WEBVTT - The USA's Impending Telemedicine Cliff 0:00:01.760 --> 0:00:02.880 CAUs Media. 0:00:05.200 --> 0:00:08.479 Hello and welcome to the podcast. It's me James. Today 0:00:08.600 --> 0:00:12.080 we have a very special episode in which everyone is 0:00:12.119 --> 0:00:14.440 a doctor. I will believe in discussion, of course, as 0:00:14.480 --> 0:00:17.239 a doctor of modern European history. But I'm joined today 0:00:17.440 --> 0:00:22.560 by venktash Ramnath, who is a practicing pullmanologist, a professor 0:00:22.600 --> 0:00:26.200 at UC San Diego Health, a medical director of several 0:00:26.200 --> 0:00:29.160 it use in royal and urban settings, and also the 0:00:29.200 --> 0:00:32.800 author of the substack be a health architect. Welcome to 0:00:32.840 --> 0:00:34.440 the Shoving Test. Thanks for joining us. 0:00:34.440 --> 0:00:35.200 Great to be here. 0:00:35.400 --> 0:00:38.640 I'm also joined by doctor Carve Holder, a gastro enterologist 0:00:39.120 --> 0:00:43.600 and the host of our favorite medical podcast, The House 0:00:43.640 --> 0:00:44.040 of Pod. 0:00:44.240 --> 0:00:46.920 Of the many you listen to, I'm sure yeah. 0:00:46.920 --> 0:00:48.839 What they might call a super user in a medical 0:00:48.880 --> 0:00:53.239 podcast space you listen to more than most importantly Cave 0:00:53.400 --> 0:00:57.720 of course, our friend, our resident doctor with a useful doctorate. 0:00:58.200 --> 0:01:03.280 So what we want to talk about today is Medicare 0:01:03.840 --> 0:01:07.240 and specifically some of the cuts to medicare. More broadly, 0:01:08.200 --> 0:01:12.120 the I don't know really have to put this challenges 0:01:13.080 --> 0:01:15.399 for people working in healthcare and the Trump administration right. 0:01:15.400 --> 0:01:19.600 We addressed specifically gender affirming care in a previous episode, 0:01:19.680 --> 0:01:22.399 but it doesn't start and end there, right, That might 0:01:22.440 --> 0:01:24.399 be the thing that sort of the culture wars have 0:01:24.440 --> 0:01:27.160 been focusing on recently. But I want to talk more 0:01:27.200 --> 0:01:30.959 broadly about the challenges facing healthcare. So first of all, 0:01:31.520 --> 0:01:35.679 would one of you care to explain medicare for people 0:01:35.680 --> 0:01:38.000 who are not familiar And some listeners might not be 0:01:38.160 --> 0:01:40.520 living in the United States, or they might just not 0:01:40.560 --> 0:01:42.880 have encountered this yet in their life, So could one 0:01:42.920 --> 0:01:46.120 of you explain what this particular sort of type of 0:01:46.160 --> 0:01:48.960 health insurance is and how it's maybe more vulnerable than 0:01:49.000 --> 0:01:52.120 other types to federal government changes. 0:01:52.960 --> 0:01:54.440 I could take a stab at it. 0:01:54.800 --> 0:01:58.080 I'm not a health policy want but I am a 0:01:58.080 --> 0:02:00.920 physician that has to deal with Medicare all the time. 0:02:01.040 --> 0:02:04.880 So Medicare, in sort of general terms, is a type 0:02:04.880 --> 0:02:08.359 of health insurance that is provided by the federal government. 0:02:08.840 --> 0:02:11.880 It is almost exclusively for individuals above the age of 0:02:11.960 --> 0:02:15.320 sixty five, as it dates back to the nineteen sixties 0:02:15.360 --> 0:02:19.640 with Lyndon Johnson's Great Society Program, and so since that 0:02:19.800 --> 0:02:25.160 time there has been this blanket coverage for any individuals 0:02:25.160 --> 0:02:29.840 above that age, such that all their medical services or products, 0:02:30.280 --> 0:02:33.760 whatever they need for their healthcare is actually covered by 0:02:33.880 --> 0:02:34.440 the government. 0:02:34.480 --> 0:02:35.760 This is the federal government. 0:02:36.040 --> 0:02:38.080 Now, the interesting thing about Medicare is that there are 0:02:38.080 --> 0:02:41.960 different parts to it. There's Part A, which is primarily 0:02:42.400 --> 0:02:47.520 for some essential services and includes hospital care. There's Part B, 0:02:47.800 --> 0:02:53.000 which includes whatever physicians fees go into that healthcare. And 0:02:53.040 --> 0:02:56.520 then there's Part D, which relates to pharmaceutical prices, so 0:02:56.600 --> 0:02:59.920 your drug costs. It's not comprehensive in the sense that 0:03:00.400 --> 0:03:04.720 there's always something more that individuals need, but Medicare, for 0:03:04.760 --> 0:03:08.959 all intents and purposes, is the sort of standard and 0:03:09.000 --> 0:03:14.120 it should cover most of individual's needs. Now that said, 0:03:14.680 --> 0:03:18.280 the commercial payers, that is, the other insurance companies that 0:03:18.360 --> 0:03:22.840 are not federally government sponsored, take their lead from Medicare. 0:03:22.919 --> 0:03:26.440 So a lot of the different payment rates or coverages 0:03:26.480 --> 0:03:30.040 and services they all look to what the centers of 0:03:30.080 --> 0:03:34.079 Medicare and Medicaid services dictate as far as what is 0:03:34.120 --> 0:03:38.640 an acceptable reimbursement rate, what are the rules around what 0:03:38.680 --> 0:03:41.880 should be covered and what should not. So that's why 0:03:42.000 --> 0:03:46.120 Medicare is such an important entity for the United States. 0:03:46.240 --> 0:03:47.920 Yeah, I'll add to that. 0:03:48.320 --> 0:03:51.560 They set the lead of importance here too, because if 0:03:51.560 --> 0:03:55.440 we're talking about telemedicine telehealth, how important that is to 0:03:56.120 --> 0:03:59.640 medicare patients to everyone in the country at this point. 0:04:00.440 --> 0:04:03.320 Then if they are to cut it, if that happens, 0:04:03.360 --> 0:04:05.200 as I think we're probably going to discuss. If that 0:04:05.240 --> 0:04:09.320 goes away, then the other private insurance companies are going 0:04:09.360 --> 0:04:09.720 to follow. 0:04:09.800 --> 0:04:10.200 That's right. 0:04:10.240 --> 0:04:14.280 It could be across the board changes led by these 0:04:14.360 --> 0:04:15.200 changes of medicare. 0:04:15.400 --> 0:04:17.960 Yeah, so let's talk about those changes. Then, as you 0:04:18.000 --> 0:04:21.280 mentioned right, there's this telemedicine it's a waiver right that 0:04:21.320 --> 0:04:26.400 has allowed telemedicine to be funded through this for the 0:04:26.480 --> 0:04:29.760 last five years. I suppose it's going to expire by 0:04:29.760 --> 0:04:32.680 the end of this month, which is March twenty twenty five. 0:04:32.720 --> 0:04:37.279 If if you're listening later, explain like why telemedicine has 0:04:37.320 --> 0:04:41.920 been such a positive step like in healthcare since if 0:04:41.920 --> 0:04:45.279 you could since twenty twenty and then what we're facing 0:04:45.600 --> 0:04:47.520 if it's no longer funded federally. 0:04:48.040 --> 0:04:50.680 May I'll start this one, but Venkesh definitely want you 0:04:50.720 --> 0:04:53.400 to weigh in on it as well. Does give a little background. 0:04:53.839 --> 0:04:56.400 Over the past five years that's grown quite a bit 0:04:56.520 --> 0:05:00.360 and it's gone from being kind of this emergency stop 0:05:00.400 --> 0:05:05.080 gap to a real cornerstone of what we consider modern healthcare, 0:05:05.520 --> 0:05:09.040 and now it's exceedingly common, like over seventy five percent 0:05:09.240 --> 0:05:13.120 of hospitals in the US connect at a distance via 0:05:13.279 --> 0:05:20.200 video conference or some technology to patients. And it's been 0:05:20.240 --> 0:05:22.840 popular on both sides. It's been popular on both sides 0:05:22.839 --> 0:05:26.440 of the aisle. When it first was done, as you mentioned, 0:05:26.560 --> 0:05:31.880 during COVID, when they said, Okay, we're gonna peel back 0:05:31.920 --> 0:05:36.200 some of the restrictions on Medicare coverage for these telehealth things, 0:05:36.760 --> 0:05:39.440 it was considered like a victory, like one of the 0:05:39.480 --> 0:05:41.320 few good things that come out of COVID. 0:05:41.800 --> 0:05:43.120 Both sides liked it. 0:05:43.120 --> 0:05:47.200 It was popular amongst patients, it was popular amongst medical providers. 0:05:47.760 --> 0:05:51.840 It was good for Republicans and Democrats alike. And as 0:05:51.839 --> 0:05:55.520 you mentioned, it's been kept going through being put in 0:05:55.560 --> 0:05:57.720 some bill or another since it was initially put in 0:05:58.320 --> 0:06:01.320 I think as they called twenty two, and it's been 0:06:01.320 --> 0:06:03.800 put in one bill or another to go with a funding. 0:06:04.120 --> 0:06:07.520 But then came this last December when Congress was going 0:06:07.520 --> 0:06:10.360 through their spending. It was only given this three month 0:06:10.440 --> 0:06:12.279 reprieve which is going to be up as you mentioned, 0:06:12.320 --> 0:06:14.680 at the end of this month, and if it goes away, 0:06:14.800 --> 0:06:16.480 there's a lot of factors will go into a lot 0:06:16.480 --> 0:06:20.880 of them. But there's a lot of people, older patients, 0:06:21.080 --> 0:06:23.400 you know, compromise patients who don't want to come into office, 0:06:23.480 --> 0:06:27.040 people with disabilities, people can't get around that well, people 0:06:27.080 --> 0:06:30.239 in rural areas, which is you know, really how it started. 0:06:30.640 --> 0:06:33.440 People who are going to be hurt all across this country. 0:06:33.640 --> 0:06:36.440 And at this point, the majority of people have had 0:06:36.720 --> 0:06:41.040 at least one experience or more in a year with telemedicine. 0:06:41.080 --> 0:06:43.040 It's become a part of a lot of people's lives. 0:06:43.320 --> 0:06:46.400 And if it goes away, you know, there's still going 0:06:46.440 --> 0:06:48.360 to be health care as it is. I mean, it 0:06:48.360 --> 0:06:50.719 doesn't mean health care is going away, but it is 0:06:50.760 --> 0:06:54.800 going to put a tremendous burden on patients and hospitals 0:06:54.920 --> 0:06:56.960 for that matter, across the country. 0:06:57.279 --> 0:06:58.400 Yeah, let me let me add to that. 0:06:58.520 --> 0:07:02.520 So, you know, telemedicine has been around for a very 0:07:02.640 --> 0:07:05.200 long time, at least technically speaking, right, I mean, you 0:07:05.240 --> 0:07:08.240 can go back to the nineteen seventies. Even when you 0:07:08.400 --> 0:07:10.920 talk about the intensive cared it which is where the 0:07:10.960 --> 0:07:13.880 sickest people in the hospital are. There are studies that 0:07:13.920 --> 0:07:18.080 come out of the nineteen seventies. However, Ever, since people 0:07:18.080 --> 0:07:21.040 have had iPhones and been on Airbnb and everything else. 0:07:21.040 --> 0:07:25.520 Since two thousand and seven, that inflection point actually had 0:07:25.560 --> 0:07:29.720 a wave of opportunity that washed right into medicine, and 0:07:29.760 --> 0:07:33.560 as Cave is saying, you know, we have such a 0:07:33.640 --> 0:07:37.480 fragmented healthcare system that has you know, folks living in 0:07:37.560 --> 0:07:42.040 rural areas, suburban areas, and urban areas, all of whom 0:07:42.480 --> 0:07:45.520 are at the mercy of what specialists may be. They're 0:07:45.720 --> 0:07:50.960 contracted at any given time for any given specialty. Now telemedicine, 0:07:51.360 --> 0:07:54.280 as it's gotten more and more popular, has kind of 0:07:54.840 --> 0:07:57.240 leveled the playing field. I mean, you can be in 0:07:57.680 --> 0:08:00.160 a rural place like where I'm sitting right now on 0:08:00.200 --> 0:08:03.080 the US Mexico border, or you can be in New 0:08:03.160 --> 0:08:06.160 York City, you know, one of the densest populations, but 0:08:06.280 --> 0:08:12.240 you may might not have access to specialty expertise without telemedicine. 0:08:12.400 --> 0:08:16.000 With telemedicine, you can now have access and I've seen 0:08:16.080 --> 0:08:18.800 patients love it. You can deal with the sickest of 0:08:18.840 --> 0:08:21.600 the sick, like I said, intensive care units, but you 0:08:21.640 --> 0:08:24.080 can also have outpatient experiences. And we've seen a number 0:08:24.080 --> 0:08:27.520 of different you know, commercial opportunities that have leveraged that. 0:08:27.680 --> 0:08:30.280 But the point is that as as we're hearing on this, 0:08:30.680 --> 0:08:35.160 you know, it's become sort of a standard operating procedure 0:08:35.200 --> 0:08:37.760 for how we deliver healthcare. And if you just pull 0:08:37.840 --> 0:08:40.880 the rug out from that, there can be some you know, 0:08:41.040 --> 0:08:44.120 unintended consequences to that that are not insignificant. 0:08:44.520 --> 0:08:46.719 Yeah, and like it makes a lot of sense to 0:08:46.720 --> 0:08:48.080 a lot of people, right, Like I think about my 0:08:48.120 --> 0:08:51.240 own experience with it. I was traveling recently and got 0:08:51.280 --> 0:08:53.720 COVID like a couple of months ago, and there was 0:08:53.760 --> 0:08:55.360 no need for me to go to a clinic and 0:08:55.480 --> 0:08:57.720 be around other people, right, I just needed to contact 0:08:57.760 --> 0:09:01.240 my doctor and get some prescriptions check in, And like 0:09:01.280 --> 0:09:02.880 it was so much better that I could do it 0:09:02.920 --> 0:09:06.559 in my pajamas from a bed rather than like having 0:09:06.600 --> 0:09:08.920 to get out. And I'm lucky to have access to 0:09:08.960 --> 0:09:11.040 a car. It can drive to the doctor's surgery is 0:09:11.040 --> 0:09:13.400 not that far away. Have a job that accommodates my schedule. 0:09:13.440 --> 0:09:16.040 But there are a million reasons way it might be 0:09:16.120 --> 0:09:20.120 very beneficial to people. So let's talk about you. You 0:09:20.160 --> 0:09:23.240 mentioned this before, but we have commercial insurers, and like 0:09:23.320 --> 0:09:26.720 people might think that this is limited to older folks, 0:09:26.800 --> 0:09:29.440 or it doesn't affect them, or it's something that only 0:09:29.480 --> 0:09:33.240 impacts people who have Medicare. But as you said, Medicare 0:09:33.360 --> 0:09:36.400 kind of sets the standard for what is covered and 0:09:36.440 --> 0:09:38.440 what isn't covered, right, So can you explain how this 0:09:38.559 --> 0:09:41.680 might end up resulting in it in just a massive 0:09:41.800 --> 0:09:44.280 like a cliff. I've seen it described as a telehealth cliff. 0:09:44.679 --> 0:09:48.559 Yeah, So, I mean basically, the sort of this convoluted 0:09:48.600 --> 0:09:52.240 way that we pay for services is it looks to 0:09:52.480 --> 0:09:55.960 one standard, even though some may argue how did that 0:09:56.000 --> 0:10:00.320 standard come about? But regardless of that, Medicare is the 0:10:00.360 --> 0:10:04.920 central authority that basically tells everyone this is what we 0:10:04.960 --> 0:10:06.880 should be doing, and this is how much we should 0:10:06.880 --> 0:10:10.480 be paying for it. Now, the commercial insurers can decide 0:10:10.520 --> 0:10:13.839 to exceed that if they wish. If they say, have 0:10:13.880 --> 0:10:18.600 an employer who's employees they want to have a special 0:10:19.000 --> 0:10:22.760 contract with, that's fine, that's not restricted. But the bottom 0:10:23.120 --> 0:10:27.280 of what is considered a reimbursable amount is really set 0:10:27.280 --> 0:10:30.200 by Medicare, and so they move the bottom. And so 0:10:30.360 --> 0:10:33.160 if you drop the bottom, you can pretty much well 0:10:33.200 --> 0:10:35.280 assured in this, you know, in a capitalist you know 0:10:35.360 --> 0:10:38.280 sort of mentality that the cost should go down, right, 0:10:38.320 --> 0:10:39.479 I mean, why should. 0:10:39.240 --> 0:10:39.880 You pay more? 0:10:40.360 --> 0:10:43.280 For something that you don't need to write, and we 0:10:43.360 --> 0:10:46.880 see that. We see that every year. Okay, every year 0:10:47.320 --> 0:10:50.960 there's new technology, but the slightly older technology, which is 0:10:51.040 --> 0:10:55.640 again covered by Medicare, they move those reimbursements down. So 0:10:55.760 --> 0:10:58.960 whether it's a sleep study, you know, for someone with 0:10:59.320 --> 0:11:02.400 obstructives leap babner, a difficulty sleeping at night, or it's 0:11:02.440 --> 0:11:07.040 some ophthalmology technology, or it's some ultrasound machine, it doesn't really. 0:11:07.000 --> 0:11:07.760 Matter what it is. 0:11:08.320 --> 0:11:12.080 Medicare is always trying to minimize costs, which is understandable. 0:11:12.080 --> 0:11:14.400 They want to make it cost effective, but they are 0:11:14.440 --> 0:11:18.920 setting the lead so everyone will follow what they do. 0:11:19.200 --> 0:11:21.839 That's kind of the way that our system is sort 0:11:21.880 --> 0:11:22.320 of set up. 0:11:22.920 --> 0:11:26.079 Yeah, you know, I might just add to that that 0:11:26.840 --> 0:11:29.079 aside from all the things we mentioned about it, how 0:11:29.440 --> 0:11:32.360 you know it helps people in rural areas, people with 0:11:32.400 --> 0:11:35.880 difficulty getting places are just really busy schedules. It also 0:11:36.280 --> 0:11:39.160 you know, helps free of hospital beds, helps prevent emergency 0:11:39.240 --> 0:11:43.160 rooms from being overwhelmed, It leads to faster testing, it 0:11:43.240 --> 0:11:46.040 leads to a higher number of people that we can see, 0:11:46.400 --> 0:11:49.640 and in terms of its quality, we know it works 0:11:49.760 --> 0:11:53.760 well and about ninety percent of cases of telemedicine to 0:11:53.800 --> 0:11:56.760 get the same outcomes if the patient was there in clinic, 0:11:57.200 --> 0:11:59.199 and that ten percent that's not it's not clear that 0:11:59.240 --> 0:12:00.760 they're getting in fear your care. 0:12:00.600 --> 0:12:01.680 In most of those cases. 0:12:02.160 --> 0:12:06.679 So it's an effective treatment, and you could make an 0:12:06.760 --> 0:12:09.360 argument that it is cost effective in some ways too, 0:12:09.679 --> 0:12:14.040 particularly clearly for like things like dermatology, pediatrics. These are 0:12:14.040 --> 0:12:16.280 things where it's clearly cost effective to have it, but 0:12:16.840 --> 0:12:20.199 even beyond that, it's not even necessarily I think a 0:12:20.240 --> 0:12:23.480 strong argument that we'll be losing money from it and 0:12:23.520 --> 0:12:26.120 that cutting it would help us in the long run. 0:12:26.160 --> 0:12:28.560 I feel like we're being smart about how to manage 0:12:28.600 --> 0:12:32.719 American healthcare system and how to keep it afloat. TELL 0:12:32.800 --> 0:12:34.480 the Medicine is going to be an important part of 0:12:34.480 --> 0:12:35.319 that going forward. 0:12:36.400 --> 0:12:38.560 I do want to add something here, and I do 0:12:38.679 --> 0:12:42.200 want to be careful about the term, because telemedicine and 0:12:42.240 --> 0:12:45.920 telehealth are not only sort of a catch all, but 0:12:45.960 --> 0:12:49.360 they're sort of used interchangeably, right, and just like anything, 0:12:49.760 --> 0:12:51.440 you have to be specific about the term. So I 0:12:51.480 --> 0:12:55.880 think what we're talking about this on this podcast is 0:12:56.320 --> 0:12:59.360 tell a medicine in terms of a two way audio 0:12:59.520 --> 0:13:03.400 visual interface where you can have a direct face to 0:13:03.480 --> 0:13:10.000 face consultation or interaction with a practicing practitioner. Usually that's 0:13:10.040 --> 0:13:11.959 going to be a physician, but it may be a 0:13:12.040 --> 0:13:15.640 nurse practitioner or other physician extender we call them. But 0:13:15.960 --> 0:13:18.680 just to be clear, you know, telemedicine also extends to 0:13:19.440 --> 0:13:23.480 other types of devices, like wearables, those things that they're 0:13:23.520 --> 0:13:26.040 either you know, trackers that you can wear as your fitbit, 0:13:26.559 --> 0:13:29.560 or a sleep device you know that you can wear around. 0:13:30.120 --> 0:13:32.520 Those kinds of things are kind of put into the 0:13:32.520 --> 0:13:37.040 telemedicine bucket and it's not clear to me at least 0:13:37.440 --> 0:13:40.600 how that is going to change. I think April first 0:13:40.840 --> 0:13:44.720 is when the face to face coverage from a professional 0:13:44.800 --> 0:13:49.120 fee standpoint that is slated to end because they did 0:13:49.559 --> 0:13:53.880 liberalize it during the COVID pandemic and it's been extended. 0:13:53.920 --> 0:13:56.720 I think another year around that and that will that 0:13:56.760 --> 0:14:00.320 will definitely change the dynamic here, but it's not clear 0:14:00.320 --> 0:14:03.440 how much of it extends to other types of remote 0:14:03.440 --> 0:14:06.760 physiologic monitoring services and products. 0:14:06.960 --> 0:14:09.520 Right, Yeah, so something like a glucose monitor or like 0:14:10.160 --> 0:14:12.600 some other yeah, which could be catastrophic for people, right 0:14:12.840 --> 0:14:15.280 if they don't get those those funded. Right, we're going 0:14:15.320 --> 0:14:17.480 to take a little break for advertisements here. Maybe you'll 0:14:17.480 --> 0:14:20.160 get an advertisement for a gluecose monitor or even. 0:14:19.960 --> 0:14:21.240 Insulin can only hope. 0:14:21.360 --> 0:14:25.520 Yeah, Yeah, I'm glad they're taking some of that money 0:14:25.720 --> 0:14:27.880 that they've made me bleed out of my wallet over 0:14:27.920 --> 0:14:30.240 the years and returning it to me in the form 0:14:30.280 --> 0:14:46.040 of podcast advertisements. All right, we're bank Let's talk more 0:14:46.120 --> 0:14:49.960 broadly about I guess the changes in the legislative environment 0:14:50.000 --> 0:14:52.440 for healthcare might be a good way to put it. Like, 0:14:52.720 --> 0:14:55.720 I think if you were an excellent op ed recently 0:14:55.760 --> 0:14:58.560 where you discussed you you were one of the many 0:14:58.600 --> 0:15:01.800 recipients of the five useful things you did at work 0:15:01.840 --> 0:15:04.920 this week email, and I thought you wrote like a 0:15:05.000 --> 0:15:09.600 really good piece about about the varied and critical work 0:15:09.640 --> 0:15:13.600 that you do. Can you talk about, like, what is 0:15:13.640 --> 0:15:18.640 the feeling among healthcare professionals, physicians who have you sort 0:15:18.640 --> 0:15:22.800 of like to speak speak as going into four years 0:15:22.840 --> 0:15:28.760 of possibly vastly reduced government spending and a sort of 0:15:28.840 --> 0:15:33.040 bizarre and haphazard cutting of the federal bureocracy that we're seeing. 0:15:33.360 --> 0:15:36.480 Yeah, it's a tough time, certainly, and coming out of 0:15:36.520 --> 0:15:40.120 the pandemic, this is not what really anybody expected. But 0:15:40.240 --> 0:15:43.440 you know, the stresses have been mounting for quite a 0:15:43.440 --> 0:15:48.440 while right. Healthcare professionals are seeing and feeling more stress 0:15:48.480 --> 0:15:52.000 at work, whether it's you know, the demands of the 0:15:52.120 --> 0:15:56.320 job meaning that there are fewer resources to spend on 0:15:56.920 --> 0:16:01.640 a heightened number of patients with you know, increasingly complex diseases, 0:16:02.640 --> 0:16:06.080 or even just the questions that we are getting from patients. 0:16:06.400 --> 0:16:09.080 You know, a lot of patients now are asking me 0:16:09.440 --> 0:16:12.880 really financial questions. I mean literally, the other day, I 0:16:12.960 --> 0:16:16.920 had a woman who was unfortunately having septic shock and 0:16:17.160 --> 0:16:20.920 was faced with having to amputate her leg, and I 0:16:21.000 --> 0:16:23.280 was speaking with her husband because she was becoming more 0:16:23.320 --> 0:16:27.080 and more delirious, and he was just asking me about, well, 0:16:27.840 --> 0:16:29.960 I'm going to have to sell my house in order 0:16:30.000 --> 0:16:34.120 to fund what might come down the pike as far 0:16:34.160 --> 0:16:36.400 as being at home with services, and I was trying 0:16:36.440 --> 0:16:38.960 to I was trying to kind of get an understanding 0:16:39.000 --> 0:16:43.080 of how he viewed his wife actually going through the 0:16:43.120 --> 0:16:46.680 thing that we're watching in the moment. But it's a 0:16:46.680 --> 0:16:49.640 preoccupation that has taken up a lot of space in 0:16:49.680 --> 0:16:52.680 the room, and it's now coming on to physicians to 0:16:52.880 --> 0:16:56.920 sort of navigate at least some questions and answer those. 0:16:56.840 --> 0:16:59.640 Questions around it. So that's a long way of saying that. 0:16:59.800 --> 0:17:04.120 You know, so physicians and nurses and other healthcare professionals 0:17:04.160 --> 0:17:06.800 are feeing more and more stress in a system that's 0:17:06.840 --> 0:17:10.679 just buckling, right, And the last thing anybody needs is 0:17:11.240 --> 0:17:14.240 to be having to do more without really a clear 0:17:14.880 --> 0:17:18.480 understanding of the purpose around it, right, And we are 0:17:18.560 --> 0:17:21.359 all for a cost effectiveness. We want that to work. 0:17:21.400 --> 0:17:25.840 We also want to provide care irrespective of someone's religious, political, 0:17:25.960 --> 0:17:28.600 or other beliefs. And yet you know, we have to 0:17:28.800 --> 0:17:32.119 work within a system that we kind of are not 0:17:32.280 --> 0:17:35.879 really understanding how they're approaching this issue. Are they are 0:17:35.880 --> 0:17:37.960 they with us or against us or somewhere in between. 0:17:38.400 --> 0:17:40.560 It's it's sort of a it's a moving target, and 0:17:40.600 --> 0:17:43.159 so I think that's what's that's what's kind of sandwiched 0:17:43.240 --> 0:17:45.320 a lot of healthcare professionals and we don't really know 0:17:46.080 --> 0:17:49.000 where to turn for some of the answers that we 0:17:49.119 --> 0:17:50.520 ourselves are looking for. 0:17:51.160 --> 0:17:54.080 I would add also, you know, we're seeing this active 0:17:54.119 --> 0:17:58.880 dismantling of the US healthcare infrastructure, and our friends in 0:17:58.960 --> 0:18:02.480 the academic world in particular, it's a very stressful time 0:18:02.480 --> 0:18:05.720 for them. Who knows if their studies are going to 0:18:05.760 --> 0:18:08.120 go through. Who knows if they're going to get their funding, 0:18:08.760 --> 0:18:10.800 who knows what's going to stay, what's going to go 0:18:10.840 --> 0:18:12.399 in the next couple of years. There's a lot of 0:18:12.400 --> 0:18:16.560 concern over that, obviously, But even in the medical world 0:18:16.640 --> 0:18:19.639 outside of the academic centers, I know a lot of 0:18:19.720 --> 0:18:23.280 doctors right now are concerned and they're concerned about what's 0:18:23.320 --> 0:18:27.000 going to happen to the state of our scientific community 0:18:27.040 --> 0:18:31.359 that helps us with new advancements in medical technology in 0:18:31.400 --> 0:18:34.159 the coming years. And it seems like, as Ventecha was 0:18:34.160 --> 0:18:38.720 alluding to, we're dismantling all our ability to follow to 0:18:38.840 --> 0:18:43.879 study to really closely track infectious disease in a time 0:18:44.440 --> 0:18:48.919 that is exceedingly dangerous across the world, with rising disease, 0:18:49.000 --> 0:18:52.840 tuberculosis in this country, measles in this country, in Uganda, 0:18:52.880 --> 0:18:54.080 there's ebola again. 0:18:55.160 --> 0:18:56.679 There's threats all over the world. 0:18:56.680 --> 0:18:58.520 And this is one of the worst times I could 0:18:58.520 --> 0:19:02.919 think of to be in this moment of austerity, and 0:19:02.960 --> 0:19:05.719 particularly because so much of it seems unclear to us 0:19:05.720 --> 0:19:09.119 why why these things are being done, you know, is 0:19:09.600 --> 0:19:12.800 it all because of this ridiculous gender ideology? Do they 0:19:12.840 --> 0:19:14.920 actually think they're saving money with some of these things. 0:19:15.359 --> 0:19:17.680 It's a very unclear time. And of course there are 0:19:17.720 --> 0:19:20.600 a lot of people in the medical world, doctors included, 0:19:20.640 --> 0:19:25.800 that are conservative or Republican voters. Getting into conversations with 0:19:25.840 --> 0:19:28.640 them about this is sort of a tough thing to 0:19:28.680 --> 0:19:33.000 do because, like Fintesha mentioned, they, like a lot of us, 0:19:33.040 --> 0:19:34.600 want to make sure we're doing this in a cost 0:19:34.640 --> 0:19:37.239 effective manner, something we talk about and we have been 0:19:37.280 --> 0:19:40.240 talking about in medicine for a long time, particularly academic medicine, 0:19:40.280 --> 0:19:42.920 interestingly enough, which is really on the cutting board. It's 0:19:42.960 --> 0:19:46.359 academic medicine that usually talks about, you know, trying to 0:19:46.359 --> 0:19:48.720 be cost effective. What tests are we going to order, 0:19:49.000 --> 0:19:50.919 what labs do we need to get, how we do 0:19:50.960 --> 0:19:53.239 in this in the most cost effective way. These are 0:19:53.280 --> 0:19:57.560 important things that are discussed and across the political spectrum 0:19:57.840 --> 0:20:01.560 in medicine. I think there is some concern even amongst 0:20:01.600 --> 0:20:04.800 some of the more right leaning doctors. But again it's 0:20:04.800 --> 0:20:07.600 hard because they've gone this far down the road, it's 0:20:07.640 --> 0:20:10.000 hard to know, you know, when they're going to pull back. 0:20:10.040 --> 0:20:11.879 What's the line in the stand for them about what 0:20:12.000 --> 0:20:13.600 is maybe too far for this administration. 0:20:14.400 --> 0:20:17.679 Yeah, and certainly like an area where we're seeing that 0:20:17.800 --> 0:20:22.440 right now is in like public health, right, we don't 0:20:22.480 --> 0:20:25.560 really know. Like I'm going to Texas next week where 0:20:25.600 --> 0:20:29.320 there's currently a measles outbreak. Yeah, and the things that 0:20:29.359 --> 0:20:31.240 we didn't think that we might be seeing in this 0:20:31.320 --> 0:20:34.360 country again, we're seeing again. And like, as you say, 0:20:34.400 --> 0:20:37.919 it's coming at a time when like not just funding 0:20:38.680 --> 0:20:43.720 is unstable, but also like the I guess, like the 0:20:43.720 --> 0:20:48.199 basics of science have been somewhat politicized right to a degree, 0:20:48.240 --> 0:20:49.919 and like people, I don't know if that's something you 0:20:49.960 --> 0:20:53.159 see in your practice, but like certainly, like I was 0:20:53.160 --> 0:20:55.320 talking to a doctor friend who said half their clients 0:20:55.320 --> 0:20:59.359 are now like declining vaccinations as I was there to get, 0:20:59.640 --> 0:21:02.439 you know, every disease that I could get. I have 0:21:02.440 --> 0:21:04.920 a lot of travel vaccinations, so I'm always getting new 0:21:04.920 --> 0:21:08.920 and exciting vaccinations. But I'm making up for some of 0:21:08.960 --> 0:21:12.040 the gap, I guess. But it's uh, it's it's a 0:21:12.080 --> 0:21:15.280 really challenging time right from that perspective as well, like 0:21:15.359 --> 0:21:16.320 the culture around it. 0:21:16.440 --> 0:21:17.240 Yeah, that's right. 0:21:17.280 --> 0:21:19.600 I mean even here in the San Francisco Bay area, 0:21:20.160 --> 0:21:23.200 you know, I've seen more vaccine hesitation than I remember 0:21:23.240 --> 0:21:24.560 ever seen before in the past. 0:21:24.880 --> 0:21:28.040 It's sort of a vaccine question because I think some 0:21:28.119 --> 0:21:30.840 of this is, let's be clear, some of this is 0:21:30.960 --> 0:21:34.360 on our messaging, you know, as healthcare professionals. I mean, 0:21:34.720 --> 0:21:37.879 there are more and more articles. In fact, there the 0:21:37.960 --> 0:21:40.720 Wall Street Journal piece a couple of weeks ago that 0:21:40.880 --> 0:21:44.199 was saying how patients you know, are increasingly not trusting 0:21:44.240 --> 0:21:47.520 their doctors, and there are data to say that we 0:21:47.520 --> 0:21:50.320 don't communicate very well. Right, So there is that, and 0:21:50.359 --> 0:21:53.320 that's on us. And you know, another op ed piece 0:21:53.359 --> 0:21:55.679 in the Boston Globe by Ash's Jaw, you know, did 0:21:55.720 --> 0:21:58.399 a mea culpa around some of the things that public 0:21:58.440 --> 0:21:59.399 health we did wrong. 0:21:59.520 --> 0:22:00.399 We got we got it. 0:22:00.400 --> 0:22:03.480 Wrong in COVID where we didn't you know, deal with 0:22:03.560 --> 0:22:07.520 some of the doubts and lack of evidentiary base for 0:22:07.680 --> 0:22:11.320