March 12, 2025 • 25 mins
What happens when a talented physician journeys from Pakistan's largest city to the heart of the American healthcare system? Dr. Sajid Zafar's remarkable path from Karachi to becoming a respected gastroenterologist in St. Louis reveals fascinating insights about medicine, migration, and the ever-evolving landscape of digestive health.
Dr. Zafar takes us behind the scenes of modern gastroenterology – a specialty that straddles the worlds of internal medicine and surgery. Performing between 1,500-2,000 procedures annually (likely more than any other medical specialty), gastroenterologists use scopes just millimeters wide to diagnose and treat conditions throughout the digestive system. From controlling bleeding and removing tumors to placing feeding tubes that once required major surgery, these minimally invasive techniques have revolutionized patient care. But the specialty also confronts difficult ethical dilemmas, particularly when families request interventions for elderly patients with advanced dementia.
The conversation takes an urgent turn when discussing the alarming rise in colorectal cancer among people under 50. This trend prompted the recent change in screening guidelines, lowering the recommended age for first colonoscopy from 50 to 45. Dr. Zafar emphasizes that family history dramatically impacts risk – if your parent or sibling had colon cancer before 60, you need screening at 40, or ten years before their diagnosis age. Unlike many aggressive cancers, colorectal cancer caught early has excellent survival rates, making proper screening potentially life-saving.
Perhaps most valuable is Dr. Zafar's wisdom about diet and digestive health. Following a primarily plant-based eating pattern himself (only 20% meat), he explains why whole fruits beat juices, how high-glycemic foods trigger problematic insulin responses, and why our sedentary modern lifestyles require more careful food choices than our physically active ancestors needed. Want to learn how simple dietary changes could transform your health? This episode delivers practical knowledge directly from a gastroenterology expert who lives what he teaches.
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:00):
Welcome to Doc Discussions.
I'm Dr Jason Edwards and thisis, in my opinion, the world's
best medical podcast.
We're here to have discussionswith physicians, to discover who
they are and what they do, andI'm joined with my good friend,
dr Sajid Zuffer today.
Sajid is a gastroenterologist.
Speaker 2 (00:17):
Thank you.
Speaker 1 (00:17):
How are you doing, sir?
Good, how are you?
Yeah, I'm doing well, good,good.
And so're from Pakistan.
Originally correct, that iscorrect.
And you went to school at DowMedical College, which is in
Karachi.
Is that correct?
And?
Speaker 2 (00:35):
then are you from Karachi originally?
Originally from Karachi.
And that's like the Miami ofPakistan, right it is the
biggest city, it is on the oceanand it is the most hustling,
bustling, most populated citymore than 20 million people.
Now, how about that?
Yeah, so it's one of the top Iwould say top 10 biggest cities
in the world.
Speaker 1 (00:54):
Yeah, and I've heard of Dow Medical School.
It's a very nice medical school.
Yeah, it is one of thosefounded in 1945.
Okay, and then, how did youmake your way to St Louis?
Speaker 2 (01:07):
40, about 45, okay, and then how did you make your
way to st louis?
So after I finished my medicalschool, um, I applied for
residency from pakistan.
Okay, and in those days you canapply by mail.
There was no email or anything.
This is 1991, okay, whenapplied.
And you would get interviews inthe mails.
(01:28):
So SLU was one of the placeswho invited me for interview.
So I took a flight and I hadother interviews also, yeah, and
about 15 or 20 interviews backthen, which was a lot of
interviews.
That's a lot of flights, and itwas good times.
And so the embassy in Karachi,they would ask for why you want
(01:56):
to go there and you would saywell, you know, I'm going there
for an interview.
And in those days I think therewas somewhat shortage of
physicians in internal medicine,so they were quite lenient in
giving interviews.
They would check your scores.
Speaker 1 (02:16):
Yeah.
Speaker 2 (02:18):
And if you graduate of a medical school in Pakistan.
And so we got interviews, gothere and did a bunch of
interviews.
The reason I ended up in StLouis was one of my wife's uncle
.
He did his undergrad in StLouis, okay, so there was some
(02:38):
familiarity with this town.
Speaker 1 (02:41):
Yeah.
Speaker 2 (02:42):
And when I interviewed, the interview went
well.
I liked the program and whenyou go through the match orders,
I matched other places also andSt Louis U was my first choice
and the rest is history.
Speaker 1 (02:57):
The rest is history, as they say.
Speaker 2 (02:59):
So I did my residency here until 95.
Okay, and then I worked primarycare, oh really, in a small
mountainous community in theAppalachia.
Now, what city was this?
It's called Bryson City North.
Speaker 1 (03:15):
Carolina?
How about that?
So that must be western NorthCarolina.
Speaker 2 (03:19):
Western North Carolina about an hour west of
Asheville.
Is it near Boone?
Boone was not too far, yeah, soKnoxville was about an hour
also.
Speaker 1 (03:32):
That's a pretty area of the country, beautiful, very
poor, beautiful.
Speaker 2 (03:35):
Very poor.
There's no factories there,there's no industry there.
I mean Smoky Mountain NationalPark.
I mean I would say half ormaybe more of the town was part
of the Smoky Mountain NationalPark.
I mean I would say half ormaybe more of the town was part
of the Smoky Mountain NationalPark, okay.
So we spent three years there,okay.
And then I decided I want to dofellowship and applied for
(03:59):
gastroenterology and ended up atColumbia, missouri.
Speaker 1 (04:02):
Oh yeah, university of Missouri, columbia, sure and
so.
Speaker 2 (04:04):
Missouri, missouri, columbia, sure.
And so Missouri has become home.
Yeah, and then in 2001, when Ifinished my fellowship, I came
back to St Louis.
St Luke's has been the homesince then.
Speaker 1 (04:17):
Yeah, first and last job.
Everybody knows you, you're.
Mr St Luke's, you're a part ofthe fabric here for sure.
Yeah, you know, I think that'sone of the advantages of having
good universities in cities andin states is it attracts highly
talented people from across theglobe to your city and sometimes
(04:39):
they stay.
And so, and also in myexperience too, that the people
who come from other countriesand do their medical training
here are typically kind of thecream of the crop because, that
is true, they have their pick,and so.
I know your scores must havebeen good yeah.
Yeah, and and so now you're agastroenterologist and do you do
(04:59):
mostly procedures or do you seepatients in the clinic and talk
to them about their gastro?
Speaker 2 (05:04):
So both Okay, I mean procedure is a unique thing
about gastroenterology becausewe really do a lot of procedures
.
Yeah, I think so.
If you really calculate thenumber of procedures we do, I
don't think so.
There's any specialty whichcomes closer to us.
Yeah, whether surgicalspecialty or medical
subspecialty, because of justthe very number of procedures we
(05:26):
do, and I mean anywhere from1,500 to 2,000 procedures a year
performed by a busygastroenterologist and some more
.
Speaker 1 (05:39):
And that's colonoscopies, endoscopies, and
that's when you go down thethroat with the camera Right and
colonoscopy the other end, andthen ERCPs, yeah, other
procedures ingastroenterologists.
Speaker 2 (05:54):
So not all gastroenterologists do all the
procedures.
Some specialize, some specialize, some only do that, some don't
do that.
So endoscopic ultrasound andanything, I mean I think we can
pretty much get anywhere wherethe scope goes and we can do a
lot of things.
We've got a lot of toys andtools through the scope.
(06:15):
We're talking about a fewmillimeter channels and then we
just put probes through that anddo everything cutting, stopping
bleeding, removing tumors andpolyps and doing a lot of
injections, and so all throughthose probes we do everything
and you and I have mutualpatients patients who have
(06:36):
gastro esophageal junctiontumors or esophageal cancers.
Speaker 1 (06:40):
Putting feeding tubes , feeding tubes for people who
are having difficulty swallowingfor maybe a head and neck
cancer, rectal cancer, and Iwould say GI probably interacts
with a lot of differentspecialties.
Speaker 2 (06:53):
I feel sometimes GI should have been a surgical
subspecialty.
Yeah, it's somewhere in between.
Right, we are somewhere inbetween.
I mean, certainly internalmedicine is our foundation.
We all have to do internalmedicine residency first before
you become a gastroenterologist,just because in GI a lot of
people don't know.
I mean, we deal with liver,which is a big subspecialty of
(07:13):
gastroenterology, and that'scompletely medical subspecialty.
We deal with diseases ofgallbladder and pancreas.
We deal with diseases ofgallbladder and pancreas.
But a lot of bread and butterjust requires a very close
interaction with surgicalsubspecialties.
If we diagnose something whichwe can't fix, a surgeon takes
(07:34):
over and then we can do a lot ofthings minimally invasive as
compared to surgery.
A simple example is feedingtube placement, which used to be
the forte of surgeons back inthe days until we discovered
percutaneous method.
Speaker 1 (07:48):
And that's really cool for people who have not
seen it.
It's a very simple procedurebut it really saves you surgery.
And so quickly describe it andyou tell me where I'm wrong.
A tube goes down the throat andit has a flashlight on the end
and you shine it through thestomach and you can see it
through the belly Right and thenthat's, and then you bring and
that's become.
Speaker 2 (08:06):
That becomes my entrance point.
Speaker 1 (08:08):
From the outside in.
Speaker 2 (08:09):
Yeah, you need to have that good light reflection.
Yeah, if you don't have a goodlight reflection, it mean you
may be hitting another organ inbetween and of course there's
been reports of liver in betweenor colon in between, yeah, so
you need to have a good lightreflection.
Speaker 1 (08:25):
And then it's a pretty slick procedure really,
yeah, so you're feeding in, andthen removal is also very easy.
Speaker 2 (08:33):
If you don't need it after that, just come to office.
We just gently pull it out, andso it can be very helpful to
the people.
Who has a good indicationPerson with radiation
esophagitis, head and neckcancer.
Speaker 1 (08:53):
Yeah, sometimes the cancers get so big in the head
and neck area that they can'tswallow, and so that's a
shortcut to get food in.
Speaker 2 (09:00):
Until they get stronger and tumor shrinks down
and the radiation effects aregone.
Speaker 1 (09:05):
Yeah, and then we treat them with chemotherapy and
radiation for the cancer up top.
And you know, patients do somuch better if they have a
feeding tube in.
Sometimes it's hard to convincethem to get one, but it's so
much easier on them.
Speaker 2 (09:16):
Now the bad part about the feeding tube part
since we started this discussionis like today we got a consult
for a 94 year old patient, okay,who has dementia, has no
quality of life.
There is no future for her tobecome ambulatory or active part
(09:37):
or anything.
Yeah, she is sort of checkedand the family is insisting to
have a feeding tube put in.
Those are the dilemmas whichbecome very difficult for us to
handle sometimes, especiallywith the aging population.
Speaker 1 (09:53):
And with dementia you know you can pull the feeding
tube out, and so there's somerisk.
Speaker 2 (09:58):
There's more risk.
I mean especially during anyprocedure or anybody who's
octogenarian or above.
It's just, risks are high andpeople don't understand, so it's
difficult to sometime and webecome the person in the middle
of all of that.
Speaker 1 (10:18):
Yeah, and you have to navigate that very delicately.
Speaker 2 (10:22):
Very, very delicately , because it can make a lot of
people unhappy.
Speaker 1 (10:26):
Yeah, so in the cancer world, one thing we've
seen is that younger peoplebelow the age of 50 have had an
increase in the incidence ofrectal cancer and colon cancer.
What do you think is causingthat?
Speaker 2 (10:38):
Well, so we really don't know, the risk factor for
colon cancer include obesity,increase in animal products, of
course, family history.
I think one of the reasons wemay be discovering more is
because we start screening at 45years of age, now Sure.
(10:59):
So once you start screening,you're going to discover more
also.
Yeah, years of age now, sure.
So once you start screening,you're going to discover more
also.
Yeah, so there are a lot offactor.
I don't think there's onefactor which gives you the best
answer for that, but it's amultiple factor.
I mean, it is second mostcommonest cancer yeah in the
world and so it is out there.
we just have to be aware of it,be proactive in getting a
(11:20):
screening done and all that andthey've recently changed the
guidelines from getting acolonoscopy at 50 down to age 45
.
Yeah, almost yeah, One and ahalf two years now and the main
symptom-.
That has increased our workloadalso, yeah, and so that's why
majority of gastroenterologistsare quite busy.
Speaker 1 (11:40):
Yeah, but you still have all your hair and most of
it's not gray, and so, yeah, andso, and the main symptom
patients have with colon orrectal cancer, what is that?
Speaker 2 (11:52):
Well, so once you start having symptoms, that is
sort of late.
Speaker 1 (11:58):
Yeah.
Still the outcome is prettygood and what's the first
symptom people typically have?
So I mean, somebody can havejust rectal bleeding.
Yeah, still, the outcome ispretty good and what's the first
symptom people typically have.
Speaker 2 (12:04):
So I mean somebody can have just rectal bleeding.
Yeah, so bleeding would beprobably one of the most
commonest thing.
Speaker 1 (12:09):
Yeah.
Speaker 2 (12:10):
If it comes to abdominal pain, then things have
grown.
Speaker 1 (12:14):
Yeah.
Speaker 2 (12:14):
Things have grown that it's affecting you and
causing pain, anemia, irondeficiency, anemia, weight loss,
but rectal bleeding, I wouldsay, or change in bowel habit.
Speaker 1 (12:27):
Yeah.
Speaker 2 (12:27):
More constipation, more diarrhea and things like
that.
Yeah, I think if people havefamily history, they need to be
more proactive, and ifsomebody's father has a colon
cancer at the age of, any firstdegree relative who has a colon
cancer under the age of 60 is athigh risk, and so those are the
people who need to start theircolonoscopy at the age of 40.
(12:50):
Having said that, if afirst-degree relative of a
patient has a colon cancer atthe age of 45, a first-degree
then that person should have hisfirst colonoscopy 10 years
before that age.
Speaker 1 (13:07):
Yeah, and you start to worry about genetic diseases
like hereditary Hereditaryexactly Non-polyposis.
Speaker 2 (13:12):
H and PCC and so those are the thing.
So I think it is one of thecancer we can really make a
difference.
Yeah, and a person can make adifference, because it's not
like pancreatic cancer, it isnot like cholangiocarcinoma or a
brain tumor.
This is where, even if you area stage three cancer, your
(13:34):
five-year survival is not as bad.
Speaker 1 (13:36):
Yeah, more likely than not, you will be cured,
even if it's stage three.
Speaker 2 (13:39):
And plus with the new immunotherapy on horizon, I
think so the whole cancer gamefor solid tumors.
It's improving, it's improvingand I'm hoping for more to come.
Speaker 1 (13:50):
Yeah, now I'm going to switch gears a little bit and
talk about you personally.
You know this is audio sopeople can't see, but you're, to
me, a very healthy guy andyou've got great hair too.
Speaker 2 (14:02):
I have no hair, you have great hair.
Speaker 1 (14:04):
Life's not fair.
But you've got, and so you, Iwould imagine your diet is
pretty good.
Speaker 2 (14:11):
Is that accurate?
Speaker 1 (14:12):
Yeah, I mean, I'm sure you sin every now and then,
right, right.
Speaker 2 (14:15):
You're pretty good, Regular five, six days a week.
I mean we eat at home.
It's not like we have to go out.
Speaker 1 (14:21):
Yeah.
Speaker 2 (14:22):
We cook at home and we eat at home, and so that's
like everyday thing.
Speaker 1 (14:27):
Now, are you vegetarian?
No, I'm not Okay.
Do you eat some meat or a lotof meat?
I eat majority of the meat,except for pork or ham.
But like, what percentage ofyour diet is meat versus like
fruits, vegetables, things likethat?
Speaker 2 (14:47):
20%.
You'd say 20%, 20%.
Speaker 1 (14:50):
It's not the staple of your diet.
No, 20% and that's.
I think that's more of kind of.
My brother lives in japan andthat's.
You see that more in asia wheremeat is on the plate to kind of
flavor the plate but it's notthe main dish.
Yeah, it's not like a steakyeah, and we didn't grew up
eating just steak yeah, I grewup on a beef cattle farm, and so
(15:11):
the steak was basically free,so every every meal was a steak.
Speaker 2 (15:15):
Yeah, we didn't have.
Speaker 1 (15:16):
We had grass-fed organic before.
Speaker 2 (15:18):
it was cool and then the other thing I personally, I
mean, I eat steak, I eat beef,but beef is not what I grew up
with.
Yeah, I grew up with chickenand goat, okay, yeah.
Chicken and goat meat, and it'sstill my favorite is goat meat
now some people grew up in aeroworld, grew up on lamb, yeah,
(15:38):
and so lamb becomes their thing.
Beef was not something we ate alot when we were growing up.
Now in us, when you're eatingsteak, it's a beef steak, so
sure, but it's still.
We don't bring beef home tocook in our diets got you I mean
(15:58):
, we eat it, but we don't bringit home on a frequent basis.
Speaker 1 (16:02):
I would say so, um, we also had, uh, goats and on
our farm is that right?
And um, we had one thing that Ithis I'm totally off subject
here but we had this trailerthat would the the flatbed
trailer out in our field and itwas like the tallest thing in
the field and if you went andstood on the trailer the goat
would come and try to push youoff.
Speaker 2 (16:22):
And as a boy that's a lot of fun.
You know wrestling with thegoat up there.
What was the purpose of goat onthat farm?
Were you guys eating?
Yeah, yeah, yeah, for sure.
Speaker 1 (16:36):
Okay, so yeah, beef cattle and then some goats and
chickens and the whole thing,but yeah, and so I think that's
a healthier diet, like if youare going to have meat as a part
of your diet.
The data looks like you dobetter if you eat smaller
portions of meat, exactly, andso and more plant-based.
Yeah.
Speaker 2 (16:52):
I think so.
Studies after studies arecoming out now, yeah, regarding
emphasis on plant-based diet.
I think so.
Studies after studies arecoming out now regarding
emphasis on plant-based diet,longevity data, for sure.
I mean so it's more plant-baseddiet, I mean, if you can switch
to become a vegetarian, which Iam not certainly, yeah.
On the other hand, I think soeducation is also important.
(17:12):
I mean you see significantincidents of coronary artery
disease and diabetes mellitus incountries like India, where
there is a lot of vegetarian.
Speaker 1 (17:24):
But they eat a lot of ghee or what is fat lard.
Speaker 2 (17:28):
So they do eat ghee also.
But again, at the end of theday, you need to know the
glycemic value of certain, evenfruits and vegetable.
Which vegetable has a highglycemic index?
If you consume most of thosethings, then your sugar is going
(17:49):
to go up and sugar is going tostore as carbohydrate and you're
going to get fatty liver andyou're going to get coronary
artery disease and you're goingto get diabetes.
Speaker 1 (17:56):
And so let's go a little bit into the physiology
of that.
And so you take in sugar andyour glucose level goes up
because you're ingesting sugar,and then your insulin level goes
up and insulin is a verypowerful uh like, probably more
powerful than steroids atbuilding muscle.
(18:18):
But the problem with it is itindiscriminately puts um, uh,
builds muscle, fat, uh, muscleand fat and so, which tends to
be not healthy for you.
So it's the insulin that cancause you trouble in a lot of
this.
And foods have a glycemic indexthat you can look it up
glycemic index for an apple or asnickers bar but um, but they
(18:42):
have something called theglycemic load too, which is, in
my opinion, how quickly it goes.
That that tells you how highdoes the insulin go, because the
fiber and fruit will actuallyblunt the insulin effect and and
so uh, uh.
So an apple actually doesn'thave that high of a glycemic
load because there's so muchfiber in it.
And so I think for me, when Ilook at foods you know I've said
(19:06):
I want to eat low glycemicfoods I think almost the
glycemic load kind of gives youa better real world view of
what's good and what's bad, andso so it's not a you know and
what's bad, and so so it's not ayou know.
For the listener out there,it's not a bad thing to google
like glycemic load and get alist of foods.
Speaker 2 (19:22):
Yeah, yeah, I, I my.
My wife gave me a watermelonjuice the other day okay and she
brought it in and she made itand it was beautiful, tasty and
very good and beautiful color.
Yeah, and I had it and it was.
I said you know, this was a bigsugar log, for sure, for sure.
(19:42):
So her argument was well, thereare some vitamins in it.
Also, I said I think theadvantage you are getting from
the vitamin is much less thanthe sugar you're giving.
So we had this discussion aboutthese things.
So a lot of people will say youknow, fruits have more vitamins
and all that.
You get those two like orangejuice.
(20:04):
Now, orange juice is sugar.
To me it is sugar.
It is not indicated for peoplewho have diabetes or anything,
so you need to understand that.
But yes, it has vitamin C in it.
All citrus fruits have vitamin.
Speaker 1 (20:16):
C in it.
Speaker 2 (20:16):
All citrus fruit have vitamin C in it, but if you
start drinking a glass of orangejuice every day and your
diabetes is not well controlledand you are overweight, then
this is where the problem is andyou have bad acid reflux at the
top of it.
Then you are in orange juice,not exactly health food, right,
right, but I mean, we all grewup with the concept of eating
(20:42):
cereals in the morning, which isnothing but sugar.
Speaker 1 (20:44):
We loved it.
Speaker 2 (20:45):
Yeah, we all loved it .
I still like it.
Speaker 1 (20:48):
Yeah.
Speaker 2 (20:48):
But there are a bunch of sugars in it, for sure, I
mean.
But now I think so theawareness is coming on, but as a
kid, hey, if I'm hungry let'sgo have some cereal, for sure,
for sure, and you can find somethat are healthier than others,
but majority the one which weliked.
Yeah, the Camping French.
Speaker 1 (21:06):
Yeah, for sure those were the sweeter ones.
That's the best Kid approved.
Speaker 2 (21:12):
Kid approved.
So I tell my patient who comesin and says struggling with the
weight loss and everything, andespecially with people who are
pre-diabetic or diabetic, I tellthem anything which looks good
or tastes good has sugar in it.
Speaker 1 (21:28):
Yeah, and I think if you want something sweet, at
least eat the whole fruit.
You know your body was actuallymeant to take in the fruit that
looks like it came off of atree.
You know you can take that inand the glycemic load's not that
high because of the fiber.
But when you crush, when youcrush it in a press and take all
the sugar and leave all thefiber, then not so good.
(21:49):
No, then you got more sugar thananything else, yeah, and and
sometimes the fructose can evenbe harder on the liver than the
glucose, but I wouldn'tintentionally try to uh.
But so I think eating the wholefruit is is very reasonable,
and having a smoothie orsomething like that that has
some sweetness to it is isreasonable, just because the
fiber not only blunts theinsulin effect but also helps
(22:11):
pull the cholesterol out of theblood, right and I think so.
Speaker 2 (22:14):
You can get away with anything, and our forefathers
did got away with everything,but they worked very hard
physically yeah I mean the kindof lifestyle we have now and
we're going to be couch potatoand do nothing and no exercise
and no physical activity, thenit's a problem.
That's a great.
You can drink a glass of grease, but if you have plowed all day
(22:34):
in a field, then you knowyou'll burn it.
Speaker 1 (22:38):
If the furnace is hot enough, anything will burn,
right?
Speaker 2 (22:40):
Yes, I mean you just have to burn it.
If you're not burning it, thenit's going to just keep on
slowly accumulating,accumulating.
Speaker 1 (22:47):
Yeah, yeah, if you slightly sin, but every day it
compounds just like your 401kCompounds just like your 401k,
and so skeletal muscle.
The nice thing about muscle isit there's a glute four
transporter that takes.
It's an insulin independentuptake of glucose, and so it's
like a sink where it just takesthe glucose out of the
bloodstream.
And so if you're working hardand working that muscle, you
(23:10):
know it takes up the sugar well,and that's why you know, you
know grandpa could eat a littlebit more liberally than me and
you yes sugar well, and that'swhy you know um you know grandpa
could eat a little bit moreliberally than me and you, yes,
so, um, well, sajid, it's alwaysgood spending time with you.
Um, and I think, um, you know, I, I know, you know, um, talking
about the diet and trying togive people good and accurate
information about the diet isone of the things that we can
(23:31):
make our community healthier.
Speaker 2 (23:32):
Probably the, probably the thing absolutely
yeah, yeah, and then you knowdecrease disease burden,
cost-effective economicimprovement and everything.
Speaker 1 (23:43):
Increase length of life, increase quality of life.
Right, right, you know itdoesn't really get, as far as
health goes, more important thanthat in preventing disease.
Yeah Well, buddy, thanks forsharing time with me, thank you
for having me.
Welcome to Doc Discussions.
I'm Dr Jason Edwards and thisis, in my opinion, the world's
best medical podcast.
We're here to have discussionswith physicians, to discover who
they are and what they do, andI'm joined with my good friend,
dr Sajid Zuffer today.
Sajid is a gastroenterologist.
Speaker 2 (00:17):
Thank you.
Speaker 1 (00:17):
How are you doing, sir?
Good, how are you?
Yeah, I'm doing well, good,good.
And so're from Pakistan.
Originally correct, that iscorrect.
And you went to school at DowMedical College, which is in
Karachi.
Is that correct?
And?
Speaker 2 (00:35):
then are you from Karachi originally?
Originally from Karachi.
And that's like the Miami ofPakistan, right it is the
biggest city, it is on the oceanand it is the most hustling,
bustling, most populated citymore than 20 million people.
Now, how about that?
Yeah, so it's one of the top Iwould say top 10 biggest cities
in the world.
Speaker 1 (00:54):
Yeah, and I've heard of Dow Medical School.
It's a very nice medical school.
Yeah, it is one of thosefounded in 1945.
Okay, and then, how did youmake your way to St Louis?
Speaker 2 (01:07):
40, about 45, okay, and then how did you make your
way to st louis?
So after I finished my medicalschool, um, I applied for
residency from pakistan.
Okay, and in those days you canapply by mail.
There was no email or anything.
This is 1991, okay, whenapplied.
And you would get interviews inthe mails.
(01:28):
So SLU was one of the placeswho invited me for interview.
So I took a flight and I hadother interviews also, yeah, and
about 15 or 20 interviews backthen, which was a lot of
interviews.
That's a lot of flights, and itwas good times.
And so the embassy in Karachi,they would ask for why you want
(01:56):
to go there and you would saywell, you know, I'm going there
for an interview.
And in those days I think therewas somewhat shortage of
physicians in internal medicine,so they were quite lenient in
giving interviews.
They would check your scores.
Speaker 1 (02:16):
Yeah.
Speaker 2 (02:18):
And if you graduate of a medical school in Pakistan.
And so we got interviews, gothere and did a bunch of
interviews.
The reason I ended up in StLouis was one of my wife's uncle
.
He did his undergrad in StLouis, okay, so there was some
(02:38):
familiarity with this town.
Speaker 1 (02:41):
Yeah.
Speaker 2 (02:42):
And when I interviewed, the interview went
well.
I liked the program and whenyou go through the match orders,
I matched other places also andSt Louis U was my first choice
and the rest is history.
Speaker 1 (02:57):
The rest is history, as they say.
Speaker 2 (02:59):
So I did my residency here until 95.
Okay, and then I worked primarycare, oh really, in a small
mountainous community in theAppalachia.
Now, what city was this?
It's called Bryson City North.
Speaker 1 (03:15):
Carolina?
How about that?
So that must be western NorthCarolina.
Speaker 2 (03:19):
Western North Carolina about an hour west of
Asheville.
Is it near Boone?
Boone was not too far, yeah, soKnoxville was about an hour
also.
Speaker 1 (03:32):
That's a pretty area of the country, beautiful, very
poor, beautiful.
Speaker 2 (03:35):
Very poor.
There's no factories there,there's no industry there.
I mean Smoky Mountain NationalPark.
I mean I would say half ormaybe more of the town was part
of the Smoky Mountain NationalPark.
I mean I would say half ormaybe more of the town was part
of the Smoky Mountain NationalPark, okay.
So we spent three years there,okay.
And then I decided I want to dofellowship and applied for
(03:59):
gastroenterology and ended up atColumbia, missouri.
Speaker 1 (04:02):
Oh yeah, university of Missouri, columbia, sure and
so.
Speaker 2 (04:04):
Missouri, missouri, columbia, sure.
And so Missouri has become home.
Yeah, and then in 2001, when Ifinished my fellowship, I came
back to St Louis.
St Luke's has been the homesince then.
Speaker 1 (04:17):
Yeah, first and last job.
Everybody knows you, you're.
Mr St Luke's, you're a part ofthe fabric here for sure.
Yeah, you know, I think that'sone of the advantages of having
good universities in cities andin states is it attracts highly
talented people from across theglobe to your city and sometimes
(04:39):
they stay.
And so, and also in myexperience too, that the people
who come from other countriesand do their medical training
here are typically kind of thecream of the crop because, that
is true, they have their pick,and so.
I know your scores must havebeen good yeah.
Yeah, and and so now you're agastroenterologist and do you do
(04:59):
mostly procedures or do you seepatients in the clinic and talk
to them about their gastro?
Speaker 2 (05:04):
So both Okay, I mean procedure is a unique thing
about gastroenterology becausewe really do a lot of procedures
.
Yeah, I think so.
If you really calculate thenumber of procedures we do, I
don't think so.
There's any specialty whichcomes closer to us.
Yeah, whether surgicalspecialty or medical
subspecialty, because of justthe very number of procedures we
(05:26):
do, and I mean anywhere from1,500 to 2,000 procedures a year
performed by a busygastroenterologist and some more
.
Speaker 1 (05:39):
And that's colonoscopies, endoscopies, and
that's when you go down thethroat with the camera Right and
colonoscopy the other end, andthen ERCPs, yeah, other
procedures ingastroenterologists.
Speaker 2 (05:54):
So not all gastroenterologists do all the
procedures.
Some specialize, some specialize, some only do that, some don't
do that.
So endoscopic ultrasound andanything, I mean I think we can
pretty much get anywhere wherethe scope goes and we can do a
lot of things.
We've got a lot of toys andtools through the scope.
(06:15):
We're talking about a fewmillimeter channels and then we
just put probes through that anddo everything cutting, stopping
bleeding, removing tumors andpolyps and doing a lot of
injections, and so all throughthose probes we do everything
and you and I have mutualpatients patients who have
(06:36):
gastro esophageal junctiontumors or esophageal cancers.
Speaker 1 (06:40):
Putting feeding tubes , feeding tubes for people who
are having difficulty swallowingfor maybe a head and neck
cancer, rectal cancer, and Iwould say GI probably interacts
with a lot of differentspecialties.
Speaker 2 (06:53):
I feel sometimes GI should have been a surgical
subspecialty.
Yeah, it's somewhere in between.
Right, we are somewhere inbetween.
I mean, certainly internalmedicine is our foundation.
We all have to do internalmedicine residency first before
you become a gastroenterologist,just because in GI a lot of
people don't know.
I mean, we deal with liver,which is a big subspecialty of
(07:13):
gastroenterology, and that'scompletely medical subspecialty.
We deal with diseases ofgallbladder and pancreas.
We deal with diseases ofgallbladder and pancreas.
But a lot of bread and butterjust requires a very close
interaction with surgicalsubspecialties.
If we diagnose something whichwe can't fix, a surgeon takes
(07:34):
over and then we can do a lot ofthings minimally invasive as
compared to surgery.
A simple example is feedingtube placement, which used to be
the forte of surgeons back inthe days until we discovered
percutaneous method.
Speaker 1 (07:48):
And that's really cool for people who have not
seen it.
It's a very simple procedurebut it really saves you surgery.
And so quickly describe it andyou tell me where I'm wrong.
A tube goes down the throat andit has a flashlight on the end
and you shine it through thestomach and you can see it
through the belly Right and thenthat's, and then you bring and
that's become.
Speaker 2 (08:06):
That becomes my entrance point.
Speaker 1 (08:08):
From the outside in.
Speaker 2 (08:09):
Yeah, you need to have that good light reflection.
Yeah, if you don't have a goodlight reflection, it mean you
may be hitting another organ inbetween and of course there's
been reports of liver in betweenor colon in between, yeah, so
you need to have a good lightreflection.
Speaker 1 (08:25):
And then it's a pretty slick procedure really,
yeah, so you're feeding in, andthen removal is also very easy.
Speaker 2 (08:33):
If you don't need it after that, just come to office.
We just gently pull it out, andso it can be very helpful to
the people.
Who has a good indicationPerson with radiation
esophagitis, head and neckcancer.
Speaker 1 (08:53):
Yeah, sometimes the cancers get so big in the head
and neck area that they can'tswallow, and so that's a
shortcut to get food in.
Speaker 2 (09:00):
Until they get stronger and tumor shrinks down
and the radiation effects aregone.
Speaker 1 (09:05):
Yeah, and then we treat them with chemotherapy and
radiation for the cancer up top.
And you know, patients do somuch better if they have a
feeding tube in.
Sometimes it's hard to convincethem to get one, but it's so
much easier on them.
Speaker 2 (09:16):
Now the bad part about the feeding tube part
since we started this discussionis like today we got a consult
for a 94 year old patient, okay,who has dementia, has no
quality of life.
There is no future for her tobecome ambulatory or active part
(09:37):
or anything.
Yeah, she is sort of checkedand the family is insisting to
have a feeding tube put in.
Those are the dilemmas whichbecome very difficult for us to
handle sometimes, especiallywith the aging population.
Speaker 1 (09:53):
And with dementia you know you can pull the feeding
tube out, and so there's somerisk.
Speaker 2 (09:58):
There's more risk.
I mean especially during anyprocedure or anybody who's
octogenarian or above.
It's just, risks are high andpeople don't understand, so it's
difficult to sometime and webecome the person in the middle
of all of that.
Speaker 1 (10:18):
Yeah, and you have to navigate that very delicately.
Speaker 2 (10:22):
Very, very delicately , because it can make a lot of
people unhappy.
Speaker 1 (10:26):
Yeah, so in the cancer world, one thing we've
seen is that younger peoplebelow the age of 50 have had an
increase in the incidence ofrectal cancer and colon cancer.
What do you think is causingthat?
Speaker 2 (10:38):
Well, so we really don't know, the risk factor for
colon cancer include obesity,increase in animal products, of
course, family history.
I think one of the reasons wemay be discovering more is
because we start screening at 45years of age, now Sure.
(10:59):
So once you start screening,you're going to discover more
also.
Yeah, years of age now, sure.
So once you start screening,you're going to discover more
also.
Yeah, so there are a lot offactor.
I don't think there's onefactor which gives you the best
answer for that, but it's amultiple factor.
I mean, it is second mostcommonest cancer yeah in the
world and so it is out there.
we just have to be aware of it,be proactive in getting a
(11:20):
screening done and all that andthey've recently changed the
guidelines from getting acolonoscopy at 50 down to age 45
.
Yeah, almost yeah, One and ahalf two years now and the main
symptom-.
That has increased our workloadalso, yeah, and so that's why
majority of gastroenterologistsare quite busy.
Speaker 1 (11:40):
Yeah, but you still have all your hair and most of
it's not gray, and so, yeah, andso, and the main symptom
patients have with colon orrectal cancer, what is that?
Speaker 2 (11:52):
Well, so once you start having symptoms, that is
sort of late.
Speaker 1 (11:58):
Yeah.
Still the outcome is prettygood and what's the first
symptom people typically have?
So I mean, somebody can havejust rectal bleeding.
Yeah, still, the outcome ispretty good and what's the first
symptom people typically have.
Speaker 2 (12:04):
So I mean somebody can have just rectal bleeding.
Yeah, so bleeding would beprobably one of the most
commonest thing.
Speaker 1 (12:09):
Yeah.
Speaker 2 (12:10):
If it comes to abdominal pain, then things have
grown.
Speaker 1 (12:14):
Yeah.
Speaker 2 (12:14):
Things have grown that it's affecting you and
causing pain, anemia, irondeficiency, anemia, weight loss,
but rectal bleeding, I wouldsay, or change in bowel habit.
Speaker 1 (12:27):
Yeah.
Speaker 2 (12:27):
More constipation, more diarrhea and things like
that.
Yeah, I think if people havefamily history, they need to be
more proactive, and ifsomebody's father has a colon
cancer at the age of, any firstdegree relative who has a colon
cancer under the age of 60 is athigh risk, and so those are the
people who need to start theircolonoscopy at the age of 40.
(12:50):
Having said that, if afirst-degree relative of a
patient has a colon cancer atthe age of 45, a first-degree
then that person should have hisfirst colonoscopy 10 years
before that age.
Speaker 1 (13:07):
Yeah, and you start to worry about genetic diseases
like hereditary Hereditaryexactly Non-polyposis.
Speaker 2 (13:12):
H and PCC and so those are the thing.
So I think it is one of thecancer we can really make a
difference.
Yeah, and a person can make adifference, because it's not
like pancreatic cancer, it isnot like cholangiocarcinoma or a
brain tumor.
This is where, even if you area stage three cancer, your
(13:34):
five-year survival is not as bad.
Speaker 1 (13:36):
Yeah, more likely than not, you will be cured,
even if it's stage three.
Speaker 2 (13:39):
And plus with the new immunotherapy on horizon, I
think so the whole cancer gamefor solid tumors.
It's improving, it's improvingand I'm hoping for more to come.
Speaker 1 (13:50):
Yeah, now I'm going to switch gears a little bit and
talk about you personally.
You know this is audio sopeople can't see, but you're, to
me, a very healthy guy andyou've got great hair too.
Speaker 2 (14:02):
I have no hair, you have great hair.
Speaker 1 (14:04):
Life's not fair.
But you've got, and so you, Iwould imagine your diet is
pretty good.
Speaker 2 (14:11):
Is that accurate?
Speaker 1 (14:12):
Yeah, I mean, I'm sure you sin every now and then,
right, right.
Speaker 2 (14:15):
You're pretty good, Regular five, six days a week.
I mean we eat at home.
It's not like we have to go out.
Speaker 1 (14:21):
Yeah.
Speaker 2 (14:22):
We cook at home and we eat at home, and so that's
like everyday thing.
Speaker 1 (14:27):
Now, are you vegetarian?
No, I'm not Okay.
Do you eat some meat or a lotof meat?
I eat majority of the meat,except for pork or ham.
But like, what percentage ofyour diet is meat versus like
fruits, vegetables, things likethat?
Speaker 2 (14:47):
20%.
You'd say 20%, 20%.
Speaker 1 (14:50):
It's not the staple of your diet.
No, 20% and that's.
I think that's more of kind of.
My brother lives in japan andthat's.
You see that more in asia wheremeat is on the plate to kind of
flavor the plate but it's notthe main dish.
Yeah, it's not like a steakyeah, and we didn't grew up
eating just steak yeah, I grewup on a beef cattle farm, and so
(15:11):
the steak was basically free,so every every meal was a steak.
Speaker 2 (15:15):
Yeah, we didn't have.
Speaker 1 (15:16):
We had grass-fed organic before.
Speaker 2 (15:18):
it was cool and then the other thing I personally, I
mean, I eat steak, I eat beef,but beef is not what I grew up
with.
Yeah, I grew up with chickenand goat, okay, yeah.
Chicken and goat meat, and it'sstill my favorite is goat meat
now some people grew up in aeroworld, grew up on lamb, yeah,
(15:38):
and so lamb becomes their thing.
Beef was not something we ate alot when we were growing up.
Now in us, when you're eatingsteak, it's a beef steak, so
sure, but it's still.
We don't bring beef home tocook in our diets got you I mean
(15:58):
, we eat it, but we don't bringit home on a frequent basis.
Speaker 1 (16:02):
I would say so, um, we also had, uh, goats and on
our farm is that right?
And um, we had one thing that Ithis I'm totally off subject
here but we had this trailerthat would the the flatbed
trailer out in our field and itwas like the tallest thing in
the field and if you went andstood on the trailer the goat
would come and try to push youoff.
Speaker 2 (16:22):
And as a boy that's a lot of fun.
You know wrestling with thegoat up there.
What was the purpose of goat onthat farm?
Were you guys eating?
Yeah, yeah, yeah, for sure.
Speaker 1 (16:36):
Okay, so yeah, beef cattle and then some goats and
chickens and the whole thing,but yeah, and so I think that's
a healthier diet, like if youare going to have meat as a part
of your diet.
The data looks like you dobetter if you eat smaller
portions of meat, exactly, andso and more plant-based.
Yeah.
Speaker 2 (16:52):
I think so.
Studies after studies arecoming out now, yeah, regarding
emphasis on plant-based diet.
I think so.
Studies after studies arecoming out now regarding
emphasis on plant-based diet,longevity data, for sure.
I mean so it's more plant-baseddiet, I mean, if you can switch
to become a vegetarian, which Iam not certainly, yeah.
On the other hand, I think soeducation is also important.
(17:12):
I mean you see significantincidents of coronary artery
disease and diabetes mellitus incountries like India, where
there is a lot of vegetarian.
Speaker 1 (17:24):
But they eat a lot of ghee or what is fat lard.
Speaker 2 (17:28):
So they do eat ghee also.
But again, at the end of theday, you need to know the
glycemic value of certain, evenfruits and vegetable.
Which vegetable has a highglycemic index?
If you consume most of thosethings, then your sugar is going
(17:49):
to go up and sugar is going tostore as carbohydrate and you're
going to get fatty liver andyou're going to get coronary
artery disease and you're goingto get diabetes.
Speaker 1 (17:56):
And so let's go a little bit into the physiology
of that.
And so you take in sugar andyour glucose level goes up
because you're ingesting sugar,and then your insulin level goes
up and insulin is a verypowerful uh like, probably more
powerful than steroids atbuilding muscle.
(18:18):
But the problem with it is itindiscriminately puts um, uh,
builds muscle, fat, uh, muscleand fat and so, which tends to
be not healthy for you.
So it's the insulin that cancause you trouble in a lot of
this.
And foods have a glycemic indexthat you can look it up
glycemic index for an apple or asnickers bar but um, but they
(18:42):
have something called theglycemic load too, which is, in
my opinion, how quickly it goes.
That that tells you how highdoes the insulin go, because the
fiber and fruit will actuallyblunt the insulin effect and and
so uh, uh.
So an apple actually doesn'thave that high of a glycemic
load because there's so muchfiber in it.
And so I think for me, when Ilook at foods you know I've said
(19:06):
I want to eat low glycemicfoods I think almost the
glycemic load kind of gives youa better real world view of
what's good and what's bad, andso so it's not a you know and
what's bad, and so so it's not ayou know.
For the listener out there,it's not a bad thing to google
like glycemic load and get alist of foods.
Speaker 2 (19:22):
Yeah, yeah, I, I my.
My wife gave me a watermelonjuice the other day okay and she
brought it in and she made itand it was beautiful, tasty and
very good and beautiful color.
Yeah, and I had it and it was.
I said you know, this was a bigsugar log, for sure, for sure.
(19:42):
So her argument was well, thereare some vitamins in it.
Also, I said I think theadvantage you are getting from
the vitamin is much less thanthe sugar you're giving.
So we had this discussion aboutthese things.
So a lot of people will say youknow, fruits have more vitamins
and all that.
You get those two like orangejuice.
(20:04):
Now, orange juice is sugar.
To me it is sugar.
It is not indicated for peoplewho have diabetes or anything,
so you need to understand that.
But yes, it has vitamin C in it.
All citrus fruits have vitamin.
Speaker 1 (20:16):
C in it.
Speaker 2 (20:16):
All citrus fruit have vitamin C in it, but if you
start drinking a glass of orangejuice every day and your
diabetes is not well controlledand you are overweight, then
this is where the problem is andyou have bad acid reflux at the
top of it.
Then you are in orange juice,not exactly health food, right,
right, but I mean, we all grewup with the concept of eating
(20:42):
cereals in the morning, which isnothing but sugar.
Speaker 1 (20:44):
We loved it.
Speaker 2 (20:45):
Yeah, we all loved it .
I still like it.
Speaker 1 (20:48):
Yeah.
Speaker 2 (20:48):
But there are a bunch of sugars in it, for sure, I
mean.
But now I think so theawareness is coming on, but as a
kid, hey, if I'm hungry let'sgo have some cereal, for sure,
for sure, and you can find somethat are healthier than others,
but majority the one which weliked.
Yeah, the Camping French.
Speaker 1 (21:06):
Yeah, for sure those were the sweeter ones.
That's the best Kid approved.
Speaker 2 (21:12):
Kid approved.
So I tell my patient who comesin and says struggling with the
weight loss and everything, andespecially with people who are
pre-diabetic or diabetic, I tellthem anything which looks good
or tastes good has sugar in it.
Speaker 1 (21:28):
Yeah, and I think if you want something sweet, at
least eat the whole fruit.
You know your body was actuallymeant to take in the fruit that
looks like it came off of atree.
You know you can take that inand the glycemic load's not that
high because of the fiber.
But when you crush, when youcrush it in a press and take all
the sugar and leave all thefiber, then not so good.
(21:49):
No, then you got more sugar thananything else, yeah, and and
sometimes the fructose can evenbe harder on the liver than the
glucose, but I wouldn'tintentionally try to uh.
But so I think eating the wholefruit is is very reasonable,
and having a smoothie orsomething like that that has
some sweetness to it is isreasonable, just because the
fiber not only blunts theinsulin effect but also helps
(22:11):
pull the cholesterol out of theblood, right and I think so.
Speaker 2 (22:14):
You can get away with anything, and our forefathers
did got away with everything,but they worked very hard
physically yeah I mean the kindof lifestyle we have now and
we're going to be couch potatoand do nothing and no exercise
and no physical activity, thenit's a problem.
That's a great.
You can drink a glass of grease, but if you have plowed all day
(22:34):
in a field, then you knowyou'll burn it.
Speaker 1 (22:38):
If the furnace is hot enough, anything will burn,
right?
Speaker 2 (22:40):
Yes, I mean you just have to burn it.
If you're not burning it, thenit's going to just keep on
slowly accumulating,accumulating.
Speaker 1 (22:47):
Yeah, yeah, if you slightly sin, but every day it
compounds just like your 401kCompounds just like your 401k,
and so skeletal muscle.
The nice thing about muscle isit there's a glute four
transporter that takes.
It's an insulin independentuptake of glucose, and so it's
like a sink where it just takesthe glucose out of the
bloodstream.
And so if you're working hardand working that muscle, you
(23:10):
know it takes up the sugar well,and that's why you know, you
know grandpa could eat a littlebit more liberally than me and
you yes sugar well, and that'swhy you know um you know grandpa
could eat a little bit moreliberally than me and you, yes,
so, um, well, sajid, it's alwaysgood spending time with you.
Um, and I think, um, you know, I, I know, you know, um, talking
about the diet and trying togive people good and accurate
information about the diet isone of the things that we can
(23:31):
make our community healthier.
Speaker 2 (23:32):
Probably the, probably the thing absolutely
yeah, yeah, and then you knowdecrease disease burden,
cost-effective economicimprovement and everything.
Speaker 1 (23:43):
Increase length of life, increase quality of life.
Right, right, you know itdoesn't really get, as far as
health goes, more important thanthat in preventing disease.
Yeah Well, buddy, thanks forsharing time with me, thank you
for having me.
Popular Podcasts
Dateline NBC
Current and classic episodes, featuring compelling true-crime mysteries, powerful documentaries and in-depth investigations. Follow now to get the latest episodes of Dateline NBC completely free, or subscribe to Dateline Premium for ad-free listening and exclusive bonus content: DatelinePremium.com
24/7 News: The Latest
The latest news in 4 minutes updated every hour, every day.
Therapy Gecko
An unlicensed lizard psychologist travels the universe talking to strangers about absolutely nothing. TO CALL THE GECKO: follow me on https://www.twitch.tv/lyleforever to get a notification for when I am taking calls. I am usually live Mondays, Wednesdays, and Fridays but lately a lot of other times too. I am a gecko.