March 5, 2025 • 38 mins
James is joined by Venktesh Ramnath and Kaveh Hoda to discuss the potential for an end to Medicare funding for Telemedicine and challenges for healthcare under Trump.
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Speaker 1 (00:01):
CAUs Media.
Speaker 2 (00:05):
Hello and welcome to the podcast. It's me James. Today
we have a very special episode in which everyone is
a doctor. I will believe in discussion, of course, as
a doctor of modern European history. But I'm joined today
by venktash Ramnath, who is a practicing pullmanologist, a professor
at UC San Diego Health, a medical director of several
(00:26):
it use in royal and urban settings, and also the
author of the substack be a health architect. Welcome to
the Shoving Test. Thanks for joining us.
Speaker 3 (00:34):
Great to be here.
Speaker 2 (00:35):
I'm also joined by doctor Carve Holder, a gastro enterologist
and the host of our favorite medical podcast, The House
of Pod.
Speaker 3 (00:44):
Of the many you listen to, I'm sure yeah.
Speaker 2 (00:46):
What they might call a super user in a medical
podcast space you listen to more than most importantly Cave
of course, our friend, our resident doctor with a useful doctorate.
So what we want to talk about today is Medicare
and specifically some of the cuts to medicare. More broadly,
(01:08):
the I don't know really have to put this challenges
for people working in healthcare and the Trump administration right.
We addressed specifically gender affirming care in a previous episode,
but it doesn't start and end there, right, That might
be the thing that sort of the culture wars have
been focusing on recently. But I want to talk more
broadly about the challenges facing healthcare. So first of all,
(01:31):
would one of you care to explain medicare for people
who are not familiar And some listeners might not be
living in the United States, or they might just not
have encountered this yet in their life, So could one
of you explain what this particular sort of type of
health insurance is and how it's maybe more vulnerable than
other types to federal government changes.
Speaker 3 (01:52):
I could take a stab at it.
Speaker 4 (01:54):
I'm not a health policy want but I am a
physician that has to deal with Medicare all the time.
So Medicare, in sort of general terms, is a type
of health insurance that is provided by the federal government.
It is almost exclusively for individuals above the age of
sixty five, as it dates back to the nineteen sixties
(02:15):
with Lyndon Johnson's Great Society Program, and so since that
time there has been this blanket coverage for any individuals
above that age, such that all their medical services or products,
whatever they need for their healthcare is actually covered by
the government.
Speaker 3 (02:34):
This is the federal government.
Speaker 4 (02:36):
Now, the interesting thing about Medicare is that there are
different parts to it. There's Part A, which is primarily
for some essential services and includes hospital care. There's Part B,
which includes whatever physicians fees go into that healthcare. And
then there's Part D, which relates to pharmaceutical prices, so
(02:56):
your drug costs. It's not comprehensive in the sense that
there's always something more that individuals need, but Medicare, for
all intents and purposes, is the sort of standard and
it should cover most of individual's needs. Now that said,
the commercial payers, that is, the other insurance companies that
(03:18):
are not federally government sponsored, take their lead from Medicare.
So a lot of the different payment rates or coverages
and services they all look to what the centers of
Medicare and Medicaid services dictate as far as what is
an acceptable reimbursement rate, what are the rules around what
(03:38):
should be covered and what should not. So that's why
Medicare is such an important entity for the United States.
Speaker 3 (03:46):
Yeah, I'll add to that.
Speaker 5 (03:48):
They set the lead of importance here too, because if
we're talking about telemedicine telehealth, how important that is to
medicare patients to everyone in the country at this point.
Then if they are to cut it, if that happens,
as I think we're probably going to discuss. If that
goes away, then the other private insurance companies are going
(04:09):
to follow.
Speaker 3 (04:09):
That's right.
Speaker 5 (04:10):
It could be across the board changes led by these
changes of medicare.
Speaker 2 (04:15):
Yeah, so let's talk about those changes. Then, as you
mentioned right, there's this telemedicine it's a waiver right that
has allowed telemedicine to be funded through this for the
last five years. I suppose it's going to expire by
the end of this month, which is March twenty twenty five.
If if you're listening later, explain like why telemedicine has
(04:37):
been such a positive step like in healthcare since if
you could since twenty twenty and then what we're facing
if it's no longer funded federally.
Speaker 5 (04:48):
May I'll start this one, but Venkesh definitely want you
to weigh in on it as well. Does give a little background.
Over the past five years that's grown quite a bit
and it's gone from being kind of this emergency stop
gap to a real cornerstone of what we consider modern healthcare,
and now it's exceedingly common, like over seventy five percent
(05:09):
of hospitals in the US connect at a distance via
video conference or some technology to patients. And it's been
popular on both sides. It's been popular on both sides
of the aisle. When it first was done, as you mentioned,
during COVID, when they said, Okay, we're gonna peel back
(05:31):
some of the restrictions on Medicare coverage for these telehealth things,
it was considered like a victory, like one of the
few good things that come out of COVID.
Speaker 3 (05:41):
Both sides liked it.
Speaker 5 (05:43):
It was popular amongst patients, it was popular amongst medical providers.
It was good for Republicans and Democrats alike. And as
you mentioned, it's been kept going through being put in
some bill or another since it was initially put in
I think as they called twenty two, and it's been
put in one bill or another to go with a funding.
(06:04):
But then came this last December when Congress was going
through their spending. It was only given this three month
reprieve which is going to be up as you mentioned,
at the end of this month, and if it goes away,
there's a lot of factors will go into a lot
of them. But there's a lot of people, older patients,
you know, compromise patients who don't want to come into office,
people with disabilities, people can't get around that well, people
(06:27):
in rural areas, which is you know, really how it started.
People who are going to be hurt all across this country.
And at this point, the majority of people have had
at least one experience or more in a year with telemedicine.
It's become a part of a lot of people's lives.
And if it goes away, you know, there's still going
to be health care as it is. I mean, it
(06:48):
doesn't mean health care is going away, but it is
going to put a tremendous burden on patients and hospitals
for that matter, across the country.
Speaker 3 (06:57):
Yeah, let me let me add to that.
Speaker 4 (06:58):
So, you know, telemedicine has been around for a very
long time, at least technically speaking, right, I mean, you
can go back to the nineteen seventies. Even when you
talk about the intensive cared it which is where the
sickest people in the hospital are. There are studies that
come out of the nineteen seventies. However, Ever, since people
have had iPhones and been on Airbnb and everything else.
(07:21):
Since two thousand and seven, that inflection point actually had
a wave of opportunity that washed right into medicine, and
as Cave is saying, you know, we have such a
fragmented healthcare system that has you know, folks living in
rural areas, suburban areas, and urban areas, all of whom
(07:42):
are at the mercy of what specialists may be. They're
contracted at any given time for any given specialty. Now telemedicine,
as it's gotten more and more popular, has kind of
leveled the playing field. I mean, you can be in
a rural place like where I'm sitting right now on
the US Mexico border, or you can be in New
(08:03):
York City, you know, one of the densest populations, but
you may might not have access to specialty expertise without telemedicine.
With telemedicine, you can now have access and I've seen
patients love it. You can deal with the sickest of
the sick, like I said, intensive care units, but you
can also have outpatient experiences. And we've seen a number
(08:24):
of different you know, commercial opportunities that have leveraged that.
But the point is that as as we're hearing on this,
you know, it's become sort of a standard operating procedure
for how we deliver healthcare. And if you just pull
the rug out from that, there can be some you know,
unintended consequences to that that are not insignificant.
Speaker 2 (08:44):
Yeah, and like it makes a lot of sense to
a lot of people, right, Like I think about my
own experience with it. I was traveling recently and got
COVID like a couple of months ago, and there was
no need for me to go to a clinic and
be around other people, right, I just needed to contact
my doctor and get some prescriptions check in, And like
it was so much better that I could do it
in my pajamas from a bed rather than like having
(09:06):
to get out. And I'm lucky to have access to
a car. It can drive to the doctor's surgery is
not that far away. Have a job that accommodates my schedule.
But there are a million reasons way it might be
very beneficial to people. So let's talk about you. You
mentioned this before, but we have commercial insurers, and like
people might think that this is limited to older folks,
(09:26):
or it doesn't affect them, or it's something that only
impacts people who have Medicare. But as you said, Medicare
kind of sets the standard for what is covered and
what isn't covered, right, So can you explain how this
might end up resulting in it in just a massive
like a cliff. I've seen it described as a telehealth cliff.
Speaker 4 (09:44):
Yeah, So, I mean basically, the sort of this convoluted
way that we pay for services is it looks to
one standard, even though some may argue how did that
standard come about? But regardless of that, Medicare is the
central authority that basically tells everyone this is what we
(10:04):
should be doing, and this is how much we should
be paying for it. Now, the commercial insurers can decide
to exceed that if they wish. If they say, have
an employer who's employees they want to have a special
contract with, that's fine, that's not restricted. But the bottom
of what is considered a reimbursable amount is really set
(10:27):
by Medicare, and so they move the bottom. And so
if you drop the bottom, you can pretty much well
assured in this, you know, in a capitalist you know
sort of mentality that the cost should go down, right,
I mean, why should.
Speaker 3 (10:39):
You pay more?
Speaker 4 (10:40):
For something that you don't need to write, and we
see that. We see that every year. Okay, every year
there's new technology, but the slightly older technology, which is
again covered by Medicare, they move those reimbursements down. So
whether it's a sleep study, you know, for someone with
obstructives leap babner, a difficulty sleeping at night, or it's
(11:02):
some ophthalmology technology, or it's some ultrasound machine, it doesn't really.
Speaker 3 (11:07):
Matter what it is.
Speaker 4 (11:08):
Medicare is always trying to minimize costs, which is understandable.
They want to make it cost effective, but they are
setting the lead so everyone will follow what they do.
That's kind of the way that our system is sort
of set up.
Speaker 5 (11:22):
Yeah, you know, I might just add to that that
aside from all the things we mentioned about it, how
you know it helps people in rural areas, people with
difficulty getting places are just really busy schedules. It also
you know, helps free of hospital beds, helps prevent emergency
rooms from being overwhelmed, It leads to faster testing, it
(11:43):
leads to a higher number of people that we can see,
and in terms of its quality, we know it works
well and about ninety percent of cases of telemedicine to
get the same outcomes if the patient was there in clinic,
and that ten percent that's not it's not clear that
they're getting in fear your care.
Speaker 3 (12:00):
In most of those cases.
Speaker 5 (12:02):
So it's an effective treatment, and you could make an
argument that it is cost effective in some ways too,
particularly clearly for like things like dermatology, pediatrics. These are
things where it's clearly cost effective to have it, but
even beyond that, it's not even necessarily I think a
strong argument that we'll be losing money from it and
(12:23):
that cutting it would help us in the long run.
I feel like we're being smart about how to manage
American healthcare system and how to keep it afloat. TELL
the Medicine is going to be an important part of
that going forward.
Speaker 4 (12:36):
I do want to add something here, and I do
want to be careful about the term, because telemedicine and
telehealth are not only sort of a catch all, but
they're sort of used interchangeably, right, and just like anything,
you have to be specific about the term. So I
think what we're talking about this on this podcast is
tell a medicine in terms of a two way audio
(12:59):
visual interface where you can have a direct face to
face consultation or interaction with a practicing practitioner. Usually that's
going to be a physician, but it may be a
nurse practitioner or other physician extender we call them. But
just to be clear, you know, telemedicine also extends to
other types of devices, like wearables, those things that they're
(13:23):
either you know, trackers that you can wear as your fitbit,
or a sleep device you know that you can wear around.
Those kinds of things are kind of put into the
telemedicine bucket and it's not clear to me at least
how that is going to change. I think April first
is when the face to face coverage from a professional
(13:44):
fee standpoint that is slated to end because they did
liberalize it during the COVID pandemic and it's been extended.
I think another year around that and that will that
will definitely change the dynamic here, but it's not clear
how much of it extends to other types of remote
physiologic monitoring services and products.
Speaker 2 (14:06):
Right, Yeah, so something like a glucose monitor or like
some other yeah, which could be catastrophic for people, right
if they don't get those those funded. Right, we're going
to take a little break for advertisements here. Maybe you'll
get an advertisement for a gluecose monitor or even.
Speaker 3 (14:19):
Insulin can only hope.
Speaker 2 (14:21):
Yeah, Yeah, I'm glad they're taking some of that money
that they've made me bleed out of my wallet over
the years and returning it to me in the form
of podcast advertisements. All right, we're bank Let's talk more
(14:46):
broadly about I guess the changes in the legislative environment
for healthcare might be a good way to put it. Like,
I think if you were an excellent op ed recently
where you discussed you you were one of the many
recipients of the five useful things you did at work
this week email, and I thought you wrote like a
really good piece about about the varied and critical work
(15:09):
that you do. Can you talk about, like, what is
the feeling among healthcare professionals, physicians who have you sort
of like to speak speak as going into four years
of possibly vastly reduced government spending and a sort of
bizarre and haphazard cutting of the federal bureocracy that we're seeing.
Speaker 4 (15:33):
Yeah, it's a tough time, certainly, and coming out of
the pandemic, this is not what really anybody expected. But
you know, the stresses have been mounting for quite a
while right. Healthcare professionals are seeing and feeling more stress
at work, whether it's you know, the demands of the
job meaning that there are fewer resources to spend on
(15:56):
a heightened number of patients with you know, increasingly complex diseases,
or even just the questions that we are getting from patients.
You know, a lot of patients now are asking me
really financial questions. I mean literally, the other day, I
had a woman who was unfortunately having septic shock and
(16:17):
was faced with having to amputate her leg, and I
was speaking with her husband because she was becoming more
and more delirious, and he was just asking me about, well,
I'm going to have to sell my house in order
to fund what might come down the pike as far
as being at home with services, and I was trying
to I was trying to kind of get an understanding
(16:39):
of how he viewed his wife actually going through the
thing that we're watching in the moment. But it's a
preoccupation that has taken up a lot of space in
the room, and it's now coming on to physicians to
sort of navigate at least some questions and answer those.
Speaker 3 (16:56):
Questions around it. So that's a long way of saying that.
Speaker 4 (16:59):
You know, so physicians and nurses and other healthcare professionals
are feeing more and more stress in a system that's
just buckling, right, And the last thing anybody needs is
to be having to do more without really a clear
understanding of the purpose around it, right, And we are
all for a cost effectiveness. We want that to work.
(17:21):
We also want to provide care irrespective of someone's religious, political,
or other beliefs. And yet you know, we have to
work within a system that we kind of are not
really understanding how they're approaching this issue. Are they are
they with us or against us or somewhere in between.
It's it's sort of a it's a moving target, and
so I think that's what's that's what's kind of sandwiched
(17:43):
a lot of healthcare professionals and we don't really know
where to turn for some of the answers that we
ourselves are looking for.
Speaker 5 (17:51):
I would add also, you know, we're seeing this active
dismantling of the US healthcare infrastructure, and our friends in
the academic world in particular, it's a very stressful time
for them. Who knows if their studies are going to
go through. Who knows if they're going to get their funding,
who knows what's going to stay, what's going to go
in the next couple of years. There's a lot of
(18:12):
concern over that, obviously, But even in the medical world
outside of the academic centers, I know a lot of
doctors right now are concerned and they're concerned about what's
going to happen to the state of our scientific community
that helps us with new advancements in medical technology in
the coming years. And it seems like, as Ventecha was
(18:34):
alluding to, we're dismantling all our ability to follow to
study to really closely track infectious disease in a time
that is exceedingly dangerous across the world, with rising disease,
tuberculosis in this country, measles in this country, in Uganda,
there's ebola again.
Speaker 3 (18:55):
There's threats all over the world.
Speaker 5 (18:56):
And this is one of the worst times I could
think of to be in this moment of austerity, and
particularly because so much of it seems unclear to us
why why these things are being done, you know, is
it all because of this ridiculous gender ideology? Do they
actually think they're saving money with some of these things.
It's a very unclear time. And of course there are
(19:17):
a lot of people in the medical world, doctors included,
that are conservative or Republican voters. Getting into conversations with
them about this is sort of a tough thing to
do because, like Fintesha mentioned, they, like a lot of us,
want to make sure we're doing this in a cost
effective manner, something we talk about and we have been
talking about in medicine for a long time, particularly academic medicine,
(19:40):
interestingly enough, which is really on the cutting board. It's
academic medicine that usually talks about, you know, trying to
be cost effective. What tests are we going to order,
what labs do we need to get, how we do
in this in the most cost effective way. These are
important things that are discussed and across the political spectrum
in medicine. I think there is some concern even amongst
(20:01):
some of the more right leaning doctors. But again it's
hard because they've gone this far down the road, it's
hard to know, you know, when they're going to pull back.
What's the line in the stand for them about what
is maybe too far for this administration.
Speaker 2 (20:14):
Yeah, and certainly like an area where we're seeing that
right now is in like public health, right, we don't
really know. Like I'm going to Texas next week where
there's currently a measles outbreak. Yeah, and the things that
we didn't think that we might be seeing in this
country again, we're seeing again. And like, as you say,
it's coming at a time when like not just funding
(20:38):
is unstable, but also like the I guess, like the
basics of science have been somewhat politicized right to a degree,
and like people, I don't know if that's something you
see in your practice, but like certainly, like I was
talking to a doctor friend who said half their clients
are now like declining vaccinations as I was there to get,
(20:59):
you know, every disease that I could get. I have
a lot of travel vaccinations, so I'm always getting new
and exciting vaccinations. But I'm making up for some of
the gap, I guess. But it's uh, it's it's a
really challenging time right from that perspective as well, like
the culture around it.
Speaker 3 (21:16):
Yeah, that's right.
Speaker 5 (21:17):
I mean even here in the San Francisco Bay area,
you know, I've seen more vaccine hesitation than I remember
ever seen before in the past.
Speaker 4 (21:24):
It's sort of a vaccine question because I think some
of this is, let's be clear, some of this is
on our messaging, you know, as healthcare professionals. I mean,
there are more and more articles. In fact, there the
Wall Street Journal piece a couple of weeks ago that
was saying how patients you know, are increasingly not trusting
their doctors, and there are data to say that we
(21:47):
don't communicate very well. Right, So there is that, and
that's on us. And you know, another op ed piece
in the Boston Globe by Ash's Jaw, you know, did
a mea culpa around some of the things that public
health we did wrong.
Speaker 3 (21:59):
We got we got it.
Speaker 4 (22:00):
Wrong in COVID where we didn't you know, deal with
some of the doubts and lack of evidentiary base for
masking and some of these other things that basically hurt
us in the end. So there's definitely that. However, you know,
restoring the trust in healthcare professionals is sort of like
(22:20):
a basic step to anyone getting their healthcare. I mean,
I think people still go to their doctors, Most people
still trust their doctor to some degree, and I think
that that's at least a bright spot in where we are,
because when we've lost that, I think we're really in trouble.
I mean, that's slipping. But I think that there is
(22:42):
a way to restore that trust. But it starts so
that it just starts with a conversation. You know, if
someone has a vaccine hesitancy or they don't understand what's
going on, that's the opportunity to open the doors to
a dialogue. And I think maybe that's you know, maybe
that's the starting point for any of this. We all
(23:03):
want cost effectiveness, we all want, you know, transparency. We
also want to have choices that make sense to us.
But let's not make it an adversarial confrontation. And I
think that that goes for both sides. I would add,
though I agree with you on pretty much all of that.
I agree that we need to have those conversations, you know,
if they're difficult. We need to be able to look
(23:25):
back objectively about things that worked and didn't work. But
a lot of these sort of mia culpas that have
come out about like you know, this is where we
went wrong and why we lost trust, if I'm being honest,
including that one from Ashishyad, has a lot of in
my opinion pick me energy. A lot of people who
are trying to appeal to the incoming administration and be like, hey, look,
(23:48):
I'm cool too. I'm not always about vaccines, and to me,
that's just as bad too. And I do think we
need to have an honest conversation, and I do think
we need to be clear about how we do scigns.
Something we need to be able to explain, and you're
absolutely right, which we didn't do very well is Look,
we are working with information we have at hand.
Speaker 5 (24:08):
We're doing everything we can. This information may change. When
it changes, our recommendations aren't going to change too. And
that is tough. That is a tough message to get
across because people don't like nuance like that. People don't
like the uncertainty of that. People want to know yes
or no absolutely, and sometimes it's hard. It's hard to
find good communicators and science to do that. But that
(24:30):
you're exactly right is incumbent upon us as doctors who
have a sub stack like yours, of a podcast like mine,
who are academics who have a reach to students and
beyond to communicate these things. And even though it would
be awesome if for the next four years my podcast
(24:51):
was just about farts and poop. I know I have
to do a lot of this stuff because I know
how important this is now more than ever. So I
totally agree it's going to start with conversations.
Speaker 2 (25:04):
I think there's a big difference between this is the
information we have available and we're doing our best with it.
When we get new information, we'll do something different if
that's what that information points to. And these people are
acting out of malice to deprive you of your rights
or you know, to which is sometimes what's been suggested
by some people, and like, I think a good way
to defeat that, as you say, it's communicating around it.
(25:26):
It is very sad that, Like when I was doing
the research for my PhD dissertation, I wrote about first
I wrote about violence and the Anarchist Builders Union for
my masters and then I wrote about public health and
popular sport in the nineteen thirties in Barcelona, and a
lot of what you saw anarchists doing in Barcelona in
the nineteen thirties was talking to people about tuberculosis, educating
(25:47):
people about tuberculosis and explaining what tuberculosis was and where
it came from. And like that was in nineteen thirty
one and how.
Speaker 3 (25:57):
Far we've come baby, wow.
Speaker 2 (25:59):
Wow, Yeah, it's great. There were some other things from
the nineteen thirties which have also made an unwelcome return.
Juberculosis is not the only one. There's also the Nazi
salute in large public gatherings in the United States, which, yeah,
I don't know, and I guess i'd answer for them
both in the nineteen thirties, and they're the same answers
that apply now. I think people like people will be
(26:33):
distressed by this, right, like a lot of people of
my age and younger I guess folks a bit younger
than me for the larger part, like the pandemic was
a life defining event for a lot of younger folks, right,
and it was a scary thing. It still is a
scary thing, Like getting COVID still really sucks. And I
know people who have long COVID and the thought of
that is petrifying to me. People will be genuinely anxious
(26:57):
now right at this potential dismantling of public health apparatus,
like a rise in vaccine hesitancy, less funding for research,
such that if we enter another pandemic with some novel
infectious disease, we won't be able to respond as fast. Right,
the response to COVID for the criticisms of it, like
the speed with which we had vaccines was amazing. Some
(27:20):
of that came from like Vancousha's college at UCSD actually,
or right like salt I guess which is next door
with free parking, which is nice? So like, what would
you say to people because this is a thing I
see more and more among folks who you know, who
are friends of mine, right, is like real worry about
infectious disease, real concern about new variants of COVID or
(27:44):
about you know, the bird flu is one, right with
these other infectious diseases. I saw fifty people have died
of it as yet unexplained disease in Congo recently. What
would you say to those people? Because there concerns are
somewhat legitimate, right, Like, if we go into another pandemic,
when going to be anywhere near as effective as we
were in twenty twenty because of all these combination of
(28:06):
reasons we've.
Speaker 4 (28:06):
Discussed, that's a hard question to answer. I would say,
let me back up. You know I think that the
COVID pandemic, Yes, there are a lot of things that
went well. The vaccine development was phenomenal, I mean a revolutionary.
I mean, who would have expected that to happen. However,
it also just revealed how shattered our public health system
really is in terms of messaging, even detection, spreading information.
(28:31):
Even the vaccine distribution was completely chaotic. Right, So, so
I don't want to say that, you know, the public
health response during COVID was some sort of paragon to
be emulated or replicated, right So that said, though, absolutely,
I mean, you know, how are we going to handle
a new era of this what if you know scenario
(28:54):
where we don't know what virus is coming next? I mean,
I'm seeing these days, I'm even seeing virus is that
never caused the kind of respiratory failure in the past,
they're doing it now, whether it's RSV or a respiratory
sensitial virus or even non COVID coronavirus which should just
give you a cold the sniffles, and yet it's causing devastating,
(29:14):
you know, pneumonias. So we're in a new era and
you know, antibiotic resistance is not getting any less you know, problematic.
So what do we do in this era. Well, I
think awareness is the first thing, okay, awareness around. Yes,
I mean these diseases are transmitted from person to person.
You know, we all know somebody who doesn't want to
(29:37):
take a vaccine. I mean, I don't think there's that's
a surprise to say we know of somebody or directly
or maybe one degree of separation, right, And I think
you need to have those community conversations. You need to
have one on one conversations. Yes, it's going to be uncomfortable,
but we got to talk about it and talk to
your healthcare provider about it. I mean, yes, you can
look up stuff on TikTok. Yes, you could look up
(29:59):
stuff on Google or or you name your online resource.
But you want to have a person that can actually
understand from years of living and living and breathing this stuff,
and also who listens to you as a human being
in the same community or somewhere nearabouts right to put
(30:20):
together what the science says in some sort of meaningful
way to you, uh, and not some anonymous you know
resource that may or may not have all the you know,
all the data their fingertips, you know. So so I
guess it still goes back to how does anyone find
reliable information? Where do you go when you've got questions?
(30:41):
Most people want a human being who's lived and breathed
this with experience to help them navigate. I I certainly
see that, not just as a doctor, but as a friend,
as a family member. I'm constantly you know, they're asking
me these things, and I would suggest that you know
your audience may have both personally but also professionally to
(31:03):
those folks that can help them navigate.
Speaker 5 (31:05):
You know, and to answer your question from my perspective,
is a challenge. I because I think people should be concerned.
Speaker 3 (31:12):
In fact, I just did two parter.
Speaker 5 (31:14):
With one of the world's best virologists talking about the
possible bird flu pandemic that could arise and all the
threats that are out there, and so I do think
there are some really significant, serious risks to be worried about. However,
I'm never gonna say there's nothing that can be done
about it. There's plenty that can still be done about it.
(31:34):
I still maintain hope in the medical community for what
we're able to do and what we're able to accomplish.
And to echo what I think both of you guys
have said or would at least agree with.
Speaker 3 (31:44):
There's a lot of changes that we can make locally
amongst our small.
Speaker 5 (31:48):
Sphere of influence, and then growing out from there in
terms of getting vaccinated, in terms of wearing masks when needed,
or at least looking at the data with an open
mind and sharing good resources. Is because one thing that
the younger population is good about, and what some of
the people you're mentioning, James, is they're good at detecting
(32:10):
bullshit online and that's a skill that needs to be
honed for medical literacy as well, and I'm hopeful that
that's going to continue to improve. Maybe stupid optimism, but
I do believe the younger generation is going to continue
to be better at that than the older generation, and
I think that will help battle a lot of the
misinformation that's out there. But there are things that they
(32:32):
can do in fact, for getting back to the telehealth thing,
for example, talking about telemedicine slash telehealth as venteche sort
of broke down in terms of it being cut at
the end of the month. There are people that are
really pushing against that, including Rocanna, who's here a legislator
here in California who's proposed a new bill. I haven't
(32:53):
been able to see any of the details of it,
but there are a lot, including Amazon. By the way,
Amazon is one of like three hundred and fifty companies
that have written a letter to Congress to help push
for this funding. So if you can call a congress person,
if you can do that, if you can keep bothering
them telling them how important it is, I think those
(33:16):
are things that can help. So I think that's a
good place to start.
Speaker 2 (33:20):
Yeah, that's a really get piece of advice.
Speaker 4 (33:22):
If I could just follow up with that. I think
part of what will help with the support for some
of these programs is to take you know, take us
take a few minutes to think about what the other
side is worried about, right. I mean, we all know
about the excesses of certain online bad actors, who are
(33:43):
they use telemedicine to promote you know, ADHD medications or
other types of psychotropic medications, which was not it was
not supported, and it actually caused harm. Right, So so
there are things out there that are excesses and somewhat harmful,
and if we could as a community sort of help
(34:05):
frame the approach to dealing with some of those things
and preventing some of those problems, then I think some
of the support will kind of sort of show itself.
I think the worry is if you open up the
floodgates too wide, you know, human nature being what it is,
it's going to encourage bad behavior. Not that anybody wants that,
but there is something to be said about some scrutiny.
Speaker 3 (34:27):
Right, So if.
Speaker 4 (34:28):
We're the ones, and I completely support the use of
TELL medicine, but I also want to be careful about
how to promote its thoughtful and safe use and wed
that in the proposal and not just leave it for
others to figure out that That I think would potentially
change the conversation around while you just want this and
(34:49):
we're not going to give it to you, like the
standoff will will subside when you try to work it,
work a partnership out as opposed to a give it
to me or else kind a scenario.
Speaker 5 (34:59):
I don't disagree with that, but I also think you're
giving those more credit than I would, which is to
say that they actually really, they really would focus or
listen to. I think what they've just done is literally,
you know, take a chainsaw and cut away at major
federal funding and then kind of seeing what was really
(35:20):
bad about that and what wasn't and being like, oh, okay,
maybe we do need people in charge of nuclear security.
Speaker 3 (35:26):
Oh maybe this is popular. We'll put it back. You know.
I kind of think that.
Speaker 5 (35:30):
They're not taking as much attention or care, But I
also do agree that the point is is valid. I mean,
sure there is there fraud in some telemedicine. Yeah, I'm sure,
probably small, very small percentage. But if we can specify
its use, if we can be better about that, I agree,
I'm all for it.
Speaker 2 (35:48):
Yeah, especially right now. I was just thinking, as you're
talking about, like how important is people that accessing reproductive
healthcare and being able to access reproductive healthcare wherever they are,
and like how much more difficult that would be, right
if people didn't have telemedicine appointments. So I think we've
spoken about before on this show. But yeah, I'm sure
there are some school cases. I'm sure there are a
bunch of sis gender guys getting gender affirming hormonal care
(36:12):
through telemedicine who probably could go without and be Okay, guys,
I'd like to wrap up there, but I want to
give you a chance both to you talked a lot
about like science communication. So where can people find you online?
Where can they see you communicating your medical knowledge?
Speaker 4 (36:30):
Okay, well, so I thanks James. I have a substack
it's called be a Health Architect. You can book me
up at be a Health Architect, and you know, I
have a conversation there around an issue that certainly affects
me and those around me, which is physician burnout. But
in the larger sphere of healthcare professionals, it really touches
everybody in healthcare. So that's where I'm posting actively. I'm
(36:54):
also sharing that, you know, through various other avenues such
as X and Blue Sky and other places, so you
can you can find me there. Look forward to seeing
you there.
Speaker 3 (37:05):
Yeah.
Speaker 5 (37:05):
I would also recommend Vintechha's substack. If you're in the
medical field in particular, I think you'll appreciate it. A
focus on burnout is as important as it's ever been,
if not much much more. I mean, we were talking
about burnout moral injury in doctors before COVID, and now
you know, down a couple of years down the road,
(37:27):
it's only worse. So I think it's really important and
I do recommend it, or you know, check out his
latest article in the Los Angeles Times. As you mentioned before.
As for me, find me on Blue Sky at Cave MD.
But more importantly, just listen to the podcast The House
of Pod. If you are a fan of this show,
I think you're gonna like The House of Pod if
(37:47):
you haven't already given it a try.
Speaker 3 (37:49):
It's a lot of the same people that you hear
on this show. On the House of Pod.
Speaker 5 (37:54):
James included he's gonna be coming back to talk about
the measles and with an author of a new book
down there about the measles outbreak. And you know, we
take a look at grifters, medical grifters, We take a
look at some people that would be considered medical contrarians.
We take a look at some of the quackery and
medicine as well. So I think you'll appreciate this show.
(38:17):
If you like the whole behind the Bastards verse, I
think you'll get into the House of Podso so check
us out wherever you get your podcasts.
Speaker 2 (38:25):
Yeah, great, Thank you so much for joining us. Guys
really appreciate it.
Speaker 3 (38:28):
Thanks, thank you.
Speaker 1 (38:32):
It could happen here is a production of cool Zone Media.
For more podcasts from Cool Zone Media. Visit our website
coolzonmedia dot com, or check us out on the iHeartRadio app,
Apple podcasts, or wherever you listen to podcasts. You can
now find sources for it could happen here listened directly
in episode descriptions. Thanks for listening.
CAUs Media.
Speaker 2 (00:05):
Hello and welcome to the podcast. It's me James. Today
we have a very special episode in which everyone is
a doctor. I will believe in discussion, of course, as
a doctor of modern European history. But I'm joined today
by venktash Ramnath, who is a practicing pullmanologist, a professor
at UC San Diego Health, a medical director of several
(00:26):
it use in royal and urban settings, and also the
author of the substack be a health architect. Welcome to
the Shoving Test. Thanks for joining us.
Speaker 3 (00:34):
Great to be here.
Speaker 2 (00:35):
I'm also joined by doctor Carve Holder, a gastro enterologist
and the host of our favorite medical podcast, The House
of Pod.
Speaker 3 (00:44):
Of the many you listen to, I'm sure yeah.
Speaker 2 (00:46):
What they might call a super user in a medical
podcast space you listen to more than most importantly Cave
of course, our friend, our resident doctor with a useful doctorate.
So what we want to talk about today is Medicare
and specifically some of the cuts to medicare. More broadly,
(01:08):
the I don't know really have to put this challenges
for people working in healthcare and the Trump administration right.
We addressed specifically gender affirming care in a previous episode,
but it doesn't start and end there, right, That might
be the thing that sort of the culture wars have
been focusing on recently. But I want to talk more
broadly about the challenges facing healthcare. So first of all,
(01:31):
would one of you care to explain medicare for people
who are not familiar And some listeners might not be
living in the United States, or they might just not
have encountered this yet in their life, So could one
of you explain what this particular sort of type of
health insurance is and how it's maybe more vulnerable than
other types to federal government changes.
Speaker 3 (01:52):
I could take a stab at it.
Speaker 4 (01:54):
I'm not a health policy want but I am a
physician that has to deal with Medicare all the time.
So Medicare, in sort of general terms, is a type
of health insurance that is provided by the federal government.
It is almost exclusively for individuals above the age of
sixty five, as it dates back to the nineteen sixties
(02:15):
with Lyndon Johnson's Great Society Program, and so since that
time there has been this blanket coverage for any individuals
above that age, such that all their medical services or products,
whatever they need for their healthcare is actually covered by
the government.
Speaker 3 (02:34):
This is the federal government.
Speaker 4 (02:36):
Now, the interesting thing about Medicare is that there are
different parts to it. There's Part A, which is primarily
for some essential services and includes hospital care. There's Part B,
which includes whatever physicians fees go into that healthcare. And
then there's Part D, which relates to pharmaceutical prices, so
(02:56):
your drug costs. It's not comprehensive in the sense that
there's always something more that individuals need, but Medicare, for
all intents and purposes, is the sort of standard and
it should cover most of individual's needs. Now that said,
the commercial payers, that is, the other insurance companies that
(03:18):
are not federally government sponsored, take their lead from Medicare.
So a lot of the different payment rates or coverages
and services they all look to what the centers of
Medicare and Medicaid services dictate as far as what is
an acceptable reimbursement rate, what are the rules around what
(03:38):
should be covered and what should not. So that's why
Medicare is such an important entity for the United States.
Speaker 3 (03:46):
Yeah, I'll add to that.
Speaker 5 (03:48):
They set the lead of importance here too, because if
we're talking about telemedicine telehealth, how important that is to
medicare patients to everyone in the country at this point.
Then if they are to cut it, if that happens,
as I think we're probably going to discuss. If that
goes away, then the other private insurance companies are going
(04:09):
to follow.
Speaker 3 (04:09):
That's right.
Speaker 5 (04:10):
It could be across the board changes led by these
changes of medicare.
Speaker 2 (04:15):
Yeah, so let's talk about those changes. Then, as you
mentioned right, there's this telemedicine it's a waiver right that
has allowed telemedicine to be funded through this for the
last five years. I suppose it's going to expire by
the end of this month, which is March twenty twenty five.
If if you're listening later, explain like why telemedicine has
(04:37):
been such a positive step like in healthcare since if
you could since twenty twenty and then what we're facing
if it's no longer funded federally.
Speaker 5 (04:48):
May I'll start this one, but Venkesh definitely want you
to weigh in on it as well. Does give a little background.
Over the past five years that's grown quite a bit
and it's gone from being kind of this emergency stop
gap to a real cornerstone of what we consider modern healthcare,
and now it's exceedingly common, like over seventy five percent
(05:09):
of hospitals in the US connect at a distance via
video conference or some technology to patients. And it's been
popular on both sides. It's been popular on both sides
of the aisle. When it first was done, as you mentioned,
during COVID, when they said, Okay, we're gonna peel back
(05:31):
some of the restrictions on Medicare coverage for these telehealth things,
it was considered like a victory, like one of the
few good things that come out of COVID.
Speaker 3 (05:41):
Both sides liked it.
Speaker 5 (05:43):
It was popular amongst patients, it was popular amongst medical providers.
It was good for Republicans and Democrats alike. And as
you mentioned, it's been kept going through being put in
some bill or another since it was initially put in
I think as they called twenty two, and it's been
put in one bill or another to go with a funding.
(06:04):
But then came this last December when Congress was going
through their spending. It was only given this three month
reprieve which is going to be up as you mentioned,
at the end of this month, and if it goes away,
there's a lot of factors will go into a lot
of them. But there's a lot of people, older patients,
you know, compromise patients who don't want to come into office,
people with disabilities, people can't get around that well, people
(06:27):
in rural areas, which is you know, really how it started.
People who are going to be hurt all across this country.
And at this point, the majority of people have had
at least one experience or more in a year with telemedicine.
It's become a part of a lot of people's lives.
And if it goes away, you know, there's still going
to be health care as it is. I mean, it
(06:48):
doesn't mean health care is going away, but it is
going to put a tremendous burden on patients and hospitals
for that matter, across the country.
Speaker 3 (06:57):
Yeah, let me let me add to that.
Speaker 4 (06:58):
So, you know, telemedicine has been around for a very
long time, at least technically speaking, right, I mean, you
can go back to the nineteen seventies. Even when you
talk about the intensive cared it which is where the
sickest people in the hospital are. There are studies that
come out of the nineteen seventies. However, Ever, since people
have had iPhones and been on Airbnb and everything else.
(07:21):
Since two thousand and seven, that inflection point actually had
a wave of opportunity that washed right into medicine, and
as Cave is saying, you know, we have such a
fragmented healthcare system that has you know, folks living in
rural areas, suburban areas, and urban areas, all of whom
(07:42):
are at the mercy of what specialists may be. They're
contracted at any given time for any given specialty. Now telemedicine,
as it's gotten more and more popular, has kind of
leveled the playing field. I mean, you can be in
a rural place like where I'm sitting right now on
the US Mexico border, or you can be in New
(08:03):
York City, you know, one of the densest populations, but
you may might not have access to specialty expertise without telemedicine.
With telemedicine, you can now have access and I've seen
patients love it. You can deal with the sickest of
the sick, like I said, intensive care units, but you
can also have outpatient experiences. And we've seen a number
(08:24):
of different you know, commercial opportunities that have leveraged that.
But the point is that as as we're hearing on this,
you know, it's become sort of a standard operating procedure
for how we deliver healthcare. And if you just pull
the rug out from that, there can be some you know,
unintended consequences to that that are not insignificant.
Speaker 2 (08:44):
Yeah, and like it makes a lot of sense to
a lot of people, right, Like I think about my
own experience with it. I was traveling recently and got
COVID like a couple of months ago, and there was
no need for me to go to a clinic and
be around other people, right, I just needed to contact
my doctor and get some prescriptions check in, And like
it was so much better that I could do it
in my pajamas from a bed rather than like having
(09:06):
to get out. And I'm lucky to have access to
a car. It can drive to the doctor's surgery is
not that far away. Have a job that accommodates my schedule.
But there are a million reasons way it might be
very beneficial to people. So let's talk about you. You
mentioned this before, but we have commercial insurers, and like
people might think that this is limited to older folks,
(09:26):
or it doesn't affect them, or it's something that only
impacts people who have Medicare. But as you said, Medicare
kind of sets the standard for what is covered and
what isn't covered, right, So can you explain how this
might end up resulting in it in just a massive
like a cliff. I've seen it described as a telehealth cliff.
Speaker 4 (09:44):
Yeah, So, I mean basically, the sort of this convoluted
way that we pay for services is it looks to
one standard, even though some may argue how did that
standard come about? But regardless of that, Medicare is the
central authority that basically tells everyone this is what we
(10:04):
should be doing, and this is how much we should
be paying for it. Now, the commercial insurers can decide
to exceed that if they wish. If they say, have
an employer who's employees they want to have a special
contract with, that's fine, that's not restricted. But the bottom
of what is considered a reimbursable amount is really set
(10:27):
by Medicare, and so they move the bottom. And so
if you drop the bottom, you can pretty much well
assured in this, you know, in a capitalist you know
sort of mentality that the cost should go down, right,
I mean, why should.
Speaker 3 (10:39):
You pay more?
Speaker 4 (10:40):
For something that you don't need to write, and we
see that. We see that every year. Okay, every year
there's new technology, but the slightly older technology, which is
again covered by Medicare, they move those reimbursements down. So
whether it's a sleep study, you know, for someone with
obstructives leap babner, a difficulty sleeping at night, or it's
(11:02):
some ophthalmology technology, or it's some ultrasound machine, it doesn't really.
Speaker 3 (11:07):
Matter what it is.
Speaker 4 (11:08):
Medicare is always trying to minimize costs, which is understandable.
They want to make it cost effective, but they are
setting the lead so everyone will follow what they do.
That's kind of the way that our system is sort
of set up.
Speaker 5 (11:22):
Yeah, you know, I might just add to that that
aside from all the things we mentioned about it, how
you know it helps people in rural areas, people with
difficulty getting places are just really busy schedules. It also
you know, helps free of hospital beds, helps prevent emergency
rooms from being overwhelmed, It leads to faster testing, it
(11:43):
leads to a higher number of people that we can see,
and in terms of its quality, we know it works
well and about ninety percent of cases of telemedicine to
get the same outcomes if the patient was there in clinic,
and that ten percent that's not it's not clear that
they're getting in fear your care.
Speaker 3 (12:00):
In most of those cases.
Speaker 5 (12:02):
So it's an effective treatment, and you could make an
argument that it is cost effective in some ways too,
particularly clearly for like things like dermatology, pediatrics. These are
things where it's clearly cost effective to have it, but
even beyond that, it's not even necessarily I think a
strong argument that we'll be losing money from it and
(12:23):
that cutting it would help us in the long run.
I feel like we're being smart about how to manage
American healthcare system and how to keep it afloat. TELL
the Medicine is going to be an important part of
that going forward.
Speaker 4 (12:36):
I do want to add something here, and I do
want to be careful about the term, because telemedicine and
telehealth are not only sort of a catch all, but
they're sort of used interchangeably, right, and just like anything,
you have to be specific about the term. So I
think what we're talking about this on this podcast is
tell a medicine in terms of a two way audio
(12:59):
visual interface where you can have a direct face to
face consultation or interaction with a practicing practitioner. Usually that's
going to be a physician, but it may be a
nurse practitioner or other physician extender we call them. But
just to be clear, you know, telemedicine also extends to
other types of devices, like wearables, those things that they're
(13:23):
either you know, trackers that you can wear as your fitbit,
or a sleep device you know that you can wear around.
Those kinds of things are kind of put into the
telemedicine bucket and it's not clear to me at least
how that is going to change. I think April first
is when the face to face coverage from a professional
(13:44):
fee standpoint that is slated to end because they did
liberalize it during the COVID pandemic and it's been extended.
I think another year around that and that will that
will definitely change the dynamic here, but it's not clear
how much of it extends to other types of remote
physiologic monitoring services and products.
Speaker 2 (14:06):
Right, Yeah, so something like a glucose monitor or like
some other yeah, which could be catastrophic for people, right
if they don't get those those funded. Right, we're going
to take a little break for advertisements here. Maybe you'll
get an advertisement for a gluecose monitor or even.
Speaker 3 (14:19):
Insulin can only hope.
Speaker 2 (14:21):
Yeah, Yeah, I'm glad they're taking some of that money
that they've made me bleed out of my wallet over
the years and returning it to me in the form
of podcast advertisements. All right, we're bank Let's talk more
(14:46):
broadly about I guess the changes in the legislative environment
for healthcare might be a good way to put it. Like,
I think if you were an excellent op ed recently
where you discussed you you were one of the many
recipients of the five useful things you did at work
this week email, and I thought you wrote like a
really good piece about about the varied and critical work
(15:09):
that you do. Can you talk about, like, what is
the feeling among healthcare professionals, physicians who have you sort
of like to speak speak as going into four years
of possibly vastly reduced government spending and a sort of
bizarre and haphazard cutting of the federal bureocracy that we're seeing.
Speaker 4 (15:33):
Yeah, it's a tough time, certainly, and coming out of
the pandemic, this is not what really anybody expected. But
you know, the stresses have been mounting for quite a
while right. Healthcare professionals are seeing and feeling more stress
at work, whether it's you know, the demands of the
job meaning that there are fewer resources to spend on
(15:56):
a heightened number of patients with you know, increasingly complex diseases,
or even just the questions that we are getting from patients.
You know, a lot of patients now are asking me
really financial questions. I mean literally, the other day, I
had a woman who was unfortunately having septic shock and
(16:17):
was faced with having to amputate her leg, and I
was speaking with her husband because she was becoming more
and more delirious, and he was just asking me about, well,
I'm going to have to sell my house in order
to fund what might come down the pike as far
as being at home with services, and I was trying
to I was trying to kind of get an understanding
(16:39):
of how he viewed his wife actually going through the
thing that we're watching in the moment. But it's a
preoccupation that has taken up a lot of space in
the room, and it's now coming on to physicians to
sort of navigate at least some questions and answer those.
Speaker 3 (16:56):
Questions around it. So that's a long way of saying that.
Speaker 4 (16:59):
You know, so physicians and nurses and other healthcare professionals
are feeing more and more stress in a system that's
just buckling, right, And the last thing anybody needs is
to be having to do more without really a clear
understanding of the purpose around it, right, And we are
all for a cost effectiveness. We want that to work.
(17:21):
We also want to provide care irrespective of someone's religious, political,
or other beliefs. And yet you know, we have to
work within a system that we kind of are not
really understanding how they're approaching this issue. Are they are
they with us or against us or somewhere in between.
It's it's sort of a it's a moving target, and
so I think that's what's that's what's kind of sandwiched
(17:43):
a lot of healthcare professionals and we don't really know
where to turn for some of the answers that we
ourselves are looking for.
Speaker 5 (17:51):
I would add also, you know, we're seeing this active
dismantling of the US healthcare infrastructure, and our friends in
the academic world in particular, it's a very stressful time
for them. Who knows if their studies are going to
go through. Who knows if they're going to get their funding,
who knows what's going to stay, what's going to go
in the next couple of years. There's a lot of
(18:12):
concern over that, obviously, But even in the medical world
outside of the academic centers, I know a lot of
doctors right now are concerned and they're concerned about what's
going to happen to the state of our scientific community
that helps us with new advancements in medical technology in
the coming years. And it seems like, as Ventecha was
(18:34):
alluding to, we're dismantling all our ability to follow to
study to really closely track infectious disease in a time
that is exceedingly dangerous across the world, with rising disease,
tuberculosis in this country, measles in this country, in Uganda,
there's ebola again.
Speaker 3 (18:55):
There's threats all over the world.
Speaker 5 (18:56):
And this is one of the worst times I could
think of to be in this moment of austerity, and
particularly because so much of it seems unclear to us
why why these things are being done, you know, is
it all because of this ridiculous gender ideology? Do they
actually think they're saving money with some of these things.
It's a very unclear time. And of course there are
(19:17):
a lot of people in the medical world, doctors included,
that are conservative or Republican voters. Getting into conversations with
them about this is sort of a tough thing to
do because, like Fintesha mentioned, they, like a lot of us,
want to make sure we're doing this in a cost
effective manner, something we talk about and we have been
talking about in medicine for a long time, particularly academic medicine,
(19:40):
interestingly enough, which is really on the cutting board. It's
academic medicine that usually talks about, you know, trying to
be cost effective. What tests are we going to order,
what labs do we need to get, how we do
in this in the most cost effective way. These are
important things that are discussed and across the political spectrum
in medicine. I think there is some concern even amongst
(20:01):
some of the more right leaning doctors. But again it's
hard because they've gone this far down the road, it's
hard to know, you know, when they're going to pull back.
What's the line in the stand for them about what
is maybe too far for this administration.
Speaker 2 (20:14):
Yeah, and certainly like an area where we're seeing that
right now is in like public health, right, we don't
really know. Like I'm going to Texas next week where
there's currently a measles outbreak. Yeah, and the things that
we didn't think that we might be seeing in this
country again, we're seeing again. And like, as you say,
it's coming at a time when like not just funding
(20:38):
is unstable, but also like the I guess, like the
basics of science have been somewhat politicized right to a degree,
and like people, I don't know if that's something you
see in your practice, but like certainly, like I was
talking to a doctor friend who said half their clients
are now like declining vaccinations as I was there to get,
(20:59):
you know, every disease that I could get. I have
a lot of travel vaccinations, so I'm always getting new
and exciting vaccinations. But I'm making up for some of
the gap, I guess. But it's uh, it's it's a
really challenging time right from that perspective as well, like
the culture around it.
Speaker 3 (21:16):
Yeah, that's right.
Speaker 5 (21:17):
I mean even here in the San Francisco Bay area,
you know, I've seen more vaccine hesitation than I remember
ever seen before in the past.
Speaker 4 (21:24):
It's sort of a vaccine question because I think some
of this is, let's be clear, some of this is
on our messaging, you know, as healthcare professionals. I mean,
there are more and more articles. In fact, there the
Wall Street Journal piece a couple of weeks ago that
was saying how patients you know, are increasingly not trusting
their doctors, and there are data to say that we
(21:47):
don't communicate very well. Right, So there is that, and
that's on us. And you know, another op ed piece
in the Boston Globe by Ash's Jaw, you know, did
a mea culpa around some of the things that public
health we did wrong.
Speaker 3 (21:59):
We got we got it.
Speaker 4 (22:00):
Wrong in COVID where we didn't you know, deal with
some of the doubts and lack of evidentiary base for
masking and some of these other things that basically hurt
us in the end. So there's definitely that. However, you know,
restoring the trust in healthcare professionals is sort of like
(22:20):
a basic step to anyone getting their healthcare. I mean,
I think people still go to their doctors, Most people
still trust their doctor to some degree, and I think
that that's at least a bright spot in where we are,
because when we've lost that, I think we're really in trouble.
I mean, that's slipping. But I think that there is
(22:42):
a way to restore that trust. But it starts so
that it just starts with a conversation. You know, if
someone has a vaccine hesitancy or they don't understand what's
going on, that's the opportunity to open the doors to
a dialogue. And I think maybe that's you know, maybe
that's the starting point for any of this. We all
(23:03):
want cost effectiveness, we all want, you know, transparency. We
also want to have choices that make sense to us.
But let's not make it an adversarial confrontation. And I
think that that goes for both sides. I would add,
though I agree with you on pretty much all of that.
I agree that we need to have those conversations, you know,
if they're difficult. We need to be able to look
(23:25):
back objectively about things that worked and didn't work. But
a lot of these sort of mia culpas that have
come out about like you know, this is where we
went wrong and why we lost trust, if I'm being honest,
including that one from Ashishyad, has a lot of in
my opinion pick me energy. A lot of people who
are trying to appeal to the incoming administration and be like, hey, look,
(23:48):
I'm cool too. I'm not always about vaccines, and to me,
that's just as bad too. And I do think we
need to have an honest conversation, and I do think
we need to be clear about how we do scigns.
Something we need to be able to explain, and you're
absolutely right, which we didn't do very well is Look,
we are working with information we have at hand.
Speaker 5 (24:08):
We're doing everything we can. This information may change. When
it changes, our recommendations aren't going to change too. And
that is tough. That is a tough message to get
across because people don't like nuance like that. People don't
like the uncertainty of that. People want to know yes
or no absolutely, and sometimes it's hard. It's hard to
find good communicators and science to do that. But that
(24:30):
you're exactly right is incumbent upon us as doctors who
have a sub stack like yours, of a podcast like mine,
who are academics who have a reach to students and
beyond to communicate these things. And even though it would
be awesome if for the next four years my podcast
(24:51):
was just about farts and poop. I know I have
to do a lot of this stuff because I know
how important this is now more than ever. So I
totally agree it's going to start with conversations.
Speaker 2 (25:04):
I think there's a big difference between this is the
information we have available and we're doing our best with it.
When we get new information, we'll do something different if
that's what that information points to. And these people are
acting out of malice to deprive you of your rights
or you know, to which is sometimes what's been suggested
by some people, and like, I think a good way
to defeat that, as you say, it's communicating around it.
(25:26):
It is very sad that, Like when I was doing
the research for my PhD dissertation, I wrote about first
I wrote about violence and the Anarchist Builders Union for
my masters and then I wrote about public health and
popular sport in the nineteen thirties in Barcelona, and a
lot of what you saw anarchists doing in Barcelona in
the nineteen thirties was talking to people about tuberculosis, educating
(25:47):
people about tuberculosis and explaining what tuberculosis was and where
it came from. And like that was in nineteen thirty
one and how.
Speaker 3 (25:57):
Far we've come baby, wow.
Speaker 2 (25:59):
Wow, Yeah, it's great. There were some other things from
the nineteen thirties which have also made an unwelcome return.
Juberculosis is not the only one. There's also the Nazi
salute in large public gatherings in the United States, which, yeah,
I don't know, and I guess i'd answer for them
both in the nineteen thirties, and they're the same answers
that apply now. I think people like people will be
(26:33):
distressed by this, right, like a lot of people of
my age and younger I guess folks a bit younger
than me for the larger part, like the pandemic was
a life defining event for a lot of younger folks, right,
and it was a scary thing. It still is a
scary thing, Like getting COVID still really sucks. And I
know people who have long COVID and the thought of
that is petrifying to me. People will be genuinely anxious
(26:57):
now right at this potential dismantling of public health apparatus,
like a rise in vaccine hesitancy, less funding for research,
such that if we enter another pandemic with some novel
infectious disease, we won't be able to respond as fast. Right,
the response to COVID for the criticisms of it, like
the speed with which we had vaccines was amazing. Some
(27:20):
of that came from like Vancousha's college at UCSD actually,
or right like salt I guess which is next door
with free parking, which is nice? So like, what would
you say to people because this is a thing I
see more and more among folks who you know, who
are friends of mine, right, is like real worry about
infectious disease, real concern about new variants of COVID or
(27:44):
about you know, the bird flu is one, right with
these other infectious diseases. I saw fifty people have died
of it as yet unexplained disease in Congo recently. What
would you say to those people? Because there concerns are
somewhat legitimate, right, Like, if we go into another pandemic,
when going to be anywhere near as effective as we
were in twenty twenty because of all these combination of
(28:06):
reasons we've.
Speaker 4 (28:06):
Discussed, that's a hard question to answer. I would say,
let me back up. You know I think that the
COVID pandemic, Yes, there are a lot of things that
went well. The vaccine development was phenomenal, I mean a revolutionary.
I mean, who would have expected that to happen. However,
it also just revealed how shattered our public health system
really is in terms of messaging, even detection, spreading information.
(28:31):
Even the vaccine distribution was completely chaotic. Right, So, so
I don't want to say that, you know, the public
health response during COVID was some sort of paragon to
be emulated or replicated, right So that said, though, absolutely,
I mean, you know, how are we going to handle
a new era of this what if you know scenario
(28:54):
where we don't know what virus is coming next? I mean,
I'm seeing these days, I'm even seeing virus is that
never caused the kind of respiratory failure in the past,
they're doing it now, whether it's RSV or a respiratory
sensitial virus or even non COVID coronavirus which should just
give you a cold the sniffles, and yet it's causing devastating,
(29:14):
you know, pneumonias. So we're in a new era and
you know, antibiotic resistance is not getting any less you know, problematic.
So what do we do in this era. Well, I
think awareness is the first thing, okay, awareness around. Yes,
I mean these diseases are transmitted from person to person.
You know, we all know somebody who doesn't want to
(29:37):
take a vaccine. I mean, I don't think there's that's
a surprise to say we know of somebody or directly
or maybe one degree of separation, right, And I think
you need to have those community conversations. You need to
have one on one conversations. Yes, it's going to be uncomfortable,
but we got to talk about it and talk to
your healthcare provider about it. I mean, yes, you can
look up stuff on TikTok. Yes, you could look up
(29:59):
stuff on Google or or you name your online resource.
But you want to have a person that can actually
understand from years of living and living and breathing this stuff,
and also who listens to you as a human being
in the same community or somewhere nearabouts right to put
(30:20):
together what the science says in some sort of meaningful
way to you, uh, and not some anonymous you know
resource that may or may not have all the you know,
all the data their fingertips, you know. So so I
guess it still goes back to how does anyone find
reliable information? Where do you go when you've got questions?
(30:41):
Most people want a human being who's lived and breathed
this with experience to help them navigate. I I certainly
see that, not just as a doctor, but as a friend,
as a family member. I'm constantly you know, they're asking
me these things, and I would suggest that you know
your audience may have both personally but also professionally to
(31:03):
those folks that can help them navigate.
Speaker 5 (31:05):
You know, and to answer your question from my perspective,
is a challenge. I because I think people should be concerned.
Speaker 3 (31:12):
In fact, I just did two parter.
Speaker 5 (31:14):
With one of the world's best virologists talking about the
possible bird flu pandemic that could arise and all the
threats that are out there, and so I do think
there are some really significant, serious risks to be worried about. However,
I'm never gonna say there's nothing that can be done
about it. There's plenty that can still be done about it.
(31:34):
I still maintain hope in the medical community for what
we're able to do and what we're able to accomplish.
And to echo what I think both of you guys
have said or would at least agree with.
Speaker 3 (31:44):
There's a lot of changes that we can make locally
amongst our small.
Speaker 5 (31:48):
Sphere of influence, and then growing out from there in
terms of getting vaccinated, in terms of wearing masks when needed,
or at least looking at the data with an open
mind and sharing good resources. Is because one thing that
the younger population is good about, and what some of
the people you're mentioning, James, is they're good at detecting
(32:10):
bullshit online and that's a skill that needs to be
honed for medical literacy as well, and I'm hopeful that
that's going to continue to improve. Maybe stupid optimism, but
I do believe the younger generation is going to continue
to be better at that than the older generation, and
I think that will help battle a lot of the
misinformation that's out there. But there are things that they
(32:32):
can do in fact, for getting back to the telehealth thing,
for example, talking about telemedicine slash telehealth as venteche sort
of broke down in terms of it being cut at
the end of the month. There are people that are
really pushing against that, including Rocanna, who's here a legislator
here in California who's proposed a new bill. I haven't
(32:53):
been able to see any of the details of it,
but there are a lot, including Amazon. By the way,
Amazon is one of like three hundred and fifty companies
that have written a letter to Congress to help push
for this funding. So if you can call a congress person,
if you can do that, if you can keep bothering
them telling them how important it is, I think those
(33:16):
are things that can help. So I think that's a
good place to start.
Speaker 2 (33:20):
Yeah, that's a really get piece of advice.
Speaker 4 (33:22):
If I could just follow up with that. I think
part of what will help with the support for some
of these programs is to take you know, take us
take a few minutes to think about what the other
side is worried about, right. I mean, we all know
about the excesses of certain online bad actors, who are
(33:43):
they use telemedicine to promote you know, ADHD medications or
other types of psychotropic medications, which was not it was
not supported, and it actually caused harm. Right, So so
there are things out there that are excesses and somewhat harmful,
and if we could as a community sort of help
(34:05):
frame the approach to dealing with some of those things
and preventing some of those problems, then I think some
of the support will kind of sort of show itself.
I think the worry is if you open up the
floodgates too wide, you know, human nature being what it is,
it's going to encourage bad behavior. Not that anybody wants that,
but there is something to be said about some scrutiny.
Speaker 3 (34:27):
Right, So if.
Speaker 4 (34:28):
We're the ones, and I completely support the use of
TELL medicine, but I also want to be careful about
how to promote its thoughtful and safe use and wed
that in the proposal and not just leave it for
others to figure out that That I think would potentially
change the conversation around while you just want this and
(34:49):
we're not going to give it to you, like the
standoff will will subside when you try to work it,
work a partnership out as opposed to a give it
to me or else kind a scenario.
Speaker 5 (34:59):
I don't disagree with that, but I also think you're
giving those more credit than I would, which is to
say that they actually really, they really would focus or
listen to. I think what they've just done is literally,
you know, take a chainsaw and cut away at major
federal funding and then kind of seeing what was really
(35:20):
bad about that and what wasn't and being like, oh, okay,
maybe we do need people in charge of nuclear security.
Speaker 3 (35:26):
Oh maybe this is popular. We'll put it back. You know.
I kind of think that.
Speaker 5 (35:30):
They're not taking as much attention or care, But I
also do agree that the point is is valid. I mean,
sure there is there fraud in some telemedicine. Yeah, I'm sure,
probably small, very small percentage. But if we can specify
its use, if we can be better about that, I agree,
I'm all for it.
Speaker 2 (35:48):
Yeah, especially right now. I was just thinking, as you're
talking about, like how important is people that accessing reproductive
healthcare and being able to access reproductive healthcare wherever they are,
and like how much more difficult that would be, right
if people didn't have telemedicine appointments. So I think we've
spoken about before on this show. But yeah, I'm sure
there are some school cases. I'm sure there are a
bunch of sis gender guys getting gender affirming hormonal care
(36:12):
through telemedicine who probably could go without and be Okay, guys,
I'd like to wrap up there, but I want to
give you a chance both to you talked a lot
about like science communication. So where can people find you online?
Where can they see you communicating your medical knowledge?
Speaker 4 (36:30):
Okay, well, so I thanks James. I have a substack
it's called be a Health Architect. You can book me
up at be a Health Architect, and you know, I
have a conversation there around an issue that certainly affects
me and those around me, which is physician burnout. But
in the larger sphere of healthcare professionals, it really touches
everybody in healthcare. So that's where I'm posting actively. I'm
(36:54):
also sharing that, you know, through various other avenues such
as X and Blue Sky and other places, so you
can you can find me there. Look forward to seeing
you there.
Speaker 3 (37:05):
Yeah.
Speaker 5 (37:05):
I would also recommend Vintechha's substack. If you're in the
medical field in particular, I think you'll appreciate it. A
focus on burnout is as important as it's ever been,
if not much much more. I mean, we were talking
about burnout moral injury in doctors before COVID, and now
you know, down a couple of years down the road,
(37:27):
it's only worse. So I think it's really important and
I do recommend it, or you know, check out his
latest article in the Los Angeles Times. As you mentioned before.
As for me, find me on Blue Sky at Cave MD.
But more importantly, just listen to the podcast The House
of Pod. If you are a fan of this show,
I think you're gonna like The House of Pod if
(37:47):
you haven't already given it a try.
Speaker 3 (37:49):
It's a lot of the same people that you hear
on this show. On the House of Pod.
Speaker 5 (37:54):
James included he's gonna be coming back to talk about
the measles and with an author of a new book
down there about the measles outbreak. And you know, we
take a look at grifters, medical grifters, We take a
look at some people that would be considered medical contrarians.
We take a look at some of the quackery and
medicine as well. So I think you'll appreciate this show.
(38:17):
If you like the whole behind the Bastards verse, I
think you'll get into the House of Podso so check
us out wherever you get your podcasts.
Speaker 2 (38:25):
Yeah, great, Thank you so much for joining us. Guys
really appreciate it.
Speaker 3 (38:28):
Thanks, thank you.
Speaker 1 (38:32):
It could happen here is a production of cool Zone Media.
For more podcasts from Cool Zone Media. Visit our website
coolzonmedia dot com, or check us out on the iHeartRadio app,
Apple podcasts, or wherever you listen to podcasts. You can
now find sources for it could happen here listened directly
in episode descriptions. Thanks for listening.
It Could Happen Here News
Hosts And Creators
Robert Evans
Garrison Davis
James Stout
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