holter monitor is—

[00:50:51.960] - Dr. Gordon

24/7.

[00:50:52.520] - Gary Isaac Wolf

Going to track all night long, and I'm not making any observations at night. So the numbers are not going to match each other. But I could see that on 8 out of 10 days, the numbers rose and fell In an almost completely similar pattern.

[00:51:09.410] - Dr. Gordon

What a gift.

[00:51:10.450] - Dr. Lemanne

What a gift.

[00:51:11.560] - Dr. Gordon

Oh, my observations are accurate.

[00:51:14.460] - Gary Isaac Wolf

My observations are accurate using a very simple measurement method that doesn't cost me anything and that I don't have to go back to the doctor for. And now with that measurement method, I was able to really do some wonderful things just for myself, right? Nothing I would And I feel confident telling somebody else to do. But one of the things I learned, for instance, was for myself— I'm not saying I made a discovery that nobody's ever made before, but I learned for myself that there's a kind of feedback loop with the PVCs. So the more arrhythmias you have, the more you're likely to have. They get in this kind of pattern.

[00:51:53.610] - Dr. Gordon

Mm-hmm.

[00:51:54.010] - Gary Isaac Wolf

So if something drives them high, they may stay high for quite some time. Before they sort of drift back down into a manageable range. And that allowed me to change my medication approach, which was as soon as I feel them going up, I take the maximum allowable dose of the medication, even though I don't like the side effects. Because if I do that for a couple of days, the medication really works. You know, the— it suppresses the PVCs. And once I've got them knocked back down, they stay down for quite a long time until I have some bad luck and they come back, right? I never would have been able to kind of discover that pattern if I hadn't had really good data on how many PVCs I'm having. And I never would have been able to gather that data if I hadn't had that 2 weeks where I used my super casual method at the same time as I used the medical method and gained confidence that I was able to make those observations for myself. Now this, I'll just say one more thing. This is skilled practice. I understand that, right? I knew a lot about how to do this because I've seen so many people do successful self-tracking projects in the past.

[00:53:02.210] - Gary Isaac Wolf

So I've learned a lot from people. So I don't think it's necessarily fair to expect anybody to just tune into that the very first time they do a self-tracking project. Oh, I'm going to have, you know, a calibration phase and I'm, you know, These are a little bit— they require a little bit of skills, but they're not skills that you need a graduate degree for, right? All you really need is to have seen somebody do it a few times, get a little bit of advice, a little bit of hand-holding, sympathetic clinician, right, who kind of can help you through the medical phase of it, and then you're on your way.

[00:53:36.830] - Dr. Gordon

And I think that's one of the real values of your book. You know, I was reading examples of people self-tracking and thought, I'm never going to do that one. And then I'd get a couple pages later and say, oh, that's brilliant. I think I'm going to try that. It has to be suited to whatever I might need tracked and my patience for doing— taking on a new task that— how much effort can I put in that is meaningful so it will be rewarded? And then maybe I'll try something more difficult next time.

[00:54:08.840] - Gary Isaac Wolf

So good that So good that you felt that way because that was really the hardest thing about the book, I think. And what the book really tries to do is just give a range of examples so that everybody can find something that will help them. Because I totally know what you're saying. You don't really care about examples that don't apply to you in the moment, right? You're not trying to learn something to pass an exam. You don't need to know a bunch of stuff that, you know, so I really tried to give a very big range of examples, both in terms of skill level and in terms of the kind of troubleshooting, health-related troubleshooting across a bunch of different domains that I've seen people do in Quantified Self practice. And at the same time, really challenging, I didn't want any examples in there that were kind of magic stories.

[00:54:58.090] - Dr. Gordon

Uh-huh.

[00:54:58.430] - Gary Isaac Wolf

Even though there are magic stories. So of course, People do things that really changes their lives under conditions of a lot of pressure, of conditions that are, you know, challenging. But of course, if you put a magic story like that in, everybody just focuses on what was the intervention. Oh, I, you know, I stopped eating, you know, Irish dairy and my skin cleared up. And now it becomes a story about how nobody should eat Irish dairy or something, which is not the point at all, right?

[00:55:28.340] - Dr. Lemanne

Right.

[00:55:28.650] - Gary Isaac Wolf

So that was really challenging. The stories are kind of light in a way. You don't really see anybody making deathbed recoveries or, you know, having miracles, but that's important because you can't sell miracles, and ethically, that's not fair.

[00:55:44.670] - Dr. Gordon

Yeah.

[00:55:46.260] - Dr. Lemanne

Well, you know, the story that you just told about the heart arrhythmias shows— is soothing to me because it shows that maybe doctors won't go out of style.

[00:55:57.650] - Dr. Gordon

Too quickly.

[00:56:01.040] - Dr. Lemanne

But seriously, the way that you and your doctor collaborated there, how you needed— how both parts were needed, is really helpful, and I hope that, you know, what it does for me is it gets me to ask questions about how can I help my patients more with their tracking, and how can I kind of, you know, fit into things so that they get the most out of it, and I think that That your story with the heart arrhythmias and the mixing it up with the Holter monitor and your own tracking is just beautiful. It really, really illustrates the power of that combination, which I don't think we doctors always appreciate. You know, our patients are tracking. How can we help guide that if we can, and/or help them guide us to know what to track? And I think one of the things in your book is what to track and how to track it. Gary, this has been amazing. Is there anything else that you want to leave our listeners with, many who are struggling with chronic conditions that we doctors are also struggling to address, and ways that we can collaborate and help each other, patient and doctor, with quantified self techniques?

[00:57:18.730] - Dr. Lemanne

Absolutely.

[00:57:19.920] - Gary Isaac Wolf

Well, thank you for asking that question. And since I'm talking to 2 doctors, I do think there's some very important work to do in integrating quantified self techniques into clinical practice. I'm not sure where that integration takes place. I have a suspicion that it's going to be easier with allied health than it actually is with the MDs.

[00:57:44.990] - Dr. Lemanne

Right.

[00:57:45.220] - Gary Isaac Wolf

Right.

[00:57:45.390] - Dr. Lemanne

Say why that you think that.

[00:57:47.160] - Gary Isaac Wolf

Because I think in allied health practice, there's a little more time and a little more grounded connection to the lived experience of the patient, right? So I'm talking about the physical therapist, the nutritionist, the clinical, you know, social workers and mental health professionals.

[00:58:07.560] - Dr. Gordon

The health coach that, you know, that's a whole new field.

[00:58:11.570] - Gary Isaac Wolf

The people who have as part of their remit the question, hey, how are you doing today? How were things yesterday? How are things at home? What are you feeling in your daily life? How has it been taking the medication? Has it been easy to keep it on the schedule that you're supposed to be on? Or has— have you been drifting off that schedule? And if so, why? Right. These are the kinds of questions that really matter in daily life. When you find a doctor who really is able to engage around those questions, you're very lucky. Not every doctor is, is going to be available to you. But I think that the more clinicians in general, especially doctors who are helping people with serious and chronic long-term conditions, have the ability to engage in questions around daily life, the more these quantified self-techniques will become useful because that's really where quantified self-techniques matter. They're not necessarily going to bring in some intervention that the doctor's never heard of and the patient's like, okay, let's try this. Nobody's ever done it for cancer before, but I think if we do it, I could be cured. That's not where this lives.

[00:59:33.830] - Gary Isaac Wolf

This lives in what are all the other questions that come up around the medical treatment that actually make a big difference in whether it goes well or whether it goes poorly. So, you know, if I had my dream, every medical student would do a personal science research project. Because that's the way you teach this, that's the way you learn it. You don't learn it from a book, you learn it by asking a personal question and gathering data in daily life and learning something that really means something to you. I think if it's something that they could be given the moment they walked in, right? Like, what are you concerned about? What would you like to learn more about? What could empirical research and a scientific mindset teach you about yourself as you begin medical school? That question asked to first years, I think, could change medical practice.

[01:00:36.260] - Dr. Gordon

And they can ask a different question each year. You know, it's a, it's, it's a concept that is a little bit outside the usual academic curriculum.

[01:00:51.330] - Dr. Lemanne

And maybe it won't be for too much longer. Gary Isaac Wolfe, a journalist, author of The Quantified Self: Learning to Observe, a brilliant, beautiful, stirring book for people who love such types of excursions. And Gary, would you tell us a little bit about where people can find you and your book and your other work?

[01:01:20.400] - Gary Isaac Wolf

Well, it's very easy. The book is, you know, in all the places you would normally buy books. And if you look up my name, I'm the only Gary Isaac-Wolf out there. And I'm also really easy to find and really easy to email. And I love hearing from people who are doing personal science projects. So if you have a project that you're doing, you want to share the results, you want to ask a question, Definitely get in touch with me. I'd love to hear from you.

[01:01:49.140] - Dr. Gordon

What an invitation! That is a very impressive invitation, and on the behalf of myself and my patients who are going to take advantage of it, thank you.

[01:01:59.170] - Dr. Lemanne

And we'll put links to Gary Isaac-Wolf's online presence, including his book. Pick up a copy. It's fantastic. You won't be able to put it down. Amazing and interesting stories and a new way of looking at how you can direct your own science experiments about your own life and figure out what's important to you and ask a question about it.

[01:02:23.130] - Dr. Gordon

And really understand that there will be pages you go by with your head swimming and going, wow, I could never do that, and 2 pages later you'll go, that's a great idea, I'm gonna do that exactly with my life. So I love the variety of complication and Thank you.

[01:02:45.030] - Dr. Lemanne

If you haven't already, please, please take a moment to subscribe. Your simple click is not abstract. It's not anonymous. To us, it's very, very real. It helps us reach more patients and physicians to challenge the old ways of thinking about health and to keep these evidence-based conversations going. Hitting that subscribe button actually makes a huge, huge difference. And thank you.

[01:03:15.110] - Dr. Gordon

You have been listening to the Lemanne-Gordon Podcast, where docs talk shop.

[01:03:20.790] - Dr. Lemanne

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[01:03:30.590] - Dr. Gordon

Happy eavesdropping.

[01:03:40.120] - Dr. Lemanne

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[01:03:57.040] - Dr. Gordon

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[01:04:09.090] - Dr. Lemanne

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[01:04:23.600] - Dr. Gordon

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[01:04:30.350] - Dr. Lemanne

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[01:04:47.850] - Dr. Gordon

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