3/5/23 Podcast transcript

Sensible Medicine - 4th year fellowship _ Expertise_ LONG Covid

Wed, 03/08 00:48AM · 58mins

Speaker 1
Welcome back to sensible medicine. The day is March 5, 2023. I'm joined by Doctors Adam Cifu and Professor Marty Makary. Professors, it's good to see you. Great to see you.

Speaker 1
Here we are, back at last. We are having the rotating lineup. We're going to be going through people in the next few weeks. I missed last week. I ate some bed. We struggled with action. Last I heard, the little the nod in the beginning. 

Speaker 1
Yeah, I appreciated that. I appreciated that. Today we've got a big lineup for the listeners. The first thing we're going to talk about is extra fellowships. You know me, I love a few more years of training for low pay.

Speaker 1
The next, we're going to talk about expertise and what expertise really means, especially when there's no data. So we're going to talk about that, and then maybe we'll talk a little bit about some COVID-19 policy, if there's time.

Speaker 1
I know that's the last thing on anyone's mind these days, so let me kick it off with this introduction, and then I'll throw it to you, Adam. So this is an issue that you'd be surprised. It doesn't earn me too many friends.

Speaker 1
You'd be surprised. People don't like this position. But to be a Hemonk doctor, currently, you have to do three years of internal medicine. You got to do three years of hemonk. And that's how much we've got so far.

Speaker 1
Four years of medical school, six years of graduate medical education, ten years of training. There's a push among many, many programs to add extra years. We've got one year fellowships in multiple myeloma, one year fellowships in bone marrow transplant, one year fellowships in lymphoma, one year fellowships in breast oncology, one year fellowships in phase one.

Speaker 1
These are not ACGME accredited fellowships. Historically, as of, like, two years ago, they've not been necessary because you could easily finish the ten years of training and go on to do any one of those things, if you so choose.

Speaker 1
Of course, these are optional. Nobody has to do them. Um, but one of the arguments I make is that, like, everything optional. The more people do it, the less optional it becomes. And radiology, maybe 1520 years ago was the end of it.

Speaker 1
You did radiology. You could read images. Now you've got to do MSK or or chest or body, and often two fellowships before you can really even get a job. And so I think we have Fellowship Bloat, and it's related to, I think, the issue of just how many years we take to trade train people, and how many of those years are useful and how many are useless.

Speaker 1
And the final piece of the puzzle is I would have no problem with this extra year if they paid them what they pay an assistant professor. But of course, that's why they call it a fellowship. They're really called a fellowship because they're paying you maybe 100K less than what you'd make otherwise.

Speaker 1
All right, so obviously, I'm a critic. I think we should boycott or abolish these things. But I'm curious what you all think. Okay? And I'm curious what a surgeon thinks, because he's got to actually use his hands.

Speaker 1
So let's start it off with you, Adam. What are your thoughts on medical training? Can we shorten the years, this extra year? Right? So I think the clear default argument that people use to promote this is that there's unbelievable advances in medical knowledge.

Speaker 1
There's more and more to know. Much of medicine has gotten more and more specialized. There are fewer generalists out there. And so maybe it makes sense to have this extra time. I think I'm in your camp on this.

Speaker 1
I don't think it's necessary. I think we waste a lot of time in medical education, both in, ume, undergraduate medical education, medical school, and in GMA, because there's always this tension between.

Speaker 1
You know, what you do as a low paid worker be and what you do as a student or trainee who's being educated. I always think we haven't done a good enough job with, with moving people along in their training, saying, Listen, you've managed, you know, 15 cases of heart failure as an internal medicine resident.

Speaker 1
You're done with that. You don't have to do it anymore. You know, you're good enough at that, and you can move on. And I think that's the same thing in hematology oncology fellowships. Okay, I'll come back to you.

Speaker 1
Marty, your thoughts? I agree with you. Well, first of all, I think we have to recognize there's a crisis we have with physicians burning out or being disillusioned. And if you're in total denial of that crisis, sure, put them in residency and fellowship for 50 years and then have one year of excellent and high quality medicine.

Speaker 1
But the reality is I don't know if you saw this stat that came out, but something like 37% of women leave medicine seven years out from residency. How can you not address that? Right? And the problem is not that they're not getting enough classes on equity.

Speaker 1
Right. The problem is that they feel disillusioned with the entire field. And if you think about the entire process, starting with college, a lot of it is a bit of a scam. Right. I don't believe in education.

Speaker 1
I believe in learning. But this idea that you have to go to study geology and learn all the different names of the rocks, as, you know, part of your liberal arts education, a hundred percent of those rocks names you will forget.

Speaker 1
Two weeks after the exam, maybe you'll retain one. The name of one rock. It sounds absurd. It sounds no. When you remodel your kitchen, you got. To learn them all again, Marty. You got to learn the quartz.

Speaker 1
You got to learn the granite. Maybe that's why you need to know it. But we do the same thing in medicine. We're laughing. We do the same thing with the freaking urea cycle. Why do you have to learn that every intermediate molecule of the Krebs cycle and memorize it and regurgitate it for exams at six different points in your medical training before you finish?

Speaker 1
They keep testing it over and over again. What are we doing? We're taking these beautiful, creative minds and we're forcing them to do this regurgitation. And then they come out sometimes not learning how to take care of sick patients effectively.

Speaker 1
We scratch our heads. Why? And we say, throw more years at them in the slammer. And so in general surgery, we have five to seven years of general surgery education, and then you do another one to two years to specialize in breast.

Speaker 1
Well, if you're going to specialize in breast, why are you taking out prostates as an assistant in your general surgery residency and managing pancreatic abscesses in the middle of the night and having sleep deprivation and nearly getting into a car accident on your way home?

Speaker 1
Why are we doing that? And then we wonder how why are a third of women leaving? And I don't know what the number is for men too, but the burnout and disillusionment rate is alarmingly high, in part because we're treating our young so poorly.

Speaker 1
And all we have to do is recognize that these are beautiful, creative minds. We can be more efficient. And it's not about our cheap labor. It's about getting them to be competent and facile in the field.

Speaker 1
That's an important point. I just saw that training program recently offered to pay for embryo and egg freezing of all trainees, and I was. Like, you could just shave a few years off, okay? You don't need to be freezing your embryos.

Speaker 1
They can add another fucking four more years. It's. Stop paying the freezing the embryos and maybe, like, graduate and haven't memorized the. Crab cycle four times. Just one. Okay, so let's go to the beginning.

Speaker 1
Okay, so one. I think maybe we'll see if we all agree. Premed is lovely. Actually, of all the years of your life, it's probably the most fun, like being a college kid. But if you really knew you wanted to go to medicine, do you have to finish four years?

Speaker 1
Maybe let people go after two or three? I mean, if they know their hearts in medicine, why not have a path pathway to let them jump up sooner? Medical school, as Adam has eloquently, said, the fourth year is the most expensive vacation year of your life.

Speaker 1
One year can be poof, gone instantly. And the first two years, to Marty's point, is you're memorizing a lot of the things that you've often memorized in high school biology or college biology. So that's another poof year.

Speaker 1
I see. God residency. I think if you're going to be a great internist, three years is reasonable. If you're going to be a sub specialist, maybe make it two years and help them get to the subspecialty training and then in subspecialty.

Speaker 1
I mean, even in hemonk, 18 months is research. And what is that research? Like forcing somebody who doesn't want to do research to do some case reports? I mean, for a lot of people, that's what it is.

Speaker 1
And so maybe we can lose an extra year there. And so I think if anything, we should be talking about cutting the training by four or five years and not adding a year on the back end. Adam yeah, I'm going to object to that.

Speaker 1
Right. So I agree that training could be and should be shorter, but I've seen this in curriculum reform in medical schools as well, that what happens is students say, and I think totally appropriately, we want to be on the wards faster.

Speaker 1
So the reaction is, okay, we're going to shorten the preclinical curriculum, but instead of doing that intelligently, it just gets compressed right there's. Not taking out Krebs cycle part three and four there's.

Speaker 1
Okay, you're still going to have to memorize it four times, but you're going to have to do it in 18 months rather than two years. Okay. So if we do these things, it needs to be done very intelligently, because I have certainly no data for this, but I see in residents that there are very few people who, after finishing an internal medicine residency, are like, okay, I'm ready to practice.

Speaker 1
Right. People are worried. They're sort of like, I don't feel prepared at this point. And so there's often the default fall towards a fellowship because I'll feel more comfortable with more training.

Speaker 1
And that's sort of on us because we've had three years and we haven't gotten those people to the point that they're just like itching to go into practice and start taking care of patients the next day.

Speaker 1
And so I'm all foreshortening things, and I know you think this too, but it just has to be done in a really intelligent way where we make sure that people are prepared before they move on, usually early to the next stage.

Speaker 1
Can I ask you a question? Yeah, Adam. What do they feel uncomfortable with? And the reason I'm asking is we all believe you have to be a master at what you do. I think we're asking, where's the waste that we can cut?

Speaker 1
Do they feel that they didn't get enough time on their dermatology rotation, or they need more time in nephrology, or they need more ICU time, or they need more time in clinic where they're dealing with unknowns?

Speaker 1
Right. Well, I think the issue is sort of going back to what Venice said, is that we're not thinking about what that individual needs to do or wants to do. Right. And so the person who wants to do general internal medicine should be spending a lot of extra time in clinic figuring out how to work the system, figuring out how to work through unknowns rather than spending all this time on the inpatient service.

Speaker 1
And so they're worried about going out to practice on their own because they haven't done that enough. And on the other hand, that person who's going to start a hemonic fellowship afterwards. You know, why are they spending three months on the cardiology service?

Speaker 1
And they could be doing, you know, a little bit more sort of general hemonk while they're internal medicine residents, so they've got a leg up when they start their fellowship. I mean, all you need to know is the heart's primary purpose is to deliver chemotherapy to the target tissues.

Speaker 1
I mean, it has no other real purpose, but, you know so I think I think one of the good points points is that if you know where you're going, there should be paths to cultivate your experience along the way.

Speaker 1
I think the second good point that Adam makes, and I think we really have to emphasize is you have to cut things. And you have to cut things people don't need to know. And I know the people who teach the Krebs cycle for the umpteenth time, they don't want you to cut their job, basically teaching that class.

Speaker 1
But it has to be cut. I mean, it has to be cut. And modern medicine always reinvents itself, should start with a destination and think backwards. And then tomorrow's point and to Adam's point, I think definitely there's a crisis not a crisis, but an anxiety among young people in their first year or two years of practice.

Speaker 1
I always tell people, you don't even feel like an attending until year three. And it's not that you don't know the answer. Sometimes you know the answer, but you really miss that cushion of being able to have the attending bounce off the idea and check all your sort of decision making with the attending.

Speaker 1
You don't have that now. How would you solve that? I think maybe to Adam's point, he's always made this point. Eloquently internal medicine training is three years. It's a time. But what it should be is six diabetic ketoacidosis, seven pneumonias, 22 heart failure, exacerbations, ten mixed pictures.

Speaker 1
I mean, there should be some checklist, and it should be sort of an experiential thing, like once you've hit your I've managed Ka, or like I've managed infected gangrenous foot for the 25th time, you're off the hook for infected foot.

Speaker 1
You know, I'll do my lattice of the foot and you're going to look other things. We complain so much about the electronic medical record, right? This is. We can make it work for us, right? Because we're tracking all of this stuff, and you can say, look, when you finish your admission, H and P, you know, you're putting in, you're probably doing it already.

Speaker 1
You know the three main points of this case that you're managing, and that goes into your own little I don't know what you call it sort of portfolio of cases in Epic that then lets you know, okay, it's time to move on.

Speaker 1
It's time to move on these cases. Now. Go to the hospitalist when you're on call and you wait for something else to come in. And I got to see one more do you want to say something already? Canada does that.

Speaker 1
With surgical procedures and surgical training, you had certain milestones. There's a guy named Dr. Resnick who pioneered this, and it was really a new model of education. And that is that when you do 25 carotid EnDr directomies and you can get signed off by your supervisor, that they feel that you're pretty good at doing that procedure, then you move on to the next thing.

Speaker 1
But remember, residency and training is not really designed even the fourth year medical school, which is somewhat of a complete joke or partial joke. The joke is on the student. Yeah, who's paying? Who's financing this corrupt system?

Speaker 1
And then the hospitals get this Gme allotment, which is basically a bonus payment from the government because you do teaching, right? That comes from the old days when they argued, well, the students and residents don't know what they're doing, so they're incredibly inefficient, and they're ordering all kinds of unnecessary tests, so pay us extra to cover all this waste that they create.

Speaker 1
And now they actually make the hospital more efficient because they're incredibly cheap labor. So it's ironic and you know that they make the hospital money because when Haneman went bankrupt and they sold their residency.

Speaker 1
It went to the highest bidder and they're bidding like hundred million dollars. So you know that it's an asset, it's not a liability. If a venture capital firms that give you $100 million for your residency program, it's making you money.

Speaker 1
Duh. Okay, I gotta say this and you're gonna put you guys, I want you to push back on me because I'm going to be hard on I mean, what am I to think when these people tell me the people running these extra fellowships did not they themselves do the fellowship?

Speaker 1
Okay, that's point number one, they didn't do it because they're running it. Two, two, they're paying the person who should be paid assistant professor salary, which, by the way, it's not like the pot of gold at the end of the rainbow.

Speaker 1
It's an academic medical center. It's not going to be that great. They're paying them 50, 60, 70% what they would otherwise earn, often just a fraction of their own billings. Like they're actually earning you money.

Speaker 1
And then three, they're doing tons of like, free research labor for you, which is why you like it. Let's be honest. That's why you really like it. I mean, I would like it too. Somebody followed me all day and did a lot of my work and I get to pay them a little bit, you know, and I get to have them by helper, you know.

Speaker 1
And so I guess I called it exploitative. And I really do. And everyone's all mad at me, you know, it's too harsh. Exploitative. It is like when you take a smart person and you squander their time and you make it harder for them to like, participate in normal life, you're exploiting them and let's just call it what it is.

Speaker 1
And if you don't think you're exploiting them, then just advocate to pay them the assistant professorship salary. It's only like, I don't know, difference of $80,000. That's the cost of like, one of your drugs for one month.

Speaker 1
Like, it's not even like just take one drug and that's it. That's it. Just for money or or the spill over on a grant. Okay, so tell me that I'm being too harsh on him. Adam, here. All right, go ahead, adam, go ahead.

Speaker 1
No, mario, go. Here's a I mean, you know, vanilla, you're always a pro at saying, okay, look, like, here's a good idea, let me take it to the absolute extreme to get people, like, angry about it. You do have to admit that, like, medicine is changing, right?

Speaker 1
Medicine is getting more complicated and let's talk about that. Yeah, you can't just say. Right. I mean, you can't just say that we go on with the same amount of training forever, even though it actually the job actually gets harder.

Speaker 1
Right. And so, you know, people I don't think the idea behind this is that the people who are already on the boat are pulling up the ladder and say, we're just going to exploit the poor people who are treading water right now.

Speaker 1
They're honestly thinking, boy, you know, the people who are getting into this job don't know enough now, and they're doing so much training on the job, maybe we can do a better job of teaching them.

Speaker 1
But I agree that we need to pull back and we need to say, listen, we are saying that to train a hemon doc, it is six years post graduate, period, okay? And if we need to focus that more and specialize more, that's how we need to do it.

Speaker 1
And I think that's kind of the appropriate way forward. That's the expert way to put it, Marty. Thus, I'm going to push back on a second. Yeah. First of all, this is what I love about you, Vania. You like to challenge deeply held assumptions in the field that we've inherited and nobody has questioned.

Speaker 1
And the reality is that this idea of fellowship training serves two purposes. One, it serves as a credential to ensure that you've got some standardized level of quality, but two, it serves as a way to create an elite club, and you are only allowed in that club if you go through our training program.

Speaker 1
So, for example, when bariatric surgery started, you had really qualified people doing high volume bariatric surgery, but they didn't do a fellowship. And then a group of them said, we need a fellowship program in bariatric surgery.

Speaker 1
Now, they didn't grant they grandfathered I mean, they didn't grandfather people in because I guess they've never been boarded. But they it's probably good that they create some sort of advanced training.

Speaker 1
Here's the thing. Why do you need a certificate, though? Most of your learning happens your first year or two of practice. And what I find makes what makes a great doctor versus an average or mediocre or very scary doctor is their humility, their will, their ability to understand their limits and ask questions of somebody like Adam, who's a genius and been around forever.

Speaker 1
Right? You want somebody who not forever. I don't mean call it the way it is. Look at that gray beard. Call it the way it is. I didn't mean, I didn't mean to suggest you qualifies for Medicare, because next.

Speaker 1
Year I got ten years. Ten years. Don't worry. They'll raise the age by the time you're there. Adam okay, Marty, that's well put. Okay, so to Adam's point yes, I think a more graceful way to say it is to say, look, you've got this many years.

Speaker 1
You can do whatever the hell you want with those years, okay? But if you want to train these people differently, you got to use your years wisely. I think that's reasonable to say. The second thing I'd say is that hemonk is 18 months clinical and 18 months research.

Speaker 1
So if somebody in those 18 months says, I really want to do breast, it's incumbent on them to just go to the breast clinic in the other 18 months and just, like, plant yourself on a stool and spend some time there, and you're going to learn breast, and you're going to learn myeloma.

Speaker 1
But I think Adam raises a philosophical point, and this is what I don't know if I have actually come to the answer on it, so I was going to talk it out. Is medicine harder than it was? I will absolutely concede.

Speaker 1
There are more drugs than ever before, more therapies than ever before, but in some ways, there are more algorithms than ever before. There's more pathways than ever before. There's more crutches than ever before.

Speaker 1
And sometimes medicine does displace rather than add on. Like sometimes a new therapy displaces the older one. Rarely, like a new therapy is so good it displaces many older ones. That required more sort of careful monitoring.

Speaker 1
Medicine's safety windows get better, and so there's less sort of, you know, drug talks and, you know, for instance, you're not checking did levels on your heart failure patients like you once did. You're not checking any levels on your cumin in patients like, you know, there's less level checking.

Speaker 1
Some of that is necessary. So I guess I don't know. I think it's I mean, you know, maybe you're right. But maybe it's it's an interesting question. If, like, the job of being a doctor is more cognitively tax.

Speaker 1
I mean, I certainly think the volumes have gone up, the turnover has gone up. The sort of the business side is more efficient. But I wonder I don't know. What do you think, Adam? You've been doing it for so long as he said, you know, 40, 50 years as an attending.

Speaker 1
What do you think? Is it more taxing? Yeah, that's a great question. And it's something like you I'm not sure I've thought about how do you measure something like that? I think the fact is that because of everything else that's changed, like every person who works in America, we have gotten more productive and more efficient over the time that I've been in my career.

Speaker 1
Part of that, again, I sound like I work for Epic is because of the electronic medical record, which really enables me to have so much information at hand. I can do a better job taking care of patients with that.

Speaker 1
I use my consultants better because of that. And so there is probably a bounce of we know more, we can treat more, we can diagnose more. But on the other hand, it really is easier to do a lot of the diagnosis, a lot of the treatment than it used to be.

Speaker 1
It's interesting. I'm not sure. Yeah. Marty, how about your field in the cutting business? Well, I will tell you that what you're talking about, what we're talking about today is not a theoretical at all in surgical training.

Speaker 1
Cardiac surgery, for example, has just been completely fed up with the idea that you do five years of general surgery training where you're taking out some melanoma of the thigh, and then in order to understand how to be a good cardiac surgeon, and the argument has been, well, we teach you basic principles of surgery.

Speaker 1
No, they've been slave labor. Look at their rotation assignments, right? They're given the less. Favorable rotation assignment sometimes because they're, you know, they're seen as the people who are not super interested going off.

Speaker 1
So Cardiac surgery decided. Screw you guys. In general surgery. You can do one year of general surgery and then match into cardiac surgery. We're going to take people after one year, they can do a transitional year or whatever, and then you don't have to do five years and then match from the cardiac surgery.

Speaker 1
Vascular Surgery is considering going down now. Interestingly, very few people signed up for the program in Vascular. I forget what it was like four two initially, and then I think they tried to go lower instead of a five two or five one.

Speaker 1
This is a movement is what you're saying. Yeah, this is a movement. All right, we'll go to the second time, but I just want to have two closing points. One, people were saying that I was wrong. And one proof that that was wrong is if you survey some of the people who did this extra year, they really like it.

Speaker 1
People tend to like what they committed. Okay. As a scientist, I was like, well, you think that's data? Okay, fine. Okay. The second thing they said is, and look at you. You took an extra year to do an Mph.

Speaker 1
And I was really deeply offended because I didn't take an extra year. I did it while I had to be there anyway. And if I'd taken an extra year, I wouldn't have done it. And so I was offended that anyone would dare think I took an extra year to do it.

Speaker 1
Okay, next topic. All right, so there are many medical decisions that I think there's strong evidence, and it's pretty clear and 99 out of 100 doctors would do something. There's some medical decisions that just don't have that much evidence.

Speaker 1
There's no randomized evidence. There's barely any phase two studies. And, ah, recently I was in a situation where I was consulting on some patient and working with the the fellow, and basically the options were mild, medium, or hot.

Speaker 1
And that was the levels of treatment. We could go with the hot stuff. It has a lot of side effects. We could go with the medium stuff. We go with the mild stuff. And, you know, I had seen the person.

Speaker 1
I looked through the person's chart. I met him. I laid hands on the person. I know this person. And at the end of the day, I have to be honest. Like, how do you decide mild, medium, or hot? It is 100% gut.

Speaker 1
I mean, there is no data. No one has any data here. There is not even experience because the entity is relatively infrequent. So that in your year, maybe you'll see it four or five times. You can't even say that it's just anecdote I mean, it's an unreliable sort of personal experience.

Speaker 1
And so I laid my hands on this person. I looked at them, I looked at the chart. I'd seen him with my own two eyes, and I felt like, let's go with the medium. And then the fellow said, let's go with the medium.

Speaker 1
And of course, the nature of the modern world, they ran it by the expert at some top tier center. The expert who didn't see the person, who only sort of heard about the person in an email. And the expert was like, oh, you definitely want to go with the hot sauce.

Speaker 1
You want to go with the hot stuff. Of course, that's what the expert thinks. And in my mind, so I'll leave out the politics of how these decisions get made. But in my mind, what irritates me about this whole thing is, why don't we just have the humility to agree that nobody has any data to support medium versus hot?

Speaker 1
Like, go into a new restaurant and sometimes what they call medium, I'll call hot. Or we don't even know what the scale is. Right, okay. And the person probably who's best to make the decision is the person who's there.

Speaker 1
I mean, what are we talking about? Ivory tower doctor who runs trials and has a lab that pipetts, who doesn't see the patient? They shouldn't be making the decision. It's got to be the person who's got skin in the game.

Speaker 1
Like, I'm going to have to take care of the complications. Okay? And then it made me think even broader. The broader thesis is. I mean, I will say politely or I'll say impolitely, this expert, this expert stuff is all bullshit.

Speaker 1
I mean, experts like yet very rarely do they know something I don't know. Most of the time they're just more comfortable bullshitting. I mean, they have no data. They're just making things up. Okay, that's my hard, harsher thesis.

Speaker 1
Adam. Then we go to Marty. This is about expertise. Yeah. I think there I think there are two issues here. One of them is something that I deal with all the time as a generalist. And I would say about half of my conversations precepting residence clinics are about this is when do you refer to a specialist?

Speaker 1
Right? And for me it's is there more known that I don't know that that person can add to it. Right. And very often if a resident is saying, oh, we need to refer this person to Nephrology because they've got CKD three, my reaction is, look, they don't know anything that we don't know about managing this.

Speaker 1
And if you want to refer them to kind of get that work to somebody else, that's fine, but we don't have a question to ask. Right. And I think that gets a little bit to what you're saying is that, look, nobody knows how to manage this better than you do.

Speaker 1
And when you're in one of those kind of evidence free zones right, where you're like, this is just a hard decision because we can't really counsel people well on the risk of harms and likelihood of benefits because we don't have that information, then that comes to you sitting down with the patient.

Speaker 1
You're talking about risks and benefits. You're talking at your decision. You know, you guide them, you get their opinion and kind of that should be it, right? There is no role for consultation in that point.

Speaker 1
And, you know, things may work out well, they might not work out well, but that's the way medicine is practiced, right? And it takes some guts to do that. It takes some guts. Yeah. And we have to have guts because okay, Marty.

Speaker 1
Well, I'm I'm just deeply offended. How dare you talk about Dr. Fauchi like that? We're talking about clinical doctors. Is he a clinical doctor? It's been a while. Maybe. No, I think here's what here's my experience with it.

Speaker 1
I believe you can learn something from everybody. And so even if I disagree or have a different point of view, where they come, they come at something from a totally different angle. I like input, but the problem is what I've seen in some these multidisciplinary cancer conferences somebody will present.

Speaker 1
We got an 84 year old woman with pancreatic cancer, and here's the lesion. And then we started saying, oh, you can reset the vein and do this and reconstruct here. And then we sort of make a verdict like, this is what we recommend.

Speaker 1
What if she didn't want to have all that done? What if she frail? What if she has a very low life expectancy separate from the cancer? In that case, that's bad guidance. And when we sort of detach from the patient, don't have that input from the person who saw the patient, they should start off saying, here's a frail woman who is not that excited to be here and generally doesn't want anything done but is open, or her daughter urged her to come in here.

Speaker 1
That's how you frame a case, right? Not just put up a scan and, oh, we can cut it out here, or we can radiate it or beam it or poison it. That I think is missing from a lot of these clinical dialogues, especially you go to conferences, and they put up image after scan after scan, patient after patient.

Speaker 1
I think there's value in learning from hearing different approaches, but there's just assumptions that the patient is on board at one point. Took time. I had a complication with a patient after pancreatic surgery, and I realized, I want everyone to know this is a possibility.

Speaker 1
It doesn't matter who's doing the surgery. Anybody can have this complication. So I went through a lot of detail explaining this is a possibility, and that's a possibility. And remember, because this is pancreatic cancer, at this stage age, there is a four out of five chance that this thing will come back in a few years.

Speaker 1
And when I presented the whole thing to her, I kind of realized, like, I wouldn't have it done if I were her in this particular situation. I remember she said, you know what? Really, there's only an 18% chance I would make it to five years.

Speaker 1
I said, yeah, and go through this big procedure. And she was frail. And she said, I'm okay. Thanks. No, thank you. And I realized, hey, if I go through this formal and informed consent process properly, I'm going to have, like, 10% less patience to operate on in my practice.

Speaker 1
And you realize we're disincentivized to do it, but it's important that we do so. Well put. And I think when I was saying, like, I laid my hands on this person, part of that also means what you're saying, which is, like, I talk to this person, and, like, I, like, get a sense of, like, you know, how hard does he want to push and how old is he and how frail is he?

Speaker 1
And does he want to try the hot sauce without knowing that the hot sauce is really better than the medium sauce? So that's part of why I was. A little bit when you talk about hot sauce meat, you're talking about different levels of different Airgram.

Speaker 1
Is this part of the jargon of what you guys talk about? No, I'm just using it for the purpose of this dialogue. No, it's just like, different strengths of chemotherapy, more toxic versus less toxic, but potentially better, but unproven that it's better.

Speaker 1
And then, of course, and then afterwards, somebody was like, oh, here's the paper that supports the hot sauce. The stronger stuff. It's like a retrospective study comparing people who received the stronger stuff versus people who didn't, showing that they did better.

Speaker 1
And I was like, yeah, but you do see the potential bias is that, like, a good doctor wouldn't be giving this to a frailer person. So it's kind of confounded. You do know that. And so I'm like, at some point, I'm like, even the data is like, useless.

Speaker 1
I'm like, this is a useless data. What are you showing me? You should know this is useless. Okay, Adam, you want to say something? I just came up with the hot sauce metaphor, and he's actually going to trade market before he releases this video.

Speaker 1
So he can charge with other people. But it would make it more accessible. Yeah, there's three different chemotherapy multidrug combos with different levels of cytopenias and other toxicity. But I mean, that's often the case.

Speaker 1
It's a hot sauce. And this is a guy who's saying he doesn't like hot sauce. He's telling me he's had a bad experience with hot sauce. His medical chart tells me that. And he's saying, I'm okay with medium.

Speaker 1
It's still pretty good. And you don't really know the hottest, better flavor. It's amazing. Adam, are you going to say some? Yeah. I hate to link anything to COVID, but I have to say COVID has taught me a lot about this.

Speaker 1
When I think about evidence based medicine and what it's really clarified for me is that when we have data, it is so easy to counsel patients, right, because you can really lay out, look, this is what's best.

Speaker 1
This is what's not best. This is why. Right? The problem is when we don't have data and it's this our counseling gets so difficult for people. It's difficult in the room. Room. And it's also sort of like in the atmosphere, right?

Speaker 1
This is where we argue about things when we don't have data because we just don't know. And in a way, it's easier when you're with a patient than when you're on Twitter, because when you're with a patient, you can say, look, this is our share knowledge.

Speaker 1
What are your values? What do you want to do? On Twitter, it's just a whole bunch of people who really don't know anything, right? Because you just don't have the information. Argue with people very much because of their anxieties and their values and stuff, which are fine, but you can't come to a consensus like that.

Speaker 1
Twitter is just a place where people who don't read books argue with people who write them. That's what I always like to say. Marty, thoughts on this? Well, it's amazing how many people come in and there's no discussion about the options, right.

Speaker 1
And our expectations are set, right. So it could be some doctor is sending the patient to me saying, this surgeon can take this out. So they come to me so hopeful. Now, forget about the prognosis being extremely poor.

Speaker 1
It's just, hey, this guy can take it out. And so it's easy for me to say, hey, yeah, we can take this out. We high five, we schedule the case. We do it. Never at any point is there a discussion of an extremely high recurrence rate or the mean, what's the cure rate?

Speaker 1
That's what people want to know. When you say, oh, there's a survival benefit, or there's on average, 38% of patients will have an improved survival. They want to know what the cure rate is. Right. If you're the patient, you want to know what the cure rate is.

Speaker 1
At least that's what they're asking. It's not like the other end. No, it's saying, you're talking about a whipple, I feel like. And it's like, if I'm going to go through a whipple, I want to know the curative fraction.

Speaker 1
And being pushed on the whipple a lot now they give new adjuvant chemort and then try to take you to a whipple. I'm like, this is all unproven. Like, where's your randomized data that you're improving curative fractions rather than just doing more surgery on somebody who's already incurable.

Speaker 1
They don't want to do those kind of studies, though. What are you going to say, Adam? I want to bring it back to the COVID I was going to make a snide comment. Of course. Go on. I was just going to make a snide comm comment that Marty bought his ticket when he decided to be a menial laborer, that we just refer people to him to say, hey, take this out.

Speaker 1
Do you be off? Every now and then I'll get the question, oh, this person needs this surgery. How do I set the patient up for surgery? Do I just schedule the operating date? We actually CP. It's not a factory assembly.

Speaker 1
I just see them and evaluate them and do an informed I'll take two whipples, please, Marty. Okay. So to Adam's point about the lack of data, I do absolutely agree with you. When there's data, it's clear.

Speaker 1
When you can make a decision calculator and make that figure with all the people and show the pros and cons of the different strategies, I mean, that's really nice shared decision making when it's a data free zone.

Speaker 1
A lot of it is how you put things. A lot of it is, you know, know how your read of the person. But I do think the individual is the best way to do that with COVID One of the things that irritates me about it is somebody was like, I'll put the issue the issue was like, two year old a four year old cloth masking, okay?

Speaker 1
And obviously I've been a vocal critic of that. Then every once in a while, someone's like, oh, what do you know? You're not a pediatric ID doctor. I was like, well, they don't know shit about this issue, too.

Speaker 1
What are you talking about? They never ran any studies. Who says against it? And if I really need to go to school for all those years to have an opinion on masking a toddler that doesn't speak so well of my cognitive abilities that I would have to go 20 years of school to know it doesn't work, you just need eyes and ears.

Speaker 1
Similarly with The New York Times, they always do their survey of experts. These are the same people who said they wouldn't open an eye envelope for four days in the beginning of the pandemic. I don't want to know what they think.

Speaker 1
I want to know what the guy and the plumber thinks. I'd rather do a survey of just random people than these kinds of things. And I guess it has to do with expertise. I mean, what does it mean to be an expert if.

Speaker 1
There is nothing that you're hanging your hat on other than n of eight. I mean, I don't know are you. Referring is the eight example come from the eight mice that the FBI yeah. For the antibodies? Yeah.

Speaker 1
Miser bivalent. Yeah. Is you can learn a lot from a mouse. So I just want to push back on that a little bit. You can learn a lot about COVID vaccine, an effectiveness from a mouse? From eight mice. Do they get myocarditis?

Speaker 1
I don't think they live to tell. The tale if they do, I think the longest surviving rat is, like, four years. That's just a little fact there. It's interesting. All right, last topic. What was the last topic?

Speaker 1
Marty's? Got to go. You got to go, Marty? Yeah, I got to go. But this is getting juicy here, and you're going to talk about COVID So I'm going to stay on for five more minutes. Okay. You're going to cut it close.

Speaker 1
But where do we dive in on COVID? I mean, I think the most recent thing that got me was, okay, let's let's talk about it. We got to put it out there. I mean, this long COVID research. I don't know what to say.

Speaker 1
There recently was Eric Topel. He's back. Of course he's back. The crown prince of accurate analysis and and and critical thinking. He's got there's a J. There's a JAMA health forum paper. The Jamma Health Forum paper has, like, a huge electronic data set, and what they do is they define you as somebody who had a post COVID condition PCC.

Speaker 1
If you had one of, like, you know, a laundry list of ICD, ten codes placed in the chart five to ten weeks after the EHR documented a PCR COVID-19. All right, let me put it another way. So they're taking this big data set.

Speaker 1
Everyone is getting COVID. Some people are coming to the hospital or their doctor to be tested for COVID. That's not everybody. Most people who get COVID don't go to the doctor. I didn't go to the doctor.

Speaker 1
You know, you get tested at home. That doesn't count. If you come to the doctor, you get tested for COVID. You get put in the COVID data set, you get on the COVID arm, and then at five to 1012 weeks later in those window, you had one of these many diagnostic codes added to your chart.

Speaker 1
You get called a post COVID condition PCC, and they compare these PCC people to healthy people who are not healthy covariant matched people who didn't get COVID, okay? They're they're covariant matched.

Speaker 1
And then they follow them for a year and they ask how many of them died, how many of them had Mi, how many of them had heart failure, how many got COPD? And the answer is more people in that PCC cohort get COPD than in the cohort of people who didn't have a documented COVID who are covariant.

Speaker 1
Nashed okay, now, when I see a study like this, my obvious thought is that all things being equal, somebody with underlying COPD who gets COVID is more likely to seek medical testing and medical care for the COVID because they're getting hit really hard.

Speaker 1
And so if you follow them out into the future, I should not be surprised that they have more COPD diagnoses because that COPD is what made them see the doctor in the first place for the COVID diagnosis.

Speaker 1
And we all know that the propensity score method doesn't match very well in EHR data sets when you have so many variables you're not matching on. Okay? So the bottom line, I think, is we've got this industry of people who want you to think that COVID-19 is this new respiratory virus that will liquidate your organs and liquidate your brain.

Speaker 1
It's going to be long term debilitating effects unlike any of the other coronaviruses. This is very unique. And to bolster that argument, they do research that is just so bad. Ad I'm like, how is this even published?

Speaker 1
It's like, okay, Adam. What do we do? Because, listen, we are bad at studying things like this, right? We know this forever that we're bad at studying these sort of. Multi organ systems that cause mostly subjective problems.

Speaker 1
Right. And long COVID exist. Right. You can't deny that there are people who are worse after having COVID than they were before they had COVID. Now, I don't really think that that's more common than people who are worse after they've had flu or mycoplasma or chemotherapy or anything.

Speaker 1
Okay? But that's real. I agree that this research, most of it is garbage. I worry that what's happening is these are just people trying to grab a pot of money for further research and treatment. I'm at a loss of, like, what do we do better?

Speaker 1
We can't sort of ban. Okay, we're not going to study long COVID anymore. Right. Because there are people suffering from it. I mean, I have people in my clinic who are, like, I used to talk to them once every two years, and now I talk to them every month because they are different and they are suffering.

Speaker 1
And these are physicians and people who I would never have expected this from. So I don't know. Okay, and I share this, and I'll give you a couple of points right off the bat. One, there's no doubt about it.

Speaker 1
Anyone who says they're suffering is suffering, because that's what suffering means. It's to feel suffering. I mean, that's nothing more. If you feel terrible, you're suffering. And I think we have to give that full importance because we need to do something about it.

Speaker 1
Okay? Now, long COVID, I think, a few data points. The first thing I'd say is, of course, if somebody gets on the vent hospitalized. On two. It's going to be a long path to recovery, whether you have COVID or influenza.

Speaker 1
And, you know, don't expect to feel good in six weeks. It might take six months or even a year. You know, if you've been hospitalized, if you've been on the vent, you know, don't expect to regain your muscle mass for maybe, you know, maybe maybe never, but, you know, two years if you're lucky, maybe, you know, and so, okay, that's one phenotype.

Speaker 1
But long COVID is unique because they say you could have mild or asymptomatic or, you know, regular cold like COVID, and then you could have this long term stuff. The data points I point to are one that NIH study, which was, like, 180 people who had 65% had the post COVID symptoms.

Speaker 1
Go on. You know what I'm talking about? Annals of Internal medicine. Yeah, but I got to interrupt you, because this is where I think and obviously look, you and I are as committed to data and publishable data as possible, but I think what we're dealing with is we're dealing with a really common infection, right?

Speaker 1
Which is going to remain really common, just like every other upper respiratory tract infection that happens. Right. And some people are going to have a weird, idiosyncratic bad outcome. And I'm not just talking about like, oh, this has made my anxiety worse.

Speaker 1
Right. I mean, these are people, and they're weird things, but there are things which, as we go further, we say, look, we see this. We see people with worsening tinnitus. We see people with orthostatic hypertension, like everybody you talk to who's kind of in the field.

Speaker 1
This is what it is. Right. And I'm not optimistic that we're going to figure out a way to treat this well, because I don't think it's any different from what we were seeing ten years ago in people with due, difficult to treat subjective symptoms of multiple organs.

Speaker 1
Right. That's half of what I do as an environment. Right. And so we got to figure out a way of turning down the temperature a little bit so A, people are so worried about long COVID that it's impossible.

Speaker 1
Okay, that was one of my first point. Yes. Go on. Do you enjoy my life? Yeah. And that we're going to put an amount of money into the research, which is sort of correlates with the degree of suffering that this is truly causing.

Speaker 1
And I think what your argument is, is that, you know, a lot of people are trying to overstate the degree of suffering, you know, how prevalent Long Covet is, and that can be a big problem. It can. I mean, you know, absolutely, I agree.

Speaker 1
I agree with all that. The point I was going to make is there's no biochemical abnormality that we can yet detect. And that's kind of an important thing for pathology. But I guess I'd say one there should be randomized studies, like randomize them to Venlafaxine or not or, you know, whatever you want.

Speaker 1
But randomize people who are suffering to an intervention or not. And if they do better it doesn't matter how it works, if the Venla vaccine works or the effects or works or the prozac works or whatever.

Speaker 1
That's one whole genre of work. The second thing is, you know, we see the Havana Syndrome. Havana Syndrome was nonexistent ten years, 20 years ago. And then you remember this. This is the the people at the US.

Speaker 1
Embassy in Havana, Cuba. Right, right. Okay. And right. But we and now this is totally. Different because we had a long history with, like, sick buildings and things like that, which we know are not a thing.

Speaker 1
Right, but isn't it very similar? It's very similar, isn't it? Because once the idea came on, it spread and intelligent. It's not just Havana. Many people who've been deployed in State Department sites have reported these symptoms that talking about the symptoms yields more people reporting this.

Speaker 1
I guess that's the part of it. Long COVID. This was created by Ed Yong. I mean, he wrote the seminal article put in the Atlantic. He got it from Facebook reports. The media coverage has always exceeded the scientific basis, and they have a reason for it.

Speaker 1
Because, Adam, it's like so many things, it's the thing that helps their preconceived policy notion right now, if you want me to wear a mask, you can't justify it unless there is long COVID. And unless long COVID is biological go.

Speaker 1
On, I get all this. Yeah. And I understand why, you know, you you get your dander up about this, right. And I do think that, you know, for every hundred people that Ed Yong would say, you know, has long COVID, you know, there are three people, right?

Speaker 1
But having read all the same literature as you and knowing, yeah, there aren't biochemical markers and stuff and so on and so forth, and it's going to sound like but I know the group of symptoms, right, which I see reproducible in people, like there's something there.

Speaker 1
And I think you're right, we have to figure out how to treat that. And it's not just from COVID it's from everything, right? It's this whole group of patients who forever we've changed the name 1000 times from neurasthenia to chronic Fatigue syndrome to Epstein Barr virus to long COVID, which I really do think are sort of similar, probably post infectious stuff that we don't have a good handle on.

Speaker 1
And I kind of hope that well, maybe because a lot more people are suffering with this now, because a lot of people had COVID all of a sudden that maybe we make some progress. But we are far from that because you're right, we've got such an umbrella way of diagnosing people that we're probably catching ten times as many people who actually have something related to the disease as truly do.

Speaker 1
It's very interesting and I like those discussions. I mean, I guess the things we totally are in agreement on are people are suffering. You got to do something about it. You got to like think of these strategies.

Speaker 1
I guess the questions I have are where is long COVID in India? Where is long COVID in the Indian slums in Mumbai? I don't hear any long COVID. No, all of India's been infected. There's no long COVID.

Speaker 1
There's no long COVID in Indonesia in, like, resource poor settings where people are struggling. Is long COVID, to some degree, disease of affluence a disease of yeah. No. So clearly, clearly, where you disagree and I'm just going to say it you don't believe it exists at all.

Speaker 1
I believe it exists, but it's I just don't see a biological basis. I didn't there's no biological it exists. Like pots exist. It does exist. Yeah, but so deep inside, you're like, everybody everybody who has long COVID just feels bad, and they've got some other problem, and we're not seeing it in a slum and Mumbai, because those people don't have time to think about how they're feeling because they're just trying to live.

Speaker 1
Right. I disagree with you about that. I think there is clearly, clearly an illness that starts after COVID that people have just because I see it. And I don't think it's dissimilar to what people have had for the last 25 years after other things.

Speaker 1
And we probably agree to some extent on why don't we see it in all these less resource places. It's because there's, like, no way for those people to report it. They've got too many other things on their plate to care about a little bit of tinnitus or a little bit of dizziness.

Speaker 1
They're not on Twitter complaining about it. Right. And they didn't read Ed Young's article. They didn't read Ed Yang. That doesn't mean that it doesn't exist. No, but it has therapeutic implications.

Speaker 1
Okay, here's a therapeutic implication. In the current mode of thinking, if you have long COVID, you may sign someone's disability form so they don't go to work. You may advise them to use a gravity chair or, you know, do I mean, these are the things that people are doing, you know, or seeking these, like, you know, I don't know, plasma.

Speaker 1
They're doing all sorts of crazy things. Maybe the answer is the opposite. Maybe we should be advising them to go back to work, to put your head, you know, to go back in person and do stuff, not to take more and more time to dwell on it.

Speaker 1
Maybe the way to improve the symptoms is is the Mumbai treatment, which is that you have day to day issues to deal with. And like many things in life, I think we are in a moment in culture where if something bad happens to you, you're depressed or whatever, take a week off work and think of sometimes it's the last thing you should be doing after take a week off work.

Speaker 1
It's get back to work, get back to her, put your nose down and don't think about it. That's life. And with time, you'll feel better. Am I wrong? So I would say that listen to yourself. Right. So if you believe that these are the things we should do trials on.

Speaker 1
Yes, that's what I'm saying we should do trials on. Yes, of course. Right. And so I would say, look, if you want to do the suck it up versus be cared for trial for long COVID, terrific. And I'd like you to say, if we're going to do trials, not just give me a list of antidepressants you want to try.

Speaker 1
Right. But let's also try some other things for this. Okay. To be honest with you. Yeah, go on. I don't think we have a treatment for this because I think that if we had a treatment, we would have figured it out in the last 25 years for all the people suffering from a whole bunch of other kind of syndrome complaints that we haven't been able to explain.

Speaker 1
And so I'm a little bit pessimistic that we're going to come up with anything because it's going to take some serious breakthrough to figure out what's actually causing this problem. People. I think that's why, like, with when you don't find a biochemical pathway that's altered, that's why it's tricky, because then what do you interdict on?

Speaker 1
I mean, the reason I reach for SSRIS is right. You know, I don't know what to interdict on. Absolutely. And and it's interesting to me that I think there's a but it affects every organ system, but not a single of the 200 biochemical pathways we look that's very interesting.

Speaker 1
How is it doing that? How is it doing that? Right. I and I I think they're probably probably is a biochemical pathway that we haven't recognized, and that's why we can't. Treat it, and that's why you memorize the credit.

Speaker 1
That's why we should memorize more cycles. No. Way to bring it around. All right. This has been a good discussion. Marty missed out on all this. I think Marty might have been on my side on this one, but, you know, it is an interesting thing.

Speaker 1
I waited till the end to argue. I don't know. It's interesting. I was better off one against Mano Amano rather than two on one. I think you were. I mean, like, I guess it's hard to I don't know. It's hard to juggle all these balls in the air, because we're both, you know, anybody's suffering, you got to take that seriously.

Speaker 1
You got to do something about it. So I want to you know, my heart does go out to anyone who's suffering from anything, then. The question is, though, but I think maybe the one part maybe we do agree on is that the more people like Topo keep pushing this in the media, that's not good for people's mental health to keep, like, you know, living in fear of it.

Speaker 1
Yeah, we'll agree on that. And then how do you treat it? That I do agree with. I sort of don't want to. And this probably disses both you, me, and Topel, to be honest with you. I don't want to hear from anybody who's not actually an experienced internist who is working with people clinically who are suffering after covert, because those are the people who actually sort of understand the clinical pathway, and anybody who's.

Speaker 1
Doing a good job or a bad job looking at bad studies. I don't get it. Okay, so your point? I would tell you, and I know somebody who goes to that because we have a long COVID. Clinic. The provider. Burnout is through the roof.

Speaker 1
The providers have. A lot of burnout through the roof? Through the roof, through the roof. Because it's not everybody. Yeah, it's not. It's not nice to be a doctor with nothing to help anybody. With.

Speaker 1
Absolutely. And I'm with you. Everybody I've talked to has been like, after 4 hours of clinic, I either need to go for a walk if it's the middle of the day or I need to go home and have. A drink if it's.

Speaker 1
The end of the day and it's because we don't know what we're doing and we have trouble taking care of these people. I think it's also pointing at the biochemical pathway. Okay. Dr. Adam Sifu. It's been a.

Speaker 1
Pleasure. Great discussion. Some agreement, some disagreement. I hope people enjoy this sensible medicine. Maybe I'll put this. Out on the video. Direct your hate mail to what's? Your email address? It's everywhere.

Speaker 1
You're fine. Don't send it my. Way because I'm not going to read your comments anyway because I need to use my own. I got to say these. Comments, by the way, lose the beard. Keep the beard. Hair is too long.

Speaker 1
Get a hair. I mean, what are you doing? People? I don't care. This is not my appearance, Shell. Okay? And I don't care about. Your comments. You also all disagree with each other. By the way. Get your story straight.

Speaker 1
Before you send me advice. All right, talk soon. Thank you. I think you look quite good. I'm going to keep that in there.