Speaker 1: CAUs Media.
Speaker 2: Hello and welcome to the podcast. It's me James. Today
Speaker 2: we have a very special episode in which everyone is
Speaker 2: a doctor. I will believe in discussion, of course, as
Speaker 2: a doctor of modern European history. But I'm joined today
Speaker 2: by venktash Ramnath, who is a practicing pullmanologist, a professor
Speaker 2: at UC San Diego Health, a medical director of several
Speaker 2: it use in royal and urban settings, and also the
Speaker 2: author of the substack be a health architect. Welcome to
Speaker 2: the Shoving Test. Thanks for joining us.
Speaker 3: Great to be here.
Speaker 2: I'm also joined by doctor Carve Holder, a gastro enterologist
Speaker 2: and the host of our favorite medical podcast, The House
Speaker 2: of Pod.
Speaker 3: Of the many you listen to, I'm sure yeah.
Speaker 2: What they might call a super user in a medical
Speaker 2: podcast space you listen to more than most importantly Cave
Speaker 2: of course, our friend, our resident doctor with a useful doctorate.
Speaker 2: So what we want to talk about today is Medicare
Speaker 2: and specifically some of the cuts to medicare. More broadly,
Speaker 2: the I don't know really have to put this challenges
Speaker 2: for people working in healthcare and the Trump administration right.
Speaker 2: We addressed specifically gender affirming care in a previous episode,
Speaker 2: but it doesn't start and end there, right, That might
Speaker 2: be the thing that sort of the culture wars have
Speaker 2: been focusing on recently. But I want to talk more
Speaker 2: broadly about the challenges facing healthcare. So first of all,
Speaker 2: would one of you care to explain medicare for people
Speaker 2: who are not familiar And some listeners might not be
Speaker 2: living in the United States, or they might just not
Speaker 2: have encountered this yet in their life, So could one
Speaker 2: of you explain what this particular sort of type of
Speaker 2: health insurance is and how it's maybe more vulnerable than
Speaker 2: other types to federal government changes.
Speaker 3: I could take a stab at it.
Speaker 4: I'm not a health policy want but I am a
Speaker 4: physician that has to deal with Medicare all the time.
Speaker 4: So Medicare, in sort of general terms, is a type
Speaker 4: of health insurance that is provided by the federal government.
Speaker 4: It is almost exclusively for individuals above the age of
Speaker 4: sixty five, as it dates back to the nineteen sixties
Speaker 4: with Lyndon Johnson's Great Society Program, and so since that
Speaker 4: time there has been this blanket coverage for any individuals
Speaker 4: above that age, such that all their medical services or products,
Speaker 4: whatever they need for their healthcare is actually covered by
Speaker 4: the government.
Speaker 3: This is the federal government.
Speaker 4: Now, the interesting thing about Medicare is that there are
Speaker 4: different parts to it. There's Part A, which is primarily
Speaker 4: for some essential services and includes hospital care. There's Part B,
Speaker 4: which includes whatever physicians fees go into that healthcare. And
Speaker 4: then there's Part D, which relates to pharmaceutical prices, so
Speaker 4: your drug costs. It's not comprehensive in the sense that
Speaker 4: there's always something more that individuals need, but Medicare, for
Speaker 4: all intents and purposes, is the sort of standard and
Speaker 4: it should cover most of individual's needs. Now that said,
Speaker 4: the commercial payers, that is, the other insurance companies that
Speaker 4: are not federally government sponsored, take their lead from Medicare.
Speaker 4: So a lot of the different payment rates or coverages
Speaker 4: and services they all look to what the centers of
Speaker 4: Medicare and Medicaid services dictate as far as what is
Speaker 4: an acceptable reimbursement rate, what are the rules around what
Speaker 4: should be covered and what should not. So that's why
Speaker 4: Medicare is such an important entity for the United States.
Speaker 3: Yeah, I'll add to that.
Speaker 5: They set the lead of importance here too, because if
Speaker 5: we're talking about telemedicine telehealth, how important that is to
Speaker 5: medicare patients to everyone in the country at this point.
Speaker 5: Then if they are to cut it, if that happens,
Speaker 5: as I think we're probably going to discuss. If that
Speaker 5: goes away, then the other private insurance companies are going
Speaker 5: to follow.
Speaker 3: That's right.
Speaker 5: It could be across the board changes led by these
Speaker 5: changes of medicare.
Speaker 2: Yeah, so let's talk about those changes. Then, as you
Speaker 2: mentioned right, there's this telemedicine it's a waiver right that
Speaker 2: has allowed telemedicine to be funded through this for the
Speaker 2: last five years. I suppose it's going to expire by
Speaker 2: the end of this month, which is March twenty twenty five.
Speaker 2: If if you're listening later, explain like why telemedicine has
Speaker 2: been such a positive step like in healthcare since if
Speaker 2: you could since twenty twenty and then what we're facing
Speaker 2: if it's no longer funded federally.
Speaker 5: May I'll start this one, but Venkesh definitely want you
Speaker 5: to weigh in on it as well. Does give a little background.
Speaker 5: Over the past five years that's grown quite a bit
Speaker 5: and it's gone from being kind of this emergency stop
Speaker 5: gap to a real cornerstone of what we consider modern healthcare,
Speaker 5: and now it's exceedingly common, like over seventy five percent
Speaker 5: of hospitals in the US connect at a distance via
Speaker 5: video conference or some technology to patients. And it's been
Speaker 5: popular on both sides. It's been popular on both sides
Speaker 5: of the aisle. When it first was done, as you mentioned,
Speaker 5: during COVID, when they said, Okay, we're gonna peel back
Speaker 5: some of the restrictions on Medicare coverage for these telehealth things,
Speaker 5: it was considered like a victory, like one of the
Speaker 5: few good things that come out of COVID.
Speaker 3: Both sides liked it.
Speaker 5: It was popular amongst patients, it was popular amongst medical providers.
Speaker 5: It was good for Republicans and Democrats alike. And as
Speaker 5: you mentioned, it's been kept going through being put in
Speaker 5: some bill or another since it was initially put in
Speaker 5: I think as they called twenty two, and it's been
Speaker 5: put in one bill or another to go with a funding.
Speaker 5: But then came this last December when Congress was going
Speaker 5: through their spending. It was only given this three month
Speaker 5: reprieve which is going to be up as you mentioned,
Speaker 5: at the end of this month, and if it goes away,
Speaker 5: there's a lot of factors will go into a lot
Speaker 5: of them. But there's a lot of people, older patients,
Speaker 5: you know, compromise patients who don't want to come into office,
Speaker 5: people with disabilities, people can't get around that well, people
Speaker 5: in rural areas, which is you know, really how it started.
Speaker 5: People who are going to be hurt all across this country.
Speaker 5: And at this point, the majority of people have had
Speaker 5: at least one experience or more in a year with telemedicine.
Speaker 5: It's become a part of a lot of people's lives.
Speaker 5: And if it goes away, you know, there's still going
Speaker 5: to be health care as it is. I mean, it
Speaker 5: doesn't mean health care is going away, but it is
Speaker 5: going to put a tremendous burden on patients and hospitals
Speaker 5: for that matter, across the country.
Speaker 3: Yeah, let me let me add to that.
Speaker 4: So, you know, telemedicine has been around for a very
Speaker 4: long time, at least technically speaking, right, I mean, you
Speaker 4: can go back to the nineteen seventies. Even when you
Speaker 4: talk about the intensive cared it which is where the
Speaker 4: sickest people in the hospital are. There are studies that
Speaker 4: come out of the nineteen seventies. However, Ever, since people
Speaker 4: have had iPhones and been on Airbnb and everything else.
Speaker 4: Since two thousand and seven, that inflection point actually had
Speaker 4: a wave of opportunity that washed right into medicine, and
Speaker 4: as Cave is saying, you know, we have such a
Speaker 4: fragmented healthcare system that has you know, folks living in
Speaker 4: rural areas, suburban areas, and urban areas, all of whom
Speaker 4: are at the mercy of what specialists may be. They're
Speaker 4: contracted at any given time for any given specialty. Now telemedicine,
Speaker 4: as it's gotten more and more popular, has kind of
Speaker 4: leveled the playing field. I mean, you can be in
Speaker 4: a rural place like where I'm sitting right now on
Speaker 4: the US Mexico border, or you can be in New
Speaker 4: York City, you know, one of the densest populations, but
Speaker 4: you may might not have access to specialty expertise without telemedicine.
Speaker 4: With telemedicine, you can now have access and I've seen
Speaker 4: patients love it. You can deal with the sickest of
Speaker 4: the sick, like I said, intensive care units, but you
Speaker 4: can also have outpatient experiences. And we've seen a number
Speaker 4: of different you know, commercial opportunities that have leveraged that.
Speaker 4: But the point is that as as we're hearing on this,
Speaker 4: you know, it's become sort of a standard operating procedure
Speaker 4: for how we deliver healthcare. And if you just pull
Speaker 4: the rug out from that, there can be some you know,
Speaker 4: unintended consequences to that that are not insignificant.
Speaker 2: Yeah, and like it makes a lot of sense to
Speaker 2: a lot of people, right, Like I think about my
Speaker 2: own experience with it. I was traveling recently and got
Speaker 2: COVID like a couple of months ago, and there was
Speaker 2: no need for me to go to a clinic and
Speaker 2: be around other people, right, I just needed to contact
Speaker 2: my doctor and get some prescriptions check in, And like
Speaker 2: it was so much better that I could do it
Speaker 2: in my pajamas from a bed rather than like having
Speaker 2: to get out. And I'm lucky to have access to
Speaker 2: a car. It can drive to the doctor's surgery is
Speaker 2: not that far away. Have a job that accommodates my schedule.
Speaker 2: But there are a million reasons way it might be
Speaker 2: very beneficial to people. So let's talk about you. You
Speaker 2: mentioned this before, but we have commercial insurers, and like
Speaker 2: people might think that this is limited to older folks,
Speaker 2: or it doesn't affect them, or it's something that only
Speaker 2: impacts people who have Medicare. But as you said, Medicare
Speaker 2: kind of sets the standard for what is covered and
Speaker 2: what isn't covered, right, So can you explain how this
Speaker 2: might end up resulting in it in just a massive
Speaker 2: like a cliff. I've seen it described as a telehealth cliff.
Speaker 4: Yeah, So, I mean basically, the sort of this convoluted
Speaker 4: way that we pay for services is it looks to
Speaker 4: one standard, even though some may argue how did that
Speaker 4: standard come about? But regardless of that, Medicare is the
Speaker 4: central authority that basically tells everyone this is what we
Speaker 4: should be doing, and this is how much we should
Speaker 4: be paying for it. Now, the commercial insurers can decide
Speaker 4: to exceed that if they wish. If they say, have
Speaker 4: an employer who's employees they want to have a special
Speaker 4: contract with, that's fine, that's not restricted. But the bottom
Speaker 4: of what is considered a reimbursable amount is really set
Speaker 4: by Medicare, and so they move the bottom. And so
Speaker 4: if you drop the bottom, you can pretty much well
Speaker 4: assured in this, you know, in a capitalist you know
Speaker 4: sort of mentality that the cost should go down, right,
Speaker 4: I mean, why should.
Speaker 3: You pay more?
Speaker 4: For something that you don't need to write, and we
Speaker 4: see that. We see that every year. Okay, every year
Speaker 4: there's new technology, but the slightly older technology, which is
Speaker 4: again covered by Medicare, they move those reimbursements down. So
Speaker 4: whether it's a sleep study, you know, for someone with
Speaker 4: obstructives leap babner, a difficulty sleeping at night, or it's
Speaker 4: some ophthalmology technology, or it's some ultrasound machine, it doesn't really.
Speaker 3: Matter what it is.
Speaker 4: Medicare is always trying to minimize costs, which is understandable.
Speaker 4: They want to make it cost effective, but they are
Speaker 4: setting the lead so everyone will follow what they do.
Speaker 4: That's kind of the way that our system is sort
Speaker 4: of set up.
Speaker 5: Yeah, you know, I might just add to that that
Speaker 5: aside from all the things we mentioned about it, how
Speaker 5: you know it helps people in rural areas, people with
Speaker 5: difficulty getting places are just really busy schedules. It also
Speaker 5: you know, helps free of hospital beds, helps prevent emergency
Speaker 5: rooms from being overwhelmed, It leads to faster testing, it
Speaker 5: leads to a higher number of people that we can see,
Speaker 5: and in terms of its quality, we know it works
Speaker 5: well and about ninety percent of cases of telemedicine to
Speaker 5: get the same outcomes if the patient was there in clinic,
Speaker 5: and that ten percent that's not it's not clear that
Speaker 5: they're getting in fear your care.
Speaker 3: In most of those cases.
Speaker 5: So it's an effective treatment, and you could make an
Speaker 5: argument that it is cost effective in some ways too,
Speaker 5: particularly clearly for like things like dermatology, pediatrics. These are
Speaker 5: things where it's clearly cost effective to have it, but
Speaker 5: even beyond that, it's not even necessarily I think a
Speaker 5: strong argument that we'll be losing money from it and
Speaker 5: that cutting it would help us in the long run.
Speaker 5: I feel like we're being smart about how to manage
Speaker 5: American healthcare system and how to keep it afloat. TELL
Speaker 5: the Medicine is going to be an important part of
Speaker 5: that going forward.
Speaker 4: I do want to add something here, and I do
Speaker 4: want to be careful about the term, because telemedicine and
Speaker 4: telehealth are not only sort of a catch all, but
Speaker 4: they're sort of used interchangeably, right, and just like anything,
Speaker 4: you have to be specific about the term. So I
Speaker 4: think what we're talking about this on this podcast is
Speaker 4: tell a medicine in terms of a two way audio
Speaker 4: visual interface where you can have a direct face to
Speaker 4: face consultation or interaction with a practicing practitioner. Usually that's
Speaker 4: going to be a physician, but it may be a
Speaker 4: nurse practitioner or other physician extender we call them. But
Speaker 4: just to be clear, you know, telemedicine also extends to
Speaker 4: other types of devices, like wearables, those things that they're
Speaker 4: either you know, trackers that you can wear as your fitbit,
Speaker 4: or a sleep device you know that you can wear around.
Speaker 4: Those kinds of things are kind of put into the
Speaker 4: telemedicine bucket and it's not clear to me at least
Speaker 4: how that is going to change. I think April first
Speaker 4: is when the face to face coverage from a professional
Speaker 4: fee standpoint that is slated to end because they did
Speaker 4: liberalize it during the COVID pandemic and it's been extended.
Speaker 4: I think another year around that and that will that
Speaker 4: will definitely change the dynamic here, but it's not clear
Speaker 4: how much of it extends to other types of remote
Speaker 4: physiologic monitoring services and products.
Speaker 2: Right, Yeah, so something like a glucose monitor or like
Speaker 2: some other yeah, which could be catastrophic for people, right
Speaker 2: if they don't get those those funded. Right, we're going
Speaker 2: to take a little break for advertisements here. Maybe you'll
Speaker 2: get an advertisement for a gluecose monitor or even.
Speaker 3: Insulin can only hope.
Speaker 2: Yeah, Yeah, I'm glad they're taking some of that money
Speaker 2: that they've made me bleed out of my wallet over
Speaker 2: the years and returning it to me in the form
Speaker 2: of podcast advertisements. All right, we're bank Let's talk more
Speaker 2: broadly about I guess the changes in the legislative environment
Speaker 2: for healthcare might be a good way to put it. Like,
Speaker 2: I think if you were an excellent op ed recently
Speaker 2: where you discussed you you were one of the many
Speaker 2: recipients of the five useful things you did at work
Speaker 2: this week email, and I thought you wrote like a
Speaker 2: really good piece about about the varied and critical work
Speaker 2: that you do. Can you talk about, like, what is
Speaker 2: the feeling among healthcare professionals, physicians who have you sort
Speaker 2: of like to speak speak as going into four years
Speaker 2: of possibly vastly reduced government spending and a sort of
Speaker 2: bizarre and haphazard cutting of the federal bureocracy that we're seeing.
Speaker 4: Yeah, it's a tough time, certainly, and coming out of
Speaker 4: the pandemic, this is not what really anybody expected. But
Speaker 4: you know, the stresses have been mounting for quite a
Speaker 4: while right. Healthcare professionals are seeing and feeling more stress
Speaker 4: at work, whether it's you know, the demands of the
Speaker 4: job meaning that there are fewer resources to spend on
Speaker 4: a heightened number of patients with you know, increasingly complex diseases,
Speaker 4: or even just the questions that we are getting from patients.
Speaker 4: You know, a lot of patients now are asking me
Speaker 4: really financial questions. I mean literally, the other day, I
Speaker 4: had a woman who was unfortunately having septic shock and
Speaker 4: was faced with having to amputate her leg, and I
Speaker 4: was speaking with her husband because she was becoming more
Speaker 4: and more delirious, and he was just asking me about, well,
Speaker 4: I'm going to have to sell my house in order
Speaker 4: to fund what might come down the pike as far
Speaker 4: as being at home with services, and I was trying
Speaker 4: to I was trying to kind of get an understanding
Speaker 4: of how he viewed his wife actually going through the
Speaker 4: thing that we're watching in the moment. But it's a
Speaker 4: preoccupation that has taken up a lot of space in
Speaker 4: the room, and it's now coming on to physicians to
Speaker 4: sort of navigate at least some questions and answer those.
Speaker 3: Questions around it. So that's a long way of saying that.
Speaker 4: You know, so physicians and nurses and other healthcare professionals
Speaker 4: are feeing more and more stress in a system that's
Speaker 4: just buckling, right, And the last thing anybody needs is
Speaker 4: to be having to do more without really a clear
Speaker 4: understanding of the purpose around it, right, And we are
Speaker 4: all for a cost effectiveness. We want that to work.
Speaker 4: We also want to provide care irrespective of someone's religious, political,
Speaker 4: or other beliefs. And yet you know, we have to
Speaker 4: work within a system that we kind of are not
Speaker 4: really understanding how they're approaching this issue. Are they are
Speaker 4: they with us or against us or somewhere in between.
Speaker 4: It's it's sort of a it's a moving target, and
Speaker 4: so I think that's what's that's what's kind of sandwiched
Speaker 4: a lot of healthcare professionals and we don't really know
Speaker 4: where to turn for some of the answers that we
Speaker 4: ourselves are looking for.
Speaker 5: I would add also, you know, we're seeing this active
Speaker 5: dismantling of the US healthcare infrastructure, and our friends in
Speaker 5: the academic world in particular, it's a very stressful time
Speaker 5: for them. Who knows if their studies are going to
Speaker 5: go through. Who knows if they're going to get their funding,
Speaker 5: who knows what's going to stay, what's going to go
Speaker 5: in the next couple of years. There's a lot of
Speaker 5: concern over that, obviously, But even in the medical world
Speaker 5: outside of the academic centers, I know a lot of
Speaker 5: doctors right now are concerned and they're concerned about what's
Speaker 5: going to happen to the state of our scientific community
Speaker 5: that helps us with new advancements in medical technology in
Speaker 5: the coming years. And it seems like, as Ventecha was
Speaker 5: alluding to, we're dismantling all our ability to follow to
Speaker 5: study to really closely track infectious disease in a time
Speaker 5: that is exceedingly dangerous across the world, with rising disease,
Speaker 5: tuberculosis in this country, measles in this country, in Uganda,
Speaker 5: there's ebola again.
Speaker 3: There's threats all over the world.
Speaker 5: And this is one of the worst times I could
Speaker 5: think of to be in this moment of austerity, and
Speaker 5: particularly because so much of it seems unclear to us
Speaker 5: why why these things are being done, you know, is
Speaker 5: it all because of this ridiculous gender ideology? Do they
Speaker 5: actually think they're saving money with some of these things.
Speaker 5: It's a very unclear time. And of course there are
Speaker 5: a lot of people in the medical world, doctors included,
Speaker 5: that are conservative or Republican voters. Getting into conversations with
Speaker 5: them about this is sort of a tough thing to
Speaker 5: do because, like Fintesha mentioned, they, like a lot of us,
Speaker 5: want to make sure we're doing this in a cost
Speaker 5: effective manner, something we talk about and we have been
Speaker 5: talking about in medicine for a long time, particularly academic medicine,
Speaker 5: interestingly enough, which is really on the cutting board. It's
Speaker 5: academic medicine that usually talks about, you know, trying to
Speaker 5: be cost effective. What tests are we going to order,
Speaker 5: what labs do we need to get, how we do
Speaker 5: in this in the most cost effective way. These are
Speaker 5: important things that are discussed and across the political spectrum
Speaker 5: in medicine. I think there is some concern even amongst
Speaker 5: some of the more right leaning doctors. But again it's
Speaker 5: hard because they've gone this far down the road, it's
Speaker 5: hard to know, you know, when they're going to pull back.
Speaker 5: What's the line in the stand for them about what
Speaker 5: is maybe too far for this administration.
Speaker 2: Yeah, and certainly like an area where we're seeing that
Speaker 2: right now is in like public health, right, we don't
Speaker 2: really know. Like I'm going to Texas next week where
Speaker 2: there's currently a measles outbreak. Yeah, and the things that
Speaker 2: we didn't think that we might be seeing in this
Speaker 2: country again, we're seeing again. And like, as you say,
Speaker 2: it's coming at a time when like not just funding
Speaker 2: is unstable, but also like the I guess, like the
Speaker 2: basics of science have been somewhat politicized right to a degree,
Speaker 2: and like people, I don't know if that's something you
Speaker 2: see in your practice, but like certainly, like I was
Speaker 2: talking to a doctor friend who said half their clients
Speaker 2: are now like declining vaccinations as I was there to get,
Speaker 2: you know, every disease that I could get. I have
Speaker 2: a lot of travel vaccinations, so I'm always getting new
Speaker 2: and exciting vaccinations. But I'm making up for some of
Speaker 2: the gap, I guess. But it's uh, it's it's a
Speaker 2: really challenging time right from that perspective as well, like
Speaker 2: the culture around it.
Speaker 3: Yeah, that's right.
Speaker 5: I mean even here in the San Francisco Bay area,
Speaker 5: you know, I've seen more vaccine hesitation than I remember
Speaker 5: ever seen before in the past.
Speaker 4: It's sort of a vaccine question because I think some
Speaker 4: of this is, let's be clear, some of this is
Speaker 4: on our messaging, you know, as healthcare professionals. I mean,
Speaker 4: there are more and more articles. In fact, there the
Speaker 4: Wall Street Journal piece a couple of weeks ago that
Speaker 4: was saying how patients you know, are increasingly not trusting
Speaker 4: their doctors, and there are data to say that we
Speaker 4: don't communicate very well. Right, So there is that, and
Speaker 4: that's on us. And you know, another op ed piece
Speaker 4: in the Boston Globe by Ash's Jaw, you know, did
Speaker 4: a mea culpa around some of the things that public
Speaker 4: health we did wrong.
Speaker 3: We got we got it.
Speaker 4: Wrong in COVID where we didn't you know, deal with
Speaker 4: some of the doubts and lack of evidentiary base for
Speaker 4: masking and some of these other things that basically hurt
Speaker 4: us in the end. So there's definitely that. However, you know,
Speaker 4: restoring the trust in healthcare professionals is sort of like
Speaker 4: a basic step to anyone getting their healthcare. I mean,
Speaker 4: I think people still go to their doctors, Most people
Speaker 4: still trust their doctor to some degree, and I think
Speaker 4: that that's at least a bright spot in where we are,
Speaker 4: because when we've lost that, I think we're really in trouble.
Speaker 4: I mean, that's slipping. But I think that there is
Speaker 4: a way to restore that trust. But it starts so
Speaker 4: that it just starts with a conversation. You know, if
Speaker 4: someone has a vaccine hesitancy or they don't understand what's
Speaker 4: going on, that's the opportunity to open the doors to
Speaker 4: a dialogue. And I think maybe that's you know, maybe
Speaker 4: that's the starting point for any of this. We all
Speaker 4: want cost effectiveness, we all want, you know, transparency. We
Speaker 4: also want to have choices that make sense to us.
Speaker 4: But let's not make it an adversarial confrontation. And I
Speaker 4: think that that goes for both sides. I would add,
Speaker 4: though I agree with you on pretty much all of that.
Speaker 4: I agree that we need to have those conversations, you know,
Speaker 4: if they're difficult. We need to be able to look
Speaker 4: back objectively about things that worked and didn't work. But
Speaker 4: a lot of these sort of mia culpas that have
Speaker 4: come out about like you know, this is where we
Speaker 4: went wrong and why we lost trust, if I'm being honest,
Speaker 4: including that one from Ashishyad, has a lot of in
Speaker 4: my opinion pick me energy. A lot of people who
Speaker 4: are trying to appeal to the incoming administration and be like, hey, look,
Speaker 4: I'm cool too. I'm not always about vaccines, and to me,
Speaker 4: that's just as bad too. And I do think we
Speaker 4: need to have an honest conversation, and I do think
Speaker 4: we need to be clear about how we do scigns.
Speaker 4: Something we need to be able to explain, and you're
Speaker 4: absolutely right, which we didn't do very well is Look,
Speaker 4: we are working with information we have at hand.
Speaker 5: We're doing everything we can. This information may change. When
Speaker 5: it changes, our recommendations aren't going to change too. And
Speaker 5: that is tough. That is a tough message to get
Speaker 5: across because people don't like nuance like that. People don't
Speaker 5: like the uncertainty of that. People want to know yes
Speaker 5: or no absolutely, and sometimes it's hard. It's hard to
Speaker 5: find good communicators and science to do that. But that
Speaker 5: you're exactly right is incumbent upon us as doctors who
Speaker 5: have a sub stack like yours, of a podcast like mine,
Speaker 5: who are academics who have a reach to students and
Speaker 5: beyond to communicate these things. And even though it would
Speaker 5: be awesome if for the next four years my podcast
Speaker 5: was just about farts and poop. I know I have
Speaker 5: to do a lot of this stuff because I know
Speaker 5: how important this is now more than ever. So I
Speaker 5: totally agree it's going to start with conversations.
Speaker 2: I think there's a big difference between this is the
Speaker 2: information we have available and we're doing our best with it.
Speaker 2: When we get new information, we'll do something different if
Speaker 2: that's what that information points to. And these people are
Speaker 2: acting out of malice to deprive you of your rights
Speaker 2: or you know, to which is sometimes what's been suggested
Speaker 2: by some people, and like, I think a good way
Speaker 2: to defeat that, as you say, it's communicating around it.
Speaker 2: It is very sad that, Like when I was doing
Speaker 2: the research for my PhD dissertation, I wrote about first
Speaker 2: I wrote about violence and the Anarchist Builders Union for
Speaker 2: my masters and then I wrote about public health and
Speaker 2: popular sport in the nineteen thirties in Barcelona, and a
Speaker 2: lot of what you saw anarchists doing in Barcelona in
Speaker 2: the nineteen thirties was talking to people about tuberculosis, educating
Speaker 2: people about tuberculosis and explaining what tuberculosis was and where
Speaker 2: it came from. And like that was in nineteen thirty
Speaker 2: one and how.
Speaker 3: Far we've come baby, wow.
Speaker 2: Wow, Yeah, it's great. There were some other things from
Speaker 2: the nineteen thirties which have also made an unwelcome return.
Speaker 2: Juberculosis is not the only one. There's also the Nazi
Speaker 2: salute in large public gatherings in the United States, which, yeah,
Speaker 2: I don't know, and I guess i'd answer for them
Speaker 2: both in the nineteen thirties, and they're the same answers
Speaker 2: that apply now. I think people like people will be
Speaker 2: distressed by this, right, like a lot of people of
Speaker 2: my age and younger I guess folks a bit younger
Speaker 2: than me for the larger part, like the pandemic was
Speaker 2: a life defining event for a lot of younger folks, right,
Speaker 2: and it was a scary thing. It still is a
Speaker 2: scary thing, Like getting COVID still really sucks. And I
Speaker 2: know people who have long COVID and the thought of
Speaker 2: that is petrifying to me. People will be genuinely anxious
Speaker 2: now right at this potential dismantling of public health apparatus,
Speaker 2: like a rise in vaccine hesitancy, less funding for research,
Speaker 2: such that if we enter another pandemic with some novel
Speaker 2: infectious disease, we won't be able to respond as fast. Right,
Speaker 2: the response to COVID for the criticisms of it, like
Speaker 2: the speed with which we had vaccines was amazing. Some
Speaker 2: of that came from like Vancousha's college at UCSD actually,
Speaker 2: or right like salt I guess which is next door
Speaker 2: with free parking, which is nice? So like, what would
Speaker 2: you say to people because this is a thing I
Speaker 2: see more and more among folks who you know, who
Speaker 2: are friends of mine, right, is like real worry about
Speaker 2: infectious disease, real concern about new variants of COVID or
Speaker 2: about you know, the bird flu is one, right with
Speaker 2: these other infectious diseases. I saw fifty people have died
Speaker 2: of it as yet unexplained disease in Congo recently. What
Speaker 2: would you say to those people? Because there concerns are
Speaker 2: somewhat legitimate, right, Like, if we go into another pandemic,
Speaker 2: when going to be anywhere near as effective as we
Speaker 2: were in twenty twenty because of all these combination of
Speaker 2: reasons we've.
Speaker 4: Discussed, that's a hard question to answer. I would say,
Speaker 4: let me back up. You know I think that the
Speaker 4: COVID pandemic, Yes, there are a lot of things that
Speaker 4: went well. The vaccine development was phenomenal, I mean a revolutionary.
Speaker 4: I mean, who would have expected that to happen. However,
Speaker 4: it also just revealed how shattered our public health system
Speaker 4: really is in terms of messaging, even detection, spreading information.
Speaker 4: Even the vaccine distribution was completely chaotic. Right, So, so
Speaker 4: I don't want to say that, you know, the public
Speaker 4: health response during COVID was some sort of paragon to
Speaker 4: be emulated or replicated, right So that said, though, absolutely,
Speaker 4: I mean, you know, how are we going to handle
Speaker 4: a new era of this what if you know scenario
Speaker 4: where we don't know what virus is coming next? I mean,
Speaker 4: I'm seeing these days, I'm even seeing virus is that
Speaker 4: never caused the kind of respiratory failure in the past,
Speaker 4: they're doing it now, whether it's RSV or a respiratory
Speaker 4: sensitial virus or even non COVID coronavirus which should just
Speaker 4: give you a cold the sniffles, and yet it's causing devastating,
Speaker 4: you know, pneumonias. So we're in a new era and
Speaker 4: you know, antibiotic resistance is not getting any less you know, problematic.
Speaker 4: So what do we do in this era. Well, I
Speaker 4: think awareness is the first thing, okay, awareness around. Yes,
Speaker 4: I mean these diseases are transmitted from person to person.
Speaker 4: You know, we all know somebody who doesn't want to
Speaker 4: take a vaccine. I mean, I don't think there's that's
Speaker 4: a surprise to say we know of somebody or directly
Speaker 4: or maybe one degree of separation, right, And I think
Speaker 4: you need to have those community conversations. You need to
Speaker 4: have one on one conversations. Yes, it's going to be uncomfortable,
Speaker 4: but we got to talk about it and talk to
Speaker 4: your healthcare provider about it. I mean, yes, you can
Speaker 4: look up stuff on TikTok. Yes, you could look up
Speaker 4: stuff on Google or or you name your online resource.
Speaker 4: But you want to have a person that can actually
Speaker 4: understand from years of living and living and breathing this stuff,
Speaker 4: and also who listens to you as a human being
Speaker 4: in the same community or somewhere nearabouts right to put
Speaker 4: together what the science says in some sort of meaningful
Speaker 4: way to you, uh, and not some anonymous you know
Speaker 4: resource that may or may not have all the you know,
Speaker 4: all the data their fingertips, you know. So so I
Speaker 4: guess it still goes back to how does anyone find
Speaker 4: reliable information? Where do you go when you've got questions?
Speaker 4: Most people want a human being who's lived and breathed
Speaker 4: this with experience to help them navigate. I I certainly
Speaker 4: see that, not just as a doctor, but as a friend,
Speaker 4: as a family member. I'm constantly you know, they're asking
Speaker 4: me these things, and I would suggest that you know
Speaker 4: your audience may have both personally but also professionally to
Speaker 4: those folks that can help them navigate.
Speaker 5: You know, and to answer your question from my perspective,
Speaker 5: is a challenge. I because I think people should be concerned.
Speaker 3: In fact, I just did two parter.
Speaker 5: With one of the world's best virologists talking about the
Speaker 5: possible bird flu pandemic that could arise and all the
Speaker 5: threats that are out there, and so I do think
Speaker 5: there are some really significant, serious risks to be worried about. However,
Speaker 5: I'm never gonna say there's nothing that can be done
Speaker 5: about it. There's plenty that can still be done about it.
Speaker 5: I still maintain hope in the medical community for what
Speaker 5: we're able to do and what we're able to accomplish.
Speaker 5: And to echo what I think both of you guys
Speaker 5: have said or would at least agree with.
Speaker 3: There's a lot of changes that we can make locally
Speaker 3: amongst our small.
Speaker 5: Sphere of influence, and then growing out from there in
Speaker 5: terms of getting vaccinated, in terms of wearing masks when needed,
Speaker 5: or at least looking at the data with an open
Speaker 5: mind and sharing good resources. Is because one thing that
Speaker 5: the younger population is good about, and what some of
Speaker 5: the people you're mentioning, James, is they're good at detecting
Speaker 5: bullshit online and that's a skill that needs to be
Speaker 5: honed for medical literacy as well, and I'm hopeful that
Speaker 5: that's going to continue to improve. Maybe stupid optimism, but
Speaker 5: I do believe the younger generation is going to continue
Speaker 5: to be better at that than the older generation, and
Speaker 5: I think that will help battle a lot of the
Speaker 5: misinformation that's out there. But there are things that they
Speaker 5: can do in fact, for getting back to the telehealth thing,
Speaker 5: for example, talking about telemedicine slash telehealth as venteche sort
Speaker 5: of broke down in terms of it being cut at
Speaker 5: the end of the month. There are people that are
Speaker 5: really pushing against that, including Rocanna, who's here a legislator
Speaker 5: here in California who's proposed a new bill. I haven't
Speaker 5: been able to see any of the details of it,
Speaker 5: but there are a lot, including Amazon. By the way,
Speaker 5: Amazon is one of like three hundred and fifty companies
Speaker 5: that have written a letter to Congress to help push
Speaker 5: for this funding. So if you can call a congress person,
Speaker 5: if you can do that, if you can keep bothering
Speaker 5: them telling them how important it is, I think those
Speaker 5: are things that can help. So I think that's a
Speaker 5: good place to start.
Speaker 2: Yeah, that's a really get piece of advice.
Speaker 4: If I could just follow up with that. I think
Speaker 4: part of what will help with the support for some
Speaker 4: of these programs is to take you know, take us
Speaker 4: take a few minutes to think about what the other
Speaker 4: side is worried about, right. I mean, we all know
Speaker 4: about the excesses of certain online bad actors, who are
Speaker 4: they use telemedicine to promote you know, ADHD medications or
Speaker 4: other types of psychotropic medications, which was not it was
Speaker 4: not supported, and it actually caused harm. Right, So so
Speaker 4: there are things out there that are excesses and somewhat harmful,
Speaker 4: and if we could as a community sort of help
Speaker 4: frame the approach to dealing with some of those things
Speaker 4: and preventing some of those problems, then I think some
Speaker 4: of the support will kind of sort of show itself.
Speaker 4: I think the worry is if you open up the
Speaker 4: floodgates too wide, you know, human nature being what it is,
Speaker 4: it's going to encourage bad behavior. Not that anybody wants that,
Speaker 4: but there is something to be said about some scrutiny.
Speaker 3: Right, So if.
Speaker 4: We're the ones, and I completely support the use of
Speaker 4: TELL medicine, but I also want to be careful about
Speaker 4: how to promote its thoughtful and safe use and wed
Speaker 4: that in the proposal and not just leave it for
Speaker 4: others to figure out that That I think would potentially
Speaker 4: change the conversation around while you just want this and
Speaker 4: we're not going to give it to you, like the
Speaker 4: standoff will will subside when you try to work it,
Speaker 4: work a partnership out as opposed to a give it
Speaker 4: to me or else kind a scenario.
Speaker 5: I don't disagree with that, but I also think you're
Speaker 5: giving those more credit than I would, which is to
Speaker 5: say that they actually really, they really would focus or
Speaker 5: listen to. I think what they've just done is literally,
Speaker 5: you know, take a chainsaw and cut away at major
Speaker 5: federal funding and then kind of seeing what was really
Speaker 5: bad about that and what wasn't and being like, oh, okay,
Speaker 5: maybe we do need people in charge of nuclear security.
Speaker 3: Oh maybe this is popular. We'll put it back. You know.
Speaker 3: I kind of think that.
Speaker 5: They're not taking as much attention or care, But I
Speaker 5: also do agree that the point is is valid. I mean,
Speaker 5: sure there is there fraud in some telemedicine. Yeah, I'm sure,
Speaker 5: probably small, very small percentage. But if we can specify
Speaker 5: its use, if we can be better about that, I agree,
Speaker 5: I'm all for it.
Speaker 2: Yeah, especially right now. I was just thinking, as you're
Speaker 2: talking about, like how important is people that accessing reproductive
Speaker 2: healthcare and being able to access reproductive healthcare wherever they are,
Speaker 2: and like how much more difficult that would be, right
Speaker 2: if people didn't have telemedicine appointments. So I think we've
Speaker 2: spoken about before on this show. But yeah, I'm sure
Speaker 2: there are some school cases. I'm sure there are a
Speaker 2: bunch of sis gender guys getting gender affirming hormonal care
Speaker 2: through telemedicine who probably could go without and be Okay, guys,
Speaker 2: I'd like to wrap up there, but I want to
Speaker 2: give you a chance both to you talked a lot
Speaker 2: about like science communication. So where can people find you online?
Speaker 2: Where can they see you communicating your medical knowledge?
Speaker 4: Okay, well, so I thanks James. I have a substack
Speaker 4: it's called be a Health Architect. You can book me
Speaker 4: up at be a Health Architect, and you know, I
Speaker 4: have a conversation there around an issue that certainly affects
Speaker 4: me and those around me, which is physician burnout. But
Speaker 4: in the larger sphere of healthcare professionals, it really touches
Speaker 4: everybody in healthcare. So that's where I'm posting actively. I'm
Speaker 4: also sharing that, you know, through various other avenues such
Speaker 4: as X and Blue Sky and other places, so you
Speaker 4: can you can find me there. Look forward to seeing
Speaker 4: you there.
Speaker 3: Yeah.
Speaker 5: I would also recommend Vintechha's substack. If you're in the
Speaker 5: medical field in particular, I think you'll appreciate it. A
Speaker 5: focus on burnout is as important as it's ever been,
Speaker 5: if not much much more. I mean, we were talking
Speaker 5: about burnout moral injury in doctors before COVID, and now
Speaker 5: you know, down a couple of years down the road,
Speaker 5: it's only worse. So I think it's really important and
Speaker 5: I do recommend it, or you know, check out his
Speaker 5: latest article in the Los Angeles Times. As you mentioned before.
Speaker 5: As for me, find me on Blue Sky at Cave MD.
Speaker 5: But more importantly, just listen to the podcast The House
Speaker 5: of Pod. If you are a fan of this show,
Speaker 5: I think you're gonna like The House of Pod if
Speaker 5: you haven't already given it a try.
Speaker 3: It's a lot of the same people that you hear
Speaker 3: on this show. On the House of Pod.
Speaker 5: James included he's gonna be coming back to talk about
Speaker 5: the measles and with an author of a new book
Speaker 5: down there about the measles outbreak. And you know, we
Speaker 5: take a look at grifters, medical grifters, We take a
Speaker 5: look at some people that would be considered medical contrarians.
Speaker 5: We take a look at some of the quackery and
Speaker 5: medicine as well. So I think you'll appreciate this show.
Speaker 5: If you like the whole behind the Bastards verse, I
Speaker 5: think you'll get into the House of Podso so check
Speaker 5: us out wherever you get your podcasts.
Speaker 2: Yeah, great, Thank you so much for joining us. Guys
Speaker 2: really appreciate it.
Speaker 3: Thanks, thank you.
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