Dr. Amy Baxter has dedicated her career to alleviating human suffering. In this remarkable and wide-ranging discussion she teaches about the research on needle fear and whether we might, with good intentions, be creating a lost generation of needle-phobic antivaxxers. She discusses her work on non-opioid pain treatment modalities, the challenges for women in medicine and business, transitioning from academic medical practice to being an entrepreneur, and much more. 

Show notes in order of appearance (with links to other shows/resources):


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– What is going on, ZPac? It’s your boy ZDoggMD. Welcome to another episode of Incident Report, which is also a audio podcast, even though you’re looking at me now if you’re watching on YouTube or Facebook. My quick housekeeping, before we jump into this really, really, really amazing show that we did with Dr. Amy Baxter, we talked about all the things which I’m gonna mention in a second. If you love what we do, you can support this show. We don’t do ads on our podcasts. The way we support it is through Facebook subscriptions. For 4.99 a month you get access to moi, live videos and private discussion with me that are aimed at improving health care, and pretty soon we’re gonna offering, this month, continuing education credits for certain videos if you are a supporter. For 4.99 a month you can use your hospital’s frickin’ CME money and get to look at, look how beautiful I am, and for those who are listening, listen to how sexy I am. That’s CME fo’ life, homies. All right, so today, and what helps us is if you go on iTunes or on the podcast app, and you actually review and subscribe to our podcast, it helps us tremendously because all the other podcast people are like, oh my God, Z Dog has so many positive reviews. Maybe we should step up our game, too, and then everyone’s game steps up. Today’s episode is a long one, but you should listen to the entire thing. Dr. Amy Baxter is a clinical associate professor of emergency medicine at the Medical College of Georgia. She is also the CEO and founder of Pain Labs?

– [Amy] Pain Care–

– Pain Care Labs. She’s sitting across from me looking at daggers–

– [Amy] Formerly MMJ Labs.

– Formerly MMJ Labs, but that sounded like a medical marijuana dispensary. She is got a million different awards and accolades like innovator of the year, like amazing woman in medicine, all kinds of stuff which I’m even splicing her saying some of those things ’cause I was asking her and she was able to list some of them, which made me very intimidated. In this episode, we go through a lot of interesting things. We talk about, first of all, her work in moral reasoning, and how men and women differ in their moral reasoning, how that may actually relate to our differences in experience in health care, in what is expected from us in health care, and even relating to burnout, but more importantly we talk about how women tend to see connections, and relations, and context of things, and how that relates to pain management, which is her passion. She is an innovator and a researcher in the space of pain management, and has invented a couple of devices that have really transformed the care of patients who may, in the future, unless they are treated appropriately, suffer from needle fear and phobia, and then, as adults, different types of pain, which we’re gonna talk about. The VibraCool and the Buzzy device. She talks about what it’s like to be an entrepreneur and what it was like to find her calling and her passion in managing pain, but also understanding contextually, and relationally, and in the bigger web of a compassionate care of human beings, why being afraid of needles, which we talk about is often triggered in young kids who get multiple injections at once in a particular age window, why that can lead to adult fear of physicians and a lack of uptake of vaccines such as HPV, and a destruction of community immunity. We talk about pain management in general, how we might make a dent in the opioid crisis, how Americans use most of the world’s opioids, and why that, culturally, might be. We talk about philosophy and a lot of science of pain management. This is a very, very important podcast with a tremendous guest, and I hope you listen to the whole thing, and share it widely, and now, Dr. Amy Baxter.

– It is a pleasure to be here. Thank you so much.

– Do you know that your last name, Baxter, was the name of a fictional character I created to be my assistant? I created Baxter, Baxter Jones. He had a backstory. He had an email, [email protected], and he was my assistant, so what he would do is when people would message me and be like, uh yeah, how much do you charge for speaking? I’d be like, you know, let me get you to my manager, Baxter, and Baxter was me, but Baxter couldn’t be talked to because he was a former Moldovan fighter pilot who was shot down, had PTSD, and works out of an undisclosed location in Iowa, but he really resonates with the Health 3.0 message, so he wanted to work with me, so Baxter could be a jerk. He could say, well, you know, ZDogg charges $750,000 a talk because he doesn’t wanna talk for pharma, and it was great, so your last name and my assistant, now that’s the connection.

– That’s a totally different kind of Remington Steele-esque thing than what I have to do as a female in medicine and business, so I’ve gotta have a decidedly masculine superior when I have to outsource, and I’ve not named them anything, but–

– So, you’re saying that my Baxter was not tough enough–

– No, no, I’m just saying it’s interesting that you have to get a more butch dude and I have to get a more butch dude, but from completely different reasons.

-You know what? Actually, tell me more about that, because being a woman in medicine, you’re a pediatric emergency physician. Now, we’ve talked a lot. You have the physician moms group. There’s a lot of stuff on social media where female physicians are now finding a voice that what I found when I was training at Stanford is so many of my colleagues that were women were still being hit on by the male attendings, and it was really a vaguely creepy environment that I aspired to be part of that male echelon, but I never quite made it because, you know, bald and weird, so I had to be creepy in a different way, but so have you found this to be a big challenge in your own career, and how have you sort of kind of worked that out, ’cause having Baxter, or whoever your tough guy equivalent is, is an interesting problem.

– Jim.

– It was Jim, I like that.

– It is more noticeable in the business world than it is in medicine, and part of that could be just because I’m so used to the milieu where you may get hit on, or the, particularly patients are always calling us nurse. We are always referred to by our first name instead of our last name in group meetings. There’s, always is strong, but there is a pervasive sexism that, in medicine, is just part of what you take for granted, and in the business world it is more overt, and it also really impacts how you actually get the job done, ’cause in medicine it doesn’t impact how you get the job done; it’s just annoying, but in business, if I don’t go to a networking party with makeup and a skirt, no one wants to talk to me. The entrepreneurs and startup guys who are guys can be wearing jeans and a T-shirt, but if I’m gonna get any attention whatsoever, I have to doll up a little bit, and in contrast, when you’re in academia, there’s almost a uniform of schlumpiness. You sort of bare your badge of pride with, if I am not wearing makeup and I’m wearing comfy clothes, it must mean I’m really smart. So it’s kind of this artificial dichotomy thing.

– That’s fascinating. Do you think there’s an assumption among your colleagues? Let’s talk about the medicine, ’cause you span both these worlds. You’re an entrepreneur. You’re a doctor, emergency doctor, pediatrician, so double-boarded, and you also have been doing research, so you kind of span the entire gamut, which is a little I’m a little bit jealous.

– Intimidated is, I think, what you’re looking for.

– Intimidated, A.

– Yeah.

– Pissed off, jealous, angry, a little weepy, strangely, but have you found, on the medicine side, being a woman, that people have certain expectations that you’re gonna be more agreeable, that you’re gonna be more relational, that you’re gonna be nicer, and that you’re gonna pick up those shifts?

– Well, and this is ubiquitous across both worlds, women are asked 2/3 of the time, and say yes 2/3 more often than men do. It’s really interesting, so not only are we asked to pick up shifts, but people expect us to, and we do. I mean, it’s people behave in certain ways because that’s what works, and women are more likely to agree to things, which is part of why we get asked more often.

– Do you think that that leads to higher levels of burnout, exhaustion, emotional exhaustion?

– It’s a great point. I hadn’t thought about it, but of course it makes sense, and it also, the concept of letting people down hurts us a little bit more. Here’s my big theory, okay?

– Whereas guys are like, I’ll let you down, and that’s a badge of honor.

– Well, so women are much more contextual, so women have 96 million more base pairs of DNA than men do. If you look at X versus Y chromosomes, they’re not apples and oranges.

– [ZDoggMD] Oh, I see you’re pulling size matters, okay.

– There’s a whole bunch of extra beefy genetics on that X chromosome, whereas guys have this squidgy little one and kind of a dingle-bong thing, and so–

– You know what? This isn’t the first time that a woman has referred to my dingle-bong.

– And I believe that what is on and coded for on that extra X chromosome is probably interpersonal social interactions, which is why you have more people with autism, well, you have the more males with autism characteristics. There are more hierarchical decisions that are made by males, and women tend to make moral decisions in the context of a web of social interactions, so there’s a whole before I got into medicine I was doing moral decision-making

– You’re kidding.

– research, yeah, and so the hierarchy of moral decision-making for males is very this-or-that. I can do this or I can’t do this. It’s very linear, whereas women will make very contextual moral decisions, so often women get rated as being less moral than men because they take other people’s opinions and circumstances into consideration, whereas men are just like, this is the rule; this is what I’m gonna do, or this is my goal; this is what I’m gonna do, so I think that part and parcel of that social awareness is that we also feel more obligated to take care of the community, which is probably why we do say yes more, and which is probably why anybody with half a brain is going to ask women more because they’re more likely to say yes.

– First of all, wow. I didn’t realize you–

– That’s a lot to unpack right there.

– That is–

– I been thinking.

– So, okay, there’s so much there, and we’ve been talking about this stuff in our show recently, talking about the work of Jonathan Haidt and other sort of moral psychologists about, and even looking at people like Jordan Peterson who, he’s alt-right-adjacent according to the callout culture because some people on the right kind of like his ideas, some people on the left kind of like his ideas, but his ideas are about there are innate gender differences in how we are relational, and how we do moral reasoning, and things like that, and we can’t ignore them when we’re designing systems that are hoping to provide equal opportunity but very difficult to provide equal outcomes when you have two different systems. So, equal opportunity, in this case, in medicine, I’m just thinking out loud, might mean recognizing that women are more relational, and have contextual moral reasoning that’s more complex than men’s, and that it’s easy to take advantage of that in an asymmetric way so that men will get off the hook doing those extra shifts, and women will pick it up, and it’s true in marriages, too. I find that I often offload a lot of stuff to my much more agreeable and nuanced wife who is, first of all, more educated than me. She did both medicine and radiology. She also helps manage the kids much more than I do, in terms of doing homework, and doing violin, and all those other things, and she works nights as a teleradiologist, and she’s still on faculty at Stanford, and all this other stuff, but I’m like, um, yeah, I just got a letter from the medical board. Can you help me write a response, and this, and this? And she’ll say, yeah, okay, I’m super-busy, but I’ll do it, and I’m like, score, all right, I’m gonna go have fun with the boys–

– Girl, I gotta talk to her.

– I know, right?

-Or you don’t want me to talk to her.

– Well, honestly, I feel it acutely as a guilt response.

– But this is a really cool difference that I’ve noticed in business. The more I’ve gotten into the business world, the better the leadership training is. I understand working with people so much better because of the kind of glorified Myers-Briggs things, the different personality-type understandings, and how to work with people, and how to motivate people, and also how to be what those people need, and I didn’t get much, at all, of that in my medical training, in any of the fellowships, in any of the contextual situations I was in, so that’s one thing that we could bring to medicine, which is an appreciation of the different types of people, not just male-female, but also someone who is an achiever, someone who is more sensitive, someone who is more aggressive, you know, red, green, blue, yellow. There’s a bunch of different ways of looking at leadership. The other interesting thing about male-female differences in moral reasoning is, all of this stuff comes from Piaget, so Piaget made the observations with development. When he was looking at moral reasoning, he based his entire theory on boys, because they were playing marbles, and there was a rule-based scenario, and you could see a direct progression in understanding, and application, and dissemination of those rules, whereas the girls were doing practice for life. They were doing turn-taking games. They were doing nurturing games. They were doing playing house. The were modeling. They were practicing things that were all interrelational, and he couldn’t make heads or tails of that as a system to base a theory on. So, I think that that is fascinating, that yet again, just like a lot of our cardiac studies, and a lot of our studies in medicine, where we don’t have an equal proportion of women represented, our entire schema for how morality works is based on boys playing marbles.

-Wow, my mind is vaguely blown by this, because this is something that we are very passionate about on the show, which is talking about these innate, interesting bits of personality, moral reasoning, the philosophy, stuff that we don’t get taught in medicine, yet is so crucial to a humanistic understanding of taking care of our patients, but also taking care of each other in this web of connection that we have in health care, that I call Health 3.0 now, where we’re really trying to transcend this simple, caveman, Piaget boys study and saying, well no, it’s actually much more complex than that–

– Um, actually, yeah, yeah.

– Yeah, you know, and what’s interesting, so it’s funny ’cause we’re talking about all this stuff that is adjunct to what we were intending, initially, to talk about, which we’re gonna get to, which is pain, and needles, and vaccines, and opioids, and a lot of different stuff, but I think this is the central piece of helping us be better, not just doctors, not just nurses, not just respiratory therapists, human beings, and better patients, is understanding. If I understand, I made the whole team take this Big Five personality test, and to a one of us, we were all pissed off when we got the results, ’cause we were like, that’s not me, immediately,

– Huh, interesting.

– and then, within five minutes of reading carefully through it, showing it to our wives, everybody going, that is you, that’s you, that’s you, the dawning happens, where you go, oh, I am a disagreeable, not highly industrious, very OCD, highly compassionate, open, minimally conscientious human being, and it explains a lot, which means now I can optimize my strengths, minimize my deficits, and understand why I behave the way I do without so much self-blame, and then when, yeah–

– Well, maturity, I think, is realizing where you are on the bell curve of existence, and the empathy is understanding where other people are on the bell curve of existence, and so being able to not look at these traits as right or wrong, but simply spectrums, and so where you are, knowing where you are compared to where other people are is the good stuff wherein communication lies, but you have to start by appreciating that where they are on the bell curve is not wrong, it is just a different place on the spectrum of humanity, and you gotta know where you are, because you can’t bridge that gap in any manner unless you are solid with acknowledging both your strengths, and weaknesses, and opinions, and perceptions.

– I think this is true, also, of general stages of development in society and in humans, so you may still be at a kind of mythic/magic stage of development, where you see things fairly concretely, there’s an authority figure, and you have to have hierarchy, and then you may be at a much more pluralistic, post-modern stage, where all things relational, or you may be even beyond that as an integral stage, but recognizing where people are, including yourself, and realizing that if you’re a couple stages different than that, it’s gonna be very difficult to communicate to that stage without using the concepts, moral language, of that stage, and I think leadership, that’s important in leadership, in health care and beyond, which is if you can talk to all stages of an organization in some way and connect with them, you’re gonna be a much more effective leader. I think Haley Fisher-Wright and Dave Logan wrote about this in Tribal Leadership, that speaking the language of stage two of tribal leadership, which is, my life sucks, but the boss’s life is great, and that’s so much of lower-level medicine, like, oh, the nurses are like, our staffing ratios are terrible, but look at the CEO with his yacht, and being able to speak to that group, and motivate them, nudge them up to the next level, stage three, which is achievement, meritocracy, like I’m great and you’re not, so in other words, this competitive stage–

– These are things I don’t know. I’m excited to learn more about these things.

– Ah see, we teach each other, although you’re mostly teaching me. The osmotic gradient of knowledge goes this way, Amy.

– [Amy]Where’s the filter?

– Yeah, exactly, and so I think, I have this unique challenge of having to communicate with a tribe of a million-plus health care people across the spectrum. So, you may have a paramedic who’s paid $9 an hour, and you may have the chief of neurosurgery at a major academic institution, and they’re all watching the show, so how you do you speak a language, and it can’t be one language, but you have to include little bits of it. I started to do it unconsciously, but you have to recognize that thing, so understanding people’s stage of development. The other thing I wanted to unpack that you said was empathy. I’ve talked a lot on the show about empathy versus compassion. Have you sort of made that distinction in your mind, or is it… How are you defining empathy?

– For me, empathy is accepting where someone else is coming from, which means you have to understand it, and then also accept it, so it’s a two-part thing, and compassion is then wanting to take care of them based on that knowledge, but I don’t think that you have to have compassion as an outcome, but if you wanna be effective you have to have empathy.

– Got it. The way I like to think about that, I think we’re agreed, is it’s a cognitive empathy, in other words it’s having some theory of mind to go, I can understand what you’re going through, at least intellectually. I may not feel your pain, per se, and we’re talking about pain today, that’s gonna be the theme of the show, so you see a child getting an injection, a vaccine, and you can either truly have affective empathy, where you feel that shot, and you’re hurting for that child, and you hold that pain, and from that you act in some way. Now, the rational way to act when you see a child having that kind of pain is to take the pain away. It’s to actually do something to alleviate the pain, whether or not it’s in the best interest of the child. That’s what you would do, affective empathy. Now, cognitive empathy is more that, and psychopaths can have some degree of cognitive empathy. They can read people. In other words, you can be aware that this person is suffering, but you don’t take that pain on yourself. You don’t hold that burden, and then compassion is that next stage where you are absolutely motivated by love in the face of suffering, to relieve that suffering in a way that actually does good for the most conscious entities you can, so in other words, this person’s suffering: is it better to not give them the vaccination, or is better to come up with a way that we can relieve their suffering and give them the vaccination, and–

– And the fascinating thing, as an emergency doctor, is that we have become dissociated from compassion for a lot of procedures, so for me, I don’t have an empathy or a compassion for the child who’s getting the vaccine. I have an intellectual burden of, what is the impact on herd immunity, both if I make them afraid of vaccines, and if they don’t get health care later? They’re several cognitive stages removed. The empathy of whether this vaccine hurts or not, I really don’t care as much because all I care about is I want that child to be protected in the best way, but there is a meta-level of understanding the intellectual and the research underpinnings of what is safety, and what is safety for that child? What is safety for the milieu and for the community? In emergency rooms, people talk about safety, and anybody who has been an emergency doctor knows it’s not just safety for a patient. It is the milieu. It is the safety of the situation. When you get too many patients in the waiting room you have an inherently unsafe situation because any one patient is going to be neglected to an extent. Safety is not just who’s putting the cap back on the needle. It’s not just whether or not we’ve got the right patient, the right drug, at the right time. It’s also, do we have enough staff for the number of patients coming in? I’m just saying that there’s so many different levels of what we’re trying to do in medicine. When you’re in emergency medicine, you have abraded, a bit, your emotional compassion for someone who is getting a fairly minor painful procedure, like a needle, like an IV, because we see femurs sticking out of thighs. Likewise, in the situation in pediatric offices, where people are getting vaccinated, the part that motivates me is not necessarily I don’t wanna hear this child crying or screaming, it’s how can we be most efficient as a system, and how can we make that child the best prepared to be safe as they grow up, so it’s a bunch of levels.

– Okay, so everything you just said is a perfect example of, we use this metaphor, John Haidt’s metaphor of elephant and rider. Elephant is our unconscious limbic system: emotional reasoning, intuition, schema, pattern behavior, unconscious, automatic, and then rider is the little neocortex that’s evolved recently to try to control the situation. That’s our thinker, our verbalizer, our planner, conscious, aware thought. What you described, I think, is taking your rider that is normally the slave to the elephant. In other words the elephant’s bigger. It’s automatic. It’s emotional. The rider is usually just its press secretary. It’s there to explain why you’re, to rationalize, post hoc, why you made a decision based on your gut, but you’re saying, actually, if we’re doing our job right in emergency medicine, you’re actually looking at so many different things in a conscious, rational way, not just that emotional empathy, not just even the cognitive empathy of they are suffering. It’s the bigger picture. If they suffer a little now, they might prevent a case of measles, but if we damage them mentally with suffering that we are not paying attention to because we’ve closed off to it, five different injections at once for a four-year-old, or whatever the schedule is, are we creating a human that is now so terrified of this pain, and it would be normal for a child to go, wait, I had this horrible experience with–

– [Amy] Adaptive, even.

– Adaptive. You’re gonna yell at a child for being scared of needles? You’re gonna complement them, evolutionarily. A bunch of animals held you down and stuck you in every extremity at once–

– In a place you’re supposed to be safe.

– Where you’re supposed to be safe.

– Where people have told you you’re safe, and people have told you that you’re getting taken care of, and you’re gonna be made to feel better. Go on.

– You know, it’s weird. I got triggered emotionally for a second because one of my earliest memories, both my parents are doctors, one of my earliest memories was being taken to the doctor myself, must have been a pediatrician at my mom’s hospital, and them holding me down and just I was screaming at the top of my lungs, and crying, and trying to fight, and my mom was there, standing aside while like three nurses held me down, ’cause I was a strong little punk, and I don’t remember what they did. I remember one of the things they did to me was put a blood pressure cuff on me, and I felt it squeeze. That’s all I remember–

– [Amy] Oh, the indignity.

– The indignity of it, and to this day I have white-coat hypertension if I know someone is measuring my pressure and looking at it, the pressure goes up, whereas if it’s just me at home it’s normal, so it’s interesting. Let me go back into that little digression from my Freudian past. This idea that you’re in a safe space. You’re now stabbed with these needles. It hurts, and that could then lead to a conditioning that makes you afraid of doctors, afraid of health care, afraid of medical treatment, afraid of needles, and then you come back with that person at age 11, when they’re supposed to receive their HPV vaccination. What might happen?

– I have some data for you.

– Oh my goodness.

-Oh yeah. The really interesting part of empathy with this is that we who were born before 1982, which is most of your practicing and, yeah, exactly, I turned 50 this year.

– You’re kidding me.

– Oh yeah.

– I want whatever you’re smoking. I’m 45; I feel like I’m 60.

– There’s a cream for that.

– [ZDoggMD] Oh, good.

– If you were born before 1982, you did not get boosters, which means that all of your vaccines were done before you were old enough to have verbal memory. Verbal memory happens at about 28 months to three years of age, and so our vaccines were, we only got six of them, and up until 1982 we got them all before we were two years old, so we don’t remember getting a whole bunch of vaccines at once. I don’t know what you were held down for, but whatever it was, it wasn’t a whole bunch of boosters.

– It was a rectal probe, because my parents were weird that way. No–

– This explains so much.

– Doesn’t it?

– It really does.

– Look at me. Just look at me, Amy. It explains everything.

– I’m wondering where your alien deely bobbers are. I figured you probably have, I was expecting sort of an indentation in your skull

– Oh, it’s there.

– From wearing them all the time.

– This is a facade. Anyway, so–

– Anyway, the thing is it’s hard for, one of my missions has been trying to get other physicians of my generation to have empathy for why needle pain matters, because we, again, center of the bell curve, we kind of assume that our experience was everyone else’s experience, but it was dramatically different. By the year 2000, children were getting 36 separate injections before they were six years old, and we got six or fewer before we could remember, so it’s a dramatically different cognitive landscape for the experience in the doctor’s office. Now–

– I’m gonna stop you for a second, ’cause the language you’re using is anti-vaxxer-adjacent, so this is the new callout culture is to call somebody adjacent to something terrible just by association, so in other words, because you just said, they get so many more shots now than they did in the old days, you’re guilty of using the same rhetoric that the anti-vaxxers use, therefore I’ll assume your intent is anti-vaccine.

– Aah.

– You see?

– Yeah, see that’s one of the things I run up against. All right, so we do get a whole lot more. Obviously, though, the immunogenic capacity of these vaccines is infinitesimally small compared to what we got when we were born, so–

– In other words, the number of antigens in these vaccines is less than we got,

– Is less than we got.

– so more shots, less antigens.

– Exactly.

– And that’s what we’ve talked about with Offit, as well.

– Right, right. Well, not only that, but we are preventing 99% of deaths from all these vaccine-preventable diseases. I mean, dramatic death reduction in childhood. It is–

– More shots means more diseases we’re preventing.

– Oh yeah, well, more shots means fewer children dying. When I was, you too, when we were training, we had all this meningococcal meningitis. We had children who were turning into great blobs of purple bruises and dying in hours in front of us. You and I, I just gave myself chills thinking about this. We saw these children, and we took care of these children, and so we know what we’re preventing. We saw epiglottitis. We saw children coming in who couldn’t breathe, whose uvulas were swollen to the point where they were completely obstructed and died in front of us.

– 10,000 admissions for chickenpox, for the secondary skin infections, the pneumonia, the meningitis–

– No, the encephalitis.

– Encephalitis, all–

– I think anybody who’s practiced medicine before these vaccines, you just have these snapshots of images of children that just flash by like a little camera thing with those red things, you know the–

– Oh, boy, you are old school, but now I just press a thing on my phone.

– Right, right, but you know, but just–

– Oh, those 3-D Viewmasters.

– Yeah, the little 3-D Viewmasters, yeah, yeah.

– Viewmaster, Viewmaster, right, right. When you talk about what we’re preventing with vaccines, I get this Viewmaster panorama of all of these children who have had devastating morbidity and mortality from diseases that are now preventable by vaccines, and so we don’t see that anymore. I mean, the people who are trained now don’t know what measles look like. They don’t know what chickenpox look like. The don’t know what an H. flu epiglottitis looks like. All that said, the balance between preventing all of those deaths and doing it in a way that we also keep those kids donating blood when they get older, and going in for preventative health care, and not having cancer diagnosed really, really late because they’re too afraid to go to the doctor, that’s the balance we have to find right now. To get to your question, we looked, when I started doing research on the Buzzy needle pain blocking device thing, what I did was start with the 10 to 12-year-olds, and ask them how afraid of needles they were, just to get a baseline, and then randomize them into groups, and we found that the cohort of 120 adolescents was, 64% of them were afraid of needles, which was not supposed to be. It was supposed to be, from everything published up to that point, about 25% of kids who were afraid of needles, so my immediate assumption was I have messed up my data. I have done something wrong, predisposing these children to endorse needle-phobia in higher degrees than previously have been endorsed, so I felt like a bad scientist for a long time, tried to figure out what the deal was. Then Anna Taddio, who is a phenomenal pain psychologist researcher in Toronto, she published data on 1,000 people, and had 63% incidence of needle-fearing.

– So the numbers correlate. Wow.

– So the numbers correlated,

– That’s a huge–

– so this was a bellwether. Here’s what has happened. Their parents in this cohort, so she went to an art museum, and then just randomly started asking people if they were afraid of needles, and do they vaccinate their kids, and does needle-phobia impact whether or not the vaccinate their kids, and–

– I see bias already.

– [Amy] Bunch of stuff.

– People who go to art museums,

-It’s so true.

– frickin’ hippies, okay. Of course they’re afraid of needles,

– Fair enough.

– ’cause they’re unnatural. Anyways, please continue.

– I will go on, but about the same, so the adults, the parents, 24% were afraid of needles, which was also higher than expected, but that age group of the adults of these kids who went, many of them were born in the late ’70s, early ’80s, when we started doing boosters when kids could remember, so armed with this, and I also saw a presentation that showed that only 34% of kids had completed their HPV series, I had this little pie chart pop up in my brain, and it was like, ah, here’s the people who are afraid of needles. Here’s the people who complete their HPV vaccines. That fits together perfectly. The numbers completely correlate.

– Oh, so 60-something and 30-something.

– [Amy] And 30, yeah, so it was like–

– Science.

– Yeah, it was 63 and it was 36. It was like, whoa.

– So, it was like–

– I thought, I bet I can figure out an answer to this, so I went back to my database, and got a new IRB approval, and looked at all the vaccination records of all of these kids to see if there were any overlays of what predicted the kids who were afraid of needles, and it turned out that all of, most of these 36 injections, almost all of them are before age two, and it didn’t make a bit of difference. That doesn’t correlate with fear at all, so what–

– [ZDoggMD] Got it, ’cause they don’t remember.

– Right, so what we’re doing with the infants and babies is perfectly fine from a standpoint of long-term needle fear. What the difference was, was a dose response with how afraid people were based on how many injections they got on the same day during the four-to-six-year period where you’re getting your booster shots. You don’t need to give them all on the same day. The CDC allows you to do these vaccinations any time between age four and six. The kids who got theirs spread out over time, one every single time they came in, none of them were afraid of needles in their, none of them were in the highest quartile, in their 10-to-12-year-old age range. If they got two, 9% were afraid. If they got three on the same day was their max, 26% were afraid. If they got four or five injections on the same day, 50% of them were in the highest quartile of fear five years later, and then I followed those guys for another three years, and if you were in the highest quartile of fear you were 2 1/2 times less likely to start your HPV vaccine. Now, that one was a p of 0.08, so it didn’t get to statistical significance, but there was a clear dose response that was highly statistically significant for the number of injections on the same day, max, and how afraid they were, and they all were completely vaccinated.

– You know that this isn’t trumpeted everywhere as a huge issue that we should address is crazy to me, because if this is true, so let me–

– [Amy] Published in Vaccine, July 2017.

– Ah, so let me rephrase this in my own monkey mind so I can make sure I’m getting it right. Between four and six there’s this window where these children can remember, or at least be conditioned by an experience that doesn’t really bother them when they’re less than two years old.

– [Amy] They can remember, but they can’t abstract.

– They can’t abstract, so it’s a concrete experience, and if you stick them with two or more needles, you start to see an increasing rate of needle fear later in life. If you stick them with just one, and you actually even repeat it over different days, it doesn’t reach a threshold, presumably, and they don’t get this persistent fear.

– No, in fact I think it builds resilience. I mean, they realize it’s not that big a deal. They get over it. It’s a lot easier to do a bunch of cognitive treatments and therapies to make them feel empowered, to make them feel strong, to make them feel like, you were so good with that, but I was talking to one of the people on your staff earlier today, who said that one of the pediatricians told the kids, instead of one really big shot, we’re gonna give a bunch of little ones, which worked fine up until their second shot, and by the third one they’re like, okay, yeah, forget even the little ones. This isn’t fun. In our studies, too, looking at pain, we had a clear relationship with the increased reporting of pain that was most strongly correlated with the number of injections. If you get one at a time, it’s a lot easier to go, oh, you know, that wasn’t as big a deal. I’m not so worried about this next time. Think about it from a camping perspective. You look like the kind of guy who goes camping.

– Oh, bro, uh.

– You go camping?

– Actually I don’t because my wife doesn’t like it. She’s afraid of ticks.

– Oh, shame. Well, so as a camper, if you go camping and you get one wasp or bee sting every time you go, then the fun of camping can kind of outweigh that, but if the first time you go camping

– You’re swarmed.

– you get five, then you’re never going camping again. You go to give blood. If it takes them five times to draw your blood, at least you’re not going to that phlebotomist, but you may not give blood again.

– This, to me, speaks to a few things. It’s amazing, actually. First of all, it’s evolutionarily adaptive if you are overwhelmed with a negative stimulus to become conditioned against that stimulus. The second thing is, we’ve talked on the show recently about this concept of anti-fragility in children. Now, I’ll explain it real quick. Fragility means you stress something, it breaks. It’s done, doesn’t get better from the stress. Resilience is a way of saying, I can drop this. It’s not gonna break, but it is not gonna be better for it, but children and other complex entities are anti-fragile. When you stress them within the capacity, within certain tolerances, they come back stronger, they–

– Oh my gosh, that’s exactly what vibration is, on a mechanical strain and at a certain threshold you cause damage, but sub-threshold you actually cause growth.

– And we’re absolutely gonna hit that, ’cause I think that’s crucial, and it’s also talking about

– But that’s very cool.

– these kids and their experience. You poke them with five things at once, you’ve broken their capacity, and now what you’ve done is you’ve made them fragile. Now they move forward with a fragility. Any needles, terrifying. Medicine, terrifying. Donating blood, not a good idea. But just one at a time with support: you’ve done a great job. Here’s a little glucose. Here’s some other things that’ll help you, and now they’re stronger. They’re actually able to tolerate injections and actually, maybe even like my kids, which we’ll talk about with your device, actually look forward to their injections now,

– Wow, that’s freaky.

– which is terrifying, because they know they’re going to be safe. They know Daddy’s crazy about vaccines. Daddy is crazy, but he’s also Daddy, and that they know it doesn’t hurt that much ’cause they’ve done it, and they have the coping mechanisms to do it, and they use the device, but I think even absent of that kind of thing, now, I remember giving my youngest, my oldest, actually, the five at once, but she was young, and then I think we did kind of have a couple visits where we didn’t intentionally spread them out, it just worked out that way, and she’s not, they’re not scared of needles, but this is fascinating to me, the concept of anti-fragility, resilience, the evolutionary adaptation, and then what are we doing in an unintentional way, ’cause like you said, I think, actually, I’m gonna be a little less kind than you are to the profession. I think doctors have to turn off a lot of the compassion and empathy to get through their day, and it’s just, let me make sure I click that box to make sure they got their vaccinations, and do whatever it takes to do it, ’cause we know it’s in the best interest of the child, not thinking about the scarring that you’re creating, or the damage you’re creating in a bigger system, where now this child is no longer going to be a willing participant in the medical system for these reasons. I think we’re complicit in this, but not intentionally.

– Oh yeah, it’s definitely not intentional, although we have abdicated some of our responsibility for the vaccine giving to nursing staff, and it’s really easy to say that it’s just ’cause you’re too busy and we’ve gotta do things, but the reality is that nobody likes inflicting pain, and I think that if we were a bit more hands-on, still, as a profession, doing the vaccinations, and there certainly are pediatric practices that you see on YouTube all the time, where the doctor’s the one giving the shots, and they’re doing all this great distraction stuff, and they’re finding ways to make it less painful and traumatic because they’re the ones who are giving the injections, and so many practices are having someone give the injections who doesn’t have that kind of a personal relationship with the child, the nursing staff, and it’s cognitively easier for the physician. It’s more efficient for the practice, but it means we’re even more at risk of causing the children to be afraid going forward.

– Right, right, so in an ideal world, though, because we have a lot of nurses watch the show, I think having nurses be partial owners of the relationship as well.

– And we know lots of practices where they are.

– Right, exactly.

– I mean, one of the big concepts that I try to get across is this pain-fear focus idea, that you don’t have to spend any money when you’re doing a painful procedure to someone, because you need to address both what the pain is. You also need to address how afraid they are of it, and then what they’re focusing on at the time of a painful procedure. You can direct anybody in three seconds. You’re gonna have a painful procedure? Okay, you’ve got a potted plant behind you. I want you to count how many leaves there are on that, and that kind of cognitive distraction costs nothing, is really fast, and easy, and free. The other thing that’s important to point out about our study was that we don’t know whether they got some sucrose after their injection. We don’t know if the people who got one shot at a time, they probably were different, because why, when our study was being done, why, in 2000 and just after, were parents having their kids spread them out? There’s undoubtedly a limitation in it, and some confounding there, but we also don’t know whether or not doing something to relieve pain would make it more acceptable to these children. Could we still give four injections at the same time? And now we’re doing combination vaccines, so there’s a lot, it’s down to two or three, four if it’s flu season, injections that, because of the combination vaccines, but we don’t know whether or not doing different modalities of distraction, and rewards, and a little bit more of the cognitive stuff could make those numbers of high fear go away, but I think that that’s where the state of research is right now. We need to be trying. We need to be figuring out either ways to reimburse if we were going to stagger. I don’t like spread out, because it has all the anti-vaxx kind of things

– Box the ears of these guys, yeah.

– Yeah, exactly, yeah, but if we wanna stagger them, then we have to have better reimbursement. We have to have more convenient access to vaccines. We have to have the ability to track if you get a vaccine at a pharmacy, if you get a vaccine someplace else, if we’re able, at schools. You know, in Thailand, we were talking, I was in Thailand for a while, well, a lot of their vaccines are given in public schools so it breaks the connection between health care and painful needles, and school’s already painful, so you know,

– Yeah,

– whatevs,

– so it’s part and parcel,

– you gotta go there anyway.

– yeah, torture me more. Oh, you even been in a Thai prison? It’s nothing, it’s nothing. I wanna make sure that we remember that, so we’re gonna talk about your work and innovation around pain amelioration and modulation around not just injections, but other painful issues that might help us talk about this exact issue, as well as opioid crisis, but there was something that you had said… Oh, you were talking about creating these systems of reimbursement, maybe put the vaccines in the school, saying, okay, let me give a quick metaphor that I think is a good way to think about this stuff for the listeners. We talked about elephant, unconscious, we talked about rider, little guy on top, so if we’re talking to our patients, and we’re trying to get them to get their vaccinations, first of all, don’t traumatize the elephant with four vaccines, four shots at once without modification, because you’re gonna condition that elephant to develop schemas to fear medical people, vaccines, et cetera, and then the rider will spin reasons. Well, I did a Google search, and Jenny McCarthy says they’re bad anyways, so I’m not going to get vaccinated. Did you see what’s going on with HPV? These girls are passing out, having syncopal events, and they’re convulsing, and so I’m not going to do it. You have the rider making up excuses. You have the elephant that’s conditioned, but they also walk on a path. The path that they walk on, that road that this creature takes, which each of us take, is our system. What are the reimbursements, the incentives, the structures, the technology, the tools, which we’re gonna talk about, that we can use to actually help that elephant and rider work in a way that’s more compassionate to the overall suffering, meaning improving vaccination rates, decreasing needle fear, decreasing pain at that point, although, like you said, that’s less important. It’s more how does it affect

– It’s contextual.

– the rest of the–

– Contextual, yeah. Tell me about how needle-phobia, I’m imagining it might affect overall community immunity that they call herd immunity. I like to use community immunity because it’s a softer, less triggering word for people, ’cause we’re sheeple otherwise.

– I do, too. I started calling it community immunity just ’cause it’s fun to say.

– Sounds cool, right?

– Community immunity.

– Community immunity.

– Sounds like

– It sound like

– a Schoolhouse Rock, right?

– a Sesame Street.

– Right? ♪ I’m just a bill ♪ ♪ Yes, I’m only a bill ♪ ♪ And community immunity hill ♪ ♪ Community immunity ♪ ♪ Together ♪

– Yeah.

– Exactly.

– All right, well, I’m gonna go back to Taddio, because the 24% of people that were afraid of needles that she found, she asked the adults how much their needle fear impacted their vaccinating their children, and 8% said that they either didn’t vaccinate, or didn’t fully vaccinate their children because of their own fear. Let’s do the procreation math. If 63% of kids who were born in 2000 are afraid of needles, they’re about ready, if they haven’t already started procreating. If 63% are afraid of needles, and if 8% of those 63% are going to be impacted enough to not vaccinate their children, then when you do the math, now you’ve got about 24% of people who are going to be strongly anti-vaxx. Looking at the infectiveness of things like measles, as you well know, one of the most highly infective. For every case you can have between five and 18 more cases because it spreads so much. If we have 24% of parents with this next cohort, when they start having a lot of kids, this Gen Z, if they’re not vaccinating because we haven’t figured out this problem yet, then we are going to lose our measles herd immunity almost immediately. Obviously, it’s already gone in several communities. You’ve got to have, with measles, 92% of the community vaccinated, and if you’ve got 24% of parents who are not into it because their own fear, that’s a huge issue.

– Yeah, and this is the best explanation I’ve heard for why needle-phobia matters, why we need to address it, which is why I’m having this conversation.

– Right, we’ve gotta acknowledge that we are doing this iatrogenically, and in the best of intentions, and I don’t know. I do know, as a matter of fact, that when a child is getting four vaccines at once, Buzzy does not help, because it’s too much.

– It’s too much.

– It’s too much.

– You’ve hit a threshold. You know, this is one place where we’re gonna agree a little bit with the anti-vaxxers that say, too many at once, not so much from a scientific standpoint–

– Only in the older ages. Only in age four to six.

– Only older ages where they’re–

– You can stick them like a pincushion when they’re under the age of two.

– Like Hellraiser.

– Right, that’s right.

– Oh, to think–

– Yeah, right, just full of needles.

– That’s fine.

– That’s cool. In fact, it’s encouraged, but yeah, so–

– And aesthetically pleasing.

– Very aesthetically pleasing. I love that movie, Hellraiser, by the way.

– But the older kids, we need to–

– We need to be thoughtful.

– We need to believe them. We need to acknowledge that their distress is real, and that the parents’ distress is real, and also this is a little dicey to say, but parents who are anti-vaxxers ’cause it feels wrong, they’re not wrong. It does feel wrong to watch your kid get stuck a lot,

– Yeah, oh 100%.

– and we need, and we will do better, I think, if we say, yeah, it does feel wrong, and yeah, we were probably wrong on those older kids. Not wrong to protect their lives, and to save them, but we could have done this better, and that they need to be vaccinated is incontrovertible, but how we do it is an evolution. When we started with cars, nobody had seat belts. We didn’t know all of the dangers of this great new invention. We have social media now, and we’re seeing problems. We don’t know all of the dangers. We’ll figure out the seat belts to put on cars. We’ll figure out the blocking and timing to put on social media, but we’ve got an amazing way to save lives of 99% of diseases, but there’s probably some extra safety stuff we could do in those older kids to optimize.

– I wanna make sure I’m very clear. We’re not saying delay vaccinations in a way that’s gonna create windows for infection, ’cause that’s what people like Bob Sears and these other people, because they’re saying, well, it’s safer because there’s so many antigens. We don’t wanna make our children autistic by giving too many–

– Eh, you know that’s crap.

– That’s crap. What is not crap is what you’re saying, and that’s the point we wanna say, so it might just be two or three appointments in a row, where you come back within a couple weeks–

– Only in the four to six year, ’cause you’ve got a whole range in four to six year,

– Very clear.

– so this is, yeah, none of what we have said today applies to anything before age four because all of those are very well studied. You have to give those in those very narrow windows because of the way the immune system works on its own layering. You’re not gonna get bumping up of your immunity. I’ve gone out of your frame, but

– That’s okay.

– you don’t get bumping up of the immunity unless you time them very precisely, but once you already have a level of immunity that you’re just boosting with boosters, you’ve got a two-year period, so we’re just talking about that two-year period.

– That is absolutely what I wanted to hear and make sure people knew, because what’ll happen is, this is what happens: anti-vaxxers will take this video, they will edit out you and me saying we should make sure not to give all these vaccines at once, and they will use that as propaganda, because they are concrete thinkers.

– I think that you’re tribalizing this.

– [ZDoggMD] Of course I am.

– Well, I don’t think that that helps, though. I think that if we want to get all of our community vaccinated, we need to acknowledge that there are reasons why people feel uncomfortable about their kids getting poked a lot, and they really don’t need to worry about the young age, because they’re getting teeny tiny immunogenic, and it’s not a burden or dangerous to them, but we, by villainizing or saying that people who are anti-vaxxers are concrete thinkers, that’s not true. They’re intelligent. They’re just not well-educated enough about what the reality, immunology is the hardest thing we study, so I think that saying we hear you, but the real danger to yourself and the community is these diseases, and there’s a way we can change the nuance for these boosters, which is really the only time where your kid getting freaked out is gonna impact their lives at all, and we can take care of that.

– You know, and this is something, so I’ll push back a little, and I’ll also take that criticism appropriately, because there is a good part of my brain that actually agrees 100% with you, that we should never tribalize these issues, and they are, actually, the kind of data shows that anti-vaxxers actually higher socioeconomic,

– Right, exactly.

– more educated, et cetera. However–

– Really good at rationalizing.

– Yeah, they’re very good at rationalizing, so they’re riders are very hypertrophied, so when their elephant says something that is based on fear, their riders can come up with very eloquent descriptions for why they’re right, but when I talk about, in a tribalistic way, about anti-vaxxers, I’m talking about the professional anti-vaccine advocates that do this for a living. They are causing harm on a scale that is difficult for an individual human to cause nowadays, short of going into a club with a gun, and even then they can do more harm. For those people, I’ve made a sort of rule in the sand where there’s free speech, but then there isn’t free speech where you can walk into a crowded theater

– Crowded theater.

– and yell fire.

– That’s a crowded theater.

– That’s the nuance that I like to think about, and the other thing is, and again, I’m justifying a little bit because I’m actually sensitive to that criticism, ’cause I think it’s appropriate, especially for parents on the fence, ’cause I get a lot of messages about that, and this is me thinking out loud, but part of our role on my show is to galvanize a particular tribe, which is the tribe of health care, so I do use a lot of that language, but I want you to know, particularly, because I’m sensitive of that judgment, ’cause I have it myself, that there’s a purpose, and it’s beyond blind tribalism, it’s a calculated tribalism.

– Okay, and I’m fine with that, because I respect your intelligence and the way you approach it, and our goal was absolutely the same. I mean, to think about what impact needle-phobia has, so of, I’ll take the flu vaccine, so in 2014 targeted a study, 24% of adults who do not get their vaccine don’t get it because they’re afraid of needles, so–

– [ZDoggMD] That’s a huge percentage.

– It is a huge percentage, and that’s of the ones who don’t get vaccinated, so there’s lots who don’t get vaccinated for other reasons. Well, in the 2017/2018 flu season, nope, 2016/2017, the really bad H1N1, so in that flu season there were 60,000 adult deaths, and they don’t report it for adults, but they do for peds, so in peds, 80% of the kids who died of that flu season were not vaccinated. If we look at the numbers, so we say, okay, so of the 60,000 adults who died, if it’s the same proportion, that 80% of those had not gotten their vaccine, that means that we’ve got about 47,000 who did not get vaccinated who died, and if a quarter of them, 24%, didn’t get vaccinated because they’re afraid of needles, that’s 12,000 deaths, so the anti-vaxx fear that you’re talking about is killing adults on widespread levels every year because they’re adults who don’t get their vaccines because of that, and so I think whatever method you use, and whatever tribalism or whatever concrete language, I think that’s fine because I do think that the message that anti-vaxxing is endangering not just your kid, and not just your community, but a much broader thing. That’s an important message.

– What I like about your approach, though, and what drew me to you coming on the show, actually, was something that I’d never thought about, which is, and this is part of a rational discourse: it’s being able to see where the flaws in your own thinking are. It never occurred to me that needle fear, you introduced me to this idea a couple of years back, it never occurred to me that needle fear could be a driving, ’cause it just seems–

– [Amy] A driving force of anti-vaxx?

– A driving force in anti-vaxx, and the reason it doesn’t seem that way is because of the reason you said, which is I grew up in the era where it didn’t, in the critical window, happen to me that I was poked with a bunch of needles at once to condition me that way. I think it’s not a big deal, and I could take a vaccine now. However, as you mentioned, this is not the case for others, and so that opened my eyes to the idea that the anti-vaxxers are correct. It does feel wrong. Why does it feel wrong? Because in that critical window they were conditioned, and seeing the child suffer with all these injections at once, and visibly suffer, right?

– Right, I mean, what’s your whole life doing when you’re a new parent? It’s protecting

– Protecting your child.

– that little thing from getting a hangnail, and then you’re watching that little thing get turned into Hellraiser, so of course it feels wrong. It takes a lot of intelligence to think about that. I’ll leave you with this fun support of this idea. Dan Sammon did a study in J Peds, I think, in 2005, looking at the difference in attitudes between vaxxers and anti or partial vaccinators, and in that study found that the reason that people say they don’t vaccinate their kids is because they’re worried about the immunogenic load, or they’re worried about harm from the vaccine, so I looked at that study, and they report what the least-refused vaccine is in the anti-vaccine group. Do you want to play this little game? What do you think the least-refused vaccine was for those who either don’t or partially vaccinate? What were they willing to take? What vaccine were they okay with?

– Tetanus?

– Polio.

– [ZDoggMD] Really?

– Now, what is the most immunogenic? What is the most actually dangerous vaccine? It’s oral polio, but in 2005, when the study was published on data from 2003 and ’04, from parents’ opinions whose kids were vaccinated in 1995 to 1998, they were getting the oral polio vaccine.

– [ZDoggMD] ‘Cause it’s oral.

– ‘Cause it’s oral.

– ‘Cause it’s oral. Wow, and let me leave with this.

– Break it down.

– That, mind blown. Mind blown.

– [Amy] Continuity blown.

– Actually, mind really blown. Really interesting, so I’m thinking about this very differently now. This is very helpful. Let me say one interesting thing: when they came out with the news that nasal FluMist wasn’t effective, and they needed to stop for a couple of years, you could feel a palpable panic among parents, ours included.

– [Amy] Little sphincter tightening.

– Sphincter tightening. Suddenly it went from so many bars of pressure to unmeasurably high, a singularity, an anal singularity.

-Sphincter singularity, that’s just a little,

– That’s better.

– that’s a little more PC.

– Sphincter singularity, a double S, S cubed,

– S squared.

– and it was because I think people were realizing, I’m gonna have to now subject the kid to an extra vaccination this year that wasn’t expected.

– Ooh, you know what we found out that I didn’t publish in our vaccine study ’cause you can only put in so many interesting things. The teenagers who did get their HPV vaccines, they would not get a flu vaccine unless it was nasal. We didn’t have a single person in this 120 cohort that, in their teen vaccines, got both HPV and an injected flu at the same time. They would get one or the other, or they would get HPV and nasal flu.

– [ZDoggMD] Out of choice by them, or–

– Who knows?

– Oh wow, interesting.

– It’s just yeah, that’s the limitation of, we weren’t interviewing, we were just looking at their shot records, but it was this unmistakable pattern that in flu season people were either getting an injected flu or they were getting an injected HPV and nasal flu, but if they got the injected HPV and there wasn’t nasal flu available, mm-mm, honey, they were not getting the flu shot.

– [ZDoggMD] Mind blown.

– They were, ‘scuse me, they were cherry-picking, and it was clearly the kids. There’s another study in 2016 that looked at the biggest factor in children not getting their second HPV vaccine, and it was needle fear, and you and I are like, well, we’re your parent, too bad, you’re getting it, but there is an enormous amount of 12-year-old ability to influence what your parents make you do.

– Maybe that’s a good transition to talking about what you’ve done in your work you’ve done that’s your passion now, because you actually stepped away from full-time clinical medicine to pursue this entrepreneurial passion of yours, which relates to the moral passion that you have about doing the right thing for kids and adults. Tell me about this.

– So what happened was–

– [ZDoggMD]What happened, your honor, is–

– Yeah, so I just don’t like wasting anything, and suffering seems to me to be a form of wasting if there’s ways to avoid it, so my first research was actually in nausea. I developed and validated the BARF nausea scale, thank-you-very-much.

– Good lord, I’ve seen that scale.

– [Amy] That’s my scale, baby.

– Tell me about that scale.

– It’s the Baxter Animated Retching Faces scale, ’cause research is all about the acronym. You wanna get a grant, you gotta have a solid acronym.

– [ZDoggMD] That is amazing.

– No, I had been doing a lot of pain research, and talking about pain management, and I was looking at the Wong-Baker Faces scale with the going to tears at the end, and the first one looks like, I have a hot dog.

– Zero, right.

– Yeah, I feel great. I was looking at that. I was thinking, wouldn’t this be hysterically funny if it was reading nausea, and the ultimate anchor was blowing chunks. That cracked me up so hard in the middle of my office at UT Southwestern, and then I started thinking about it, and I was like, you know, actually nausea is a really important, underrated thing, and it’s probably poorly rated. It’s a lot easier to tell if a kid’s in pain than if they’re in nausea. Anyway, so I went on, got a grant from Hope Street Kids, validated this BARF scale, and the end result is it’s now been validated in Spanish, and it’s been used in, translated into Chinese, and French, and so it’s an almost parametric scale, which makes it a lot easier to test anti-emetics in chemo, because if you use as your outcome measure whether people barf or not, you can be nauseated for days,

– And it’s miserable.

– and speaking about excurt, yeah, so if you’ve ever had pregnancy nausea, which you haven’t

– Yes, I have.

– Um, well, you are an enlightened soul.

– Because I take hormones just to try it out. My wife had it terribly.

– Right, yeah, so you can be nauseated for days, and have it be debilitating, and not actually throw up. Prior to the study, to the scale, most people had been using emesis as a proxy measure, and that’s not great. Anyway, so I kind of finished this journey with the getting published of the BARF scale, and while I was in the process of doing all of that, I became more in tune to needle pain and the suffering of needles. Around that time, my son had had a really bad experience with vaccination, and because I was lecturing on pain, and lecturing on suffering, and I was gonna be the champion to teach the staff about how to give compassionate vaccines, and I had all this stuff, and it just went horribly awry, and the nurse who gave the injections was like, yeah, that EMLA stuff doesn’t work. You’re gonna sit there and be still or this is really gonna hurt, and just jammed him in, neither of us were ready, he puked, and after that he would throw up every time he had to go to the doctor.

– [ZDoggMD] Oh my gosh.

– So, I felt kind of betrayed, like I’m in the system and I can’t protect him, and noodled on it for a year or so, and tried to think about ways to block pain that a parent could do, that wouldn’t require any kind of input from the system, and driving home after an emergency medicine shift one night, so it was early morning, my head’s a little, woo, like you get, and my hands were on the steering wheel, which was vibrating because the tires weren’t balanced, and I was like, ah, you know what? If you put–

– Because you’re a woman and you don’t rotate your tires.

– It’s so true.

– Okay, I’m just gonna go ahead and say that.

– Yeah, yeah, you’re right.

– It’s also not true at all.

– I feel morally… I blame myself, but I was thinking about things like running water on a burn, and how you block pain using those kinds of motion sensations, and then the vibration was like, ah, vibrators. That’s the answer. You do not need a running water, or a little swirly cup, or anything.

– Wait a minute, now, at 45 minutes in it took you to get to vibrators. You know, usually we get there a lot faster on this show. I’m impressed. Wait, let me just see this, so you’re going home, you’re thinking about your kid who had this horrible vaccine experience, vomiting any time now has to get vaccinated, and the steering wheel’s vibrating, and you get out of the car, and your–

– And my hands are numb.

– [ZDoggMD] They’re totally numb.

– And I go run in the house, and I’m like, where’s the personal massager? I probably said vibrator, I did,

– I’m sure you did.

– but I actually is a personal massager. I bought it off this guy in residency who’s this homeless guy who was like an entrepreneur.

– Did you know the number one item by sales volume on Amazon are female vibrators?

– You know, volume counts.

– It does, it does. Also, I entirely made that statistic up. I have no idea if it’s true, but it just feels right to me. Please continue. So you ran into your…

– Oh, you’re bad. Anyhow, I ran in the house. I said, hey, this is gonna work. We had a Wartenberg wheel, which is the pokey wheels. I was like, let’s try this. I poked my kids’ hands, and they still felt it, so it’s like oh well, never mind, and my husband said, as a Boy Scout, he said, “You know, we use frozen peas in the Scouts. “Maybe if you added that it’d be better,” so we put bag o’ frozen peas on the wrist, yellow-and-black personal massager on top of that, and I could leave marks on their hand where you’d put an IV, and they couldn’t feel it.

– [ZDoggMD] Wow.

– First of all, the die was cast that I will never win mother of the year because

– You’re a torturer.

– I admitted that I left marks on my child on purpose, and now you know.

– And you can hear the thousands of calls to CPS going out right now across the country. You’re welcome.

– Their hands look fine now.

– Yeah, are you sure?

– I am.

– So you’ve hidden the bruiseswith makeup. Please continue.

– They were dense.

– They were just dense, right.

– They were more dense, dense.

– You didn’t break the skin.

– Yeah, so and then we recreated it with a video. It was like, ooh, this is big. This is a really big idea, and so actors representation. Mind you, my kids are that boy, like one, and three, and five, and so they’re all totally like puppies on top of me, and we’re rolling around, and I’m exhausted, and so we did the video again, and they’re like, okay, fine, yeah, whatever, rolling around some more, and then I went to bed,

– This is pre social media? ‘Cause now that would have been an Insta Live, and…

– Oh yeah, no, no, no. This is pre social media. Over the next couple of years, I made a prototype for the kids, and I would take it for their injections, and started to feel more and more guilty when I was in the emergency department listening, even though I said we get immune to it, I still, I was listening to the screams of the kids, and going you know, there is a better way, but the effort to get a prototype that’s made with electrical tape in your basement FDA cleared and accepted by hospitals is really more than I wanna do, and–

– You’re working full-time clinical.

– Oh yeah, well, and head of the research department. I started a whole new research division at the group in Scottish Rite in Children’s Healthcare of Atlanta, so I was busy, and at that point the kids are now like three, and five, and seven, so it’s still a very busy time, and my husband’s a physician, also, so we’ve got, we’re both pair of docs, but the final straw, I just had a two or three week anxiety crisis, which I never get. I’m pretty chill, and realized it was because I felt like I needed to do this, and make it happen, and I wasn’t doing it, and I am not a terribly metaphysical person, but I felt like I was avoiding the call. I felt like I was having a call to do this, and I didn’t wanna do it, and finally my husband and I talked about what will it take to get this through the regulations so that people can use it? And naively we’re like, you know, it’ll take maybe a year or two, and maybe it’ll take about $30,000, and I’d have to drop back on my work schedule, and so there’s the opportunity cost of what we’d lose, but how many people will have needle-phobia? We did a little risk-benefit of how many people have needle-phobia that probably die from their needle-phobia? How many lives will it save? It’s worth it. 10 years later, 15 years,had no idea. It was 2006, and if I had known it was gonna take, I’m now at 12 years, 13 years, and there’s no way I would have done it if I knew it was gonna be this obnoxious, but…

-I’m gonna stop you for a second, ’cause first of all, that story you just told, everybody listen up, because this is an archetype. This is a pattern that I see again and again and again with entrepreneurs, with people following what becomes a calling, and it sounds, like you said, it’s a metaphysical, weird thing, but I had the exact same experience in 2009 where I talked to somebody, and they kind of, are you happy doing what you’re doing? And I was a full-time hospitalist, I’m like, yeah, sure I’m happy. What do you mean by happy? Happy meaning like what? And then I started looking inwards, and going, you know, what would really make me happy is being who I am, which is educating people, using video, and song, and these kind of things I’ve always wanted to do, and I got floridly depressed like for three months, inconsolably, as depressed as I’ve ever been as an adult, just so much apathy and sadness because, I think it’s the same thing you said.

– [Amy] You realized there’s a dissonance.

– There’s a dissonance between what is and what you know deep in you is what needs to happen, and I think a lot of health care practitioners in this tribe, they message me, and they go, you know what I’ve always wanted to do is this, and this, and this, and I go, listen, here’s the thing: do it, hedge a bit at first, like you did. Yeah, I’ll cut down the time a little, there’s option recosting, ’cause in retrospect you’ll be like, I never should have done that, but there’s no way you wouldn’t have done it, because it is absolutely the path and the calling. Anyway, I just wanna put a point on it.

– There’s cool metaphor that Amanda Palmer gives in her book, The Art of Asking, and she talks about how this dog is sitting on a nail, and just whining piteously, and so somebody walks by, and the farmer’s standing right next to his dog. He sees the dog crying. The farmer’s not doing anything, and he looks askance. Next day is kind of angry at the farmer. Finally, third day, stops and says, “Why aren’t you getting him of the nail?” and the farmer says, “He can get off any time he wants to.” He said, “Well, why isn’t he?” and the farmer says, “Well, I guess it doesn’t hurt enough yet.”

– Oh, that’s it. That’s what it is.

– And so yes, it’s you’ve got these situations in your life, and when it hurts enough you’ll do something really big to move and get off of that nail.

– Now, the danger is if that thing that you do is self-harm, in other words the pain in your life is so bad that to get off that ride, you decide to get off that ride, and I think people feel powerless in those situations. That’s a whole ‘nother talk about depression and anxiety, but in this talk of finding your path, you did something very similar in that you said, okay, here’s clinical medicine, here’s all my interest, this has emerged from actually everything that is me, so you were always interested in pain, and in research, and in children, and in suffering, and now, out emerges this idea, and it’s how the hell do you build a prototype for this thing?

– Right?

– [ZDoggMD] What do you do?

– Well, prototypes are easy, because you just take apart cell phones, and you smash them, and you learn how to solder, and it’s pretty badass, not gonna lie,

– See, that’s pretty awesome.

– and you do, and then you buy the electrical tape, and you stick stuff together, so that’s really fun and easy. The hard thing is getting money, and learning how to make a real device, and also, I still, I think, my greatest self-value is my research intellect and my academic achievements, and so I would have lost something significant if I go out there with a device that doesn’t work, so the primary thing, the first step in deciding I was gonna do this was figuring out, how can I get money to research it, because I’m not gonna go forward until I have solid data and confidence intervals, and standard deviations on how it’s actually working and for whom, and just know and understand the physiology better. There is a program called the Small Business Innovative Research Grant, and you can form a company, and get grant money from the NIH. Turns out, it’s a Reagan-era program, 3% of what the National Institutes of Health, and the CDC, and the NSF give out every year has to be given to small businesses who are doing research and development on public health issues.

– Who knew? This is fascinating. Now everyone knows.

– Now everybody knows, so they, in fact, I just finished putting in my second fast-track grant for opioid reduction with external neuromodulation, midnight two nights ago, so I have been 14, 15 hours a day writing this grant, and putting this stuff in, but in 2006, I found out about this mechanism, and decided that’s what I need to do, so in order to get the research done I had to start a company, and once I started the company, after two or three tries got about a million dollars to do the R and D on the research, and that was not only money for learning about how to make molds, and how to build prototypes with, at the time we didn’t have 3-D printing. At the time it was called stereolithography, but super-expensive, $2,000 each for the original Buzzys, to print them so that we could do a study with them, and so that’s how I funded,

– [ZDoggMD] Wow.

– and how I got started on the entrepreneurial route. It was just so I could get somebody else to pay for my research.

– You know what? That’s smart.

– And kids listening at home, if it’s research worth doing, it’s worth having somebody else pay for it,

– 100%.

– so

– Never pay

– If you can’t get a grant,

– for your own research.

– you can’t get a grant, then it’s probably not a good enough idea to research.

– As we say in the business, don’t get high on your own supply.

– [Amy]I don’t know what you’re talking about.

– I don’t either, but I heard someone say that once, maybe Tom. Now I think people are gonna be really interested now, because we’ve teased them enough. What the hell is Buzzy? Show us the Buzzy. Tell us how it works. So this–

– Why, I happen to have one right here.

– And I gotta say, I use this on my kids. This ish works.

– All right, so this is what Buzzy is, and–

– Raise it up a little bit higher.

– Oh, I’m sorry.

– There you go, yeah.

– So,

– [ZDoggMD] Now it looks like

– On my tombstone,

– That Spanish character

– I’m gonna have–

– Who’s like, ay, ay, ay, mi estomago.

– This is how he sounds. Nice, yeah.

– Ah.

– The reason that Buzzy works is because the system in our body designed to take in sensation all, there you go, there you go, so our sensory system all comes together in the dorsal column of the spinal cord, and the most important sensations, or the most intense sensations, are transmitted through interneurons, and that goes straight up to the brain.

– Okay.

– So,

– I remember that

– it’s sort of a

– from med school.

– Right, well, and this is also something we never learned in medical school. I know now a lot of stuff that I didn’t learn in med school. One was how pain actually works, and the concept of pain being the physical, peripheral stuff that comes in, and then the central stuff that goes up, and then how it’s processed in the brain, so peripherally, you’ve got mechanoreceptors, which feel pressure, they feel tension, they feel vibration, they feel light and deep, so you’ve got two fast and two slow kinds, and you’ve got light and deep, and both of those, so when you are in pain, if you overcome that signal by, you bump your elbow and you rub it, so what you’re doing is you’re stimulating four different kinds of mechanoreceptors that then inhibit, in the spinal cord, the pain sensation, ’cause what’s going on here is much more interesting to the brain, so just that vibration goes up. If you burn your finger again, you stick it under cold water, the reason that that burn pain goes away is because the motion, the light touch motion of the Meissner corpuscles, and the cold that’s going through C fibers, that is much more stimulating than the pain, so the pain gets directly inhibited, and only that motion stuff goes up.

– You just go schooled, snitches. Meissner’s corpuscles, C fibers, dorsal–

– Pacinian corpuscles, too.

– [ZDoggMD] Pacinian corpuscles for the mechanical stuff.

– I have truthed you so hard you’re gonna fall over.

– I got served with science. I love that stuff so much. So keep going, keep going. Here’s your Buzzy.

– Thank you so much, so the common term for this is gate control, and Melzack and Wall, in 1965, published this inhibitory pathway demonstrating that you can inhibit pain if you overstimulate other sensations. The cool part about what Buzzy does is twofold. One is that we use extremely high-frequency vibration, so high-frequency vibration not only stimulates Pacinian corpuscles, but it also makes a wave that stimulates something called Ruffini corpuscles. I mean, all this stuff I actually just learned fairly recently, why this works so well, but the frequencies matter, and there are a number of studies that look at low-frequency stuff or low-amplitude stuff. It doesn’t work as well. You really have almost this 3-dimensional grid with vibration. It’s duration, it’s frequency, and it’s amplitude, and so you’ve got an X, Y, and Z coordinates, and so you’ve gotta have a stimulus that’s in the right spot for different kinds of pain.

– Right, so in other words it’s not just, it has to be a certain exact amplitude, and frequency, and positioning, and all that.

– To be optimal.

– To be optimal.

– I mean, you’re gonna get something by rubbing your elbow, so that’s probably about a 45 Hz, but–

– It’s ironic that they call it hertz,

– Oh,

– Because, see that,

– snap, what you did there,

– I gave you,

– what you did there.

– I just did that. That just happened. Keep going. That’s amazing.

– Vibration, by itself, has actually been studied with Buzzy just using vibration, and it does not significantly decrease needle pain for four to six-year-olds, I think, in that particular thing. When you add another stimulus, in this case ice, you do a couple of things. So, C fibers are part of gate control, and C does cold and pressure, so the ice is stimulating that, so you’re getting some synergy from two different inhibitory stimulus,

– That’s the business

– Stimuli.

– side of you talking, is the synergy.

– Synergy.

– That’s right.

– But the other really neat thing is that something really cold, when you feel it for a long time, your anterior cingulate gyrus is like, mm, I don’t like this feeling. It’s not dangerous, but I really don’t wanna hear this, and so it dampens down that signal. Pain’s on that same pathway, so by stimulating this descending inhibitory control, some people call it conditioned pain modulation, CPM, you’re decreasing pain by causing another stimulus that the brain says, this is not adding anything to my life. I’m gonna dampen it down. Kids don’t do that as much. You’re not born with this. It’s conditioned. Conditioned means you have to learn it, so this is why Buzzy actually works better for adults and older kids, because they’ve got that feedback loop of decreasing sensitivity to a noxious stimulus.

– Wow, so actually it’s decreased by association, so in other words those fibers in the anterior cingulate gyrus are the pain and the cold, they kind of come together. If you actually stimulate the other, the other one will decrease by association. Am I understanding that correct?

– Right, and I don’t think it’s necessarily by association. I think it’s just a pathway.

– [ZDoggMD] It’s a pathway.

– It’s just, so they go down to the dorsal horn and say, let’s inhibit the stimulus from here, ’cause we don’t really care about this so much right now, so that it’s that inhibition.

– Yeah, I wanted to make that connection just so I could bring it back to being alt-right adjacent, so this is pain-adjacent.

– Is it? Well, and this is what they call neuromodulation, so if you’ve seen things about neuromodulation, well, neuro is just brain and nerve, and modulation is just changing, so you’re just changing, so you can do an implanted electrical stimulator. You can do a TENS unit. You can do this pathway, and modulate the neurologic transmission lots of different ways. It’s not complicated.

– And that’s what these implantable units, like you said, the TENS units, and things like that, a lot of our fans actually have those units. They’ve talked about it. I have a lot of listeners with chronic pain, issues like that, and so–

– Take magnesium, all you people in chronic pain.

– [ZDoggMD] Take magnesium?

– Yeah.

– [ZDoggMD] Tell me about that, just real quick.

– I’ve gotten really interested in all of the non-pharmacologic mechanisms of reducing pain. Magnesium has four different anti-inflammatory and neuromodulatory abilities. One is it’s an NMDA blocker like ketamine or something, so when you take too much opioids, or when you take opioids at all, then, because it’s dampening your pain system, there’s something called the NMDA system that ramps up the amount of opioids you need to be able to get that same effect, so that’s why you take more and more, so you can do something, that NMDA, you can block that NMDA system. Ketamine is a classic NMDA blocker. You can block that system, and you don’t need as much opioids to get the same bang for your buck. Turns out magnesium is a really potent NMDA blocker that doesn’t have any of the side effects of ketamine. Two–

– [ZDoggMD] So you can go down the mag hole.

– People with chronic inflammatory diseases, almost all of them are magnesium deficient. 50% of the population in general is magnesium deficient, and magnesium is an anti-inflammatory, so people who had elevated CRPs with rheumatoid arthritis, they treat them with magnesium, their CRPs go down to normal levels. So 500 milligrams of mag citrate when I’m having chronic pain flares, that’s what I take. Try to take it every day.

– Does it keep you regular, too, ’cause the mag citrate?

– Not that kind. It’s a different formulation.

– What are the dietary sources of mag?

– I have no idea.

– I have no idea.

– Probably green leafy things. They’ve got everything good.

– It’s always.

– Right, it’s probably nuts and green leafy things.

– Yeah, so magnesium, as a–

– Just a supplement, but it also is, it’s a specific neuro anti-inflammatory. In fact, they noticed that the babies of moms who went into preterm labor who got mag were less likely to have neurodeficits and damage, so now they give mag IV to almost everybody, not as tocolysis to stop the process of–

– As an anti-neuroinflammatory.

– But it’s as a neuroprotectant.

– So they actually are doing that for that reason?

– Yeah, yeah, yeah.

– Wow.

– It’s like we’re siloed.

– Science.

– OB/GYN literature, it’s all over there, but it’s not in the pain, it is actually is in the pain literature.

– This is like a dorsal ganglion that sends out nerve roots everywhere around the country so you just make connections, man. No, actually this is amazing, so magnesium is a neuromodulator, anti-neuroinflammatory,

– [Amy] NMDA blocker.

– NMDA blocker, and then cold and mechanical stimulation, through the pathways you talked about–

– [Amy] Are external neuromodulations.

– External neuromodulation, so magnesium is a central, or is it also peripheral?

– I don’t even, well,

– We don’t know?

– I mean, I think the term neuromodulation really could be very

– It’s a wastebasket term.

– generically broad, yeah.

– It’s like Deepak Chopra would say, quantum neuromodulation from meditation. That’s right. It’s vat I do, buddy.

– But I think that magnesium is just a, anybody who’s got pain should give it a try. The interesting thing about the difference between Buzzy and TENS, first of all, when you add cold you’re adding a whole different set of pathways, because that whole feedback loop and descending thing is different from the peripheral blockade. TENS units, so let’s talk about TENS units.

– [ZDoggMD] What does that stand for, again?

– Transcutaneous electrical nerve stimulator, so you put little patches on, and then you crank some electricity through it, and it twitches the motion nerves, so you’re doing exactly the same thing as mechanical stimulation with the vibrator, it’s just that you’re doing it by electrically causing the muscles to twitch, and then that’s what stimulates the Pacinian and Meissner corpuscles that are the most important part of gate control. TENS units have a really mixed bag of research because a lot of people can’t tolerate the sensation of electricity that you need to get that twitch, ’cause if you don’t get the twitch, then it’s like Icy Hot or something, where you’re causing a sensation which is diluting the pain sensation, but it’s not actually doing inhibition because you’re not triggering the A-beta nerves.

– [ZDoggMD] You need both to have optimal, yeah.

– Well, optimal yeah, optimal you would do not just pain, but also cognitive, and also decrease the fear that ramps up pain, but from just a, are-you-gonna-use-a-TENS-unit-type thing, they’re more convenient because you can hide them, they’re silent, but you really have to, if you’ve tried TENS, and it’s not working, and you’ve got pain, you should try it again, but really crank up the pain relief, and–

– [ZDoggMD] The electricity.

– The electricity. Sorry, yeah, really crank up the electricity to make that work. The other thing is because it’s not a mechanical force, you don’t get the, it’s almost like one note. If you have a mechanical force, a massage or something, you almost have this symphony of A-beta stimulation because the mechanical stimulation creates waves so you do get stretch, so there’s a kind of corpuscle called Ruffini corpuscles that are related to 1a afferents, which is, well, it’s another, it’s a whole other panel of–

– Afferent, efferent, po-tay-to, po-tah-to.

– Let’s call the whole thing off.

– Let’s call the whole thing off. Keep going, though. I love this.

– I’ll quit geeking out on the physiology soon, but–

– By the way, it’s really exciting to watch you light up talking about this stuff. I’m sitting across the table from you, and you’re just like, and these afferents,

– Super goober.

– It’s like a glow comes off you. No, but see, that means that you’ve found your path, your calling. I see it happen. It’s an inner glow that comes, now I sound like Deepak Chopra.

– You do sound

– The quantum glow that happens when you have found your calling. No, but all joking aside, I think clearly you are passionate about it, you’ve studied it, you’ve actually actualized it, partially through Buzzy, but then you were also talking about adults, and yeah.

– Another nail-getting-off situation for me, getting off your nail–

– [ZDoggMD] It hurt enough that you got up.

– I hurt enough that I got off. Was 2015, one of my colleagues, and I’d been super-stressed at this point, ’cause I’m trying to run a company, and I’m trying to get somebody to buy the concept because I don’t wanna run a business my whole life. I want this to be something that other people take and run with, because everybody wants that who invents something. They’re all like, hey, I’ve got an idea. Just give me 50%. Nobody steals an idea. They steal a successful,

– Business, yeah.

– established product, but I had a lot of the kids who were using Buzzy over the years with juvenile arthritis, using it for their Humira shots and stuff. They were using it for their hip pain before they went to school. We had people who were using it for, I mean, IVF, obviously, so children were being born who wouldn’t have, ’cause these people were gonna quit taking the IVF shots, but the–

– [ZDoggMD] Because of needle fear, wow.

– Because of needle fear, oh yeah, I mean, we’ll talk more about the impacts of needle fear, but one of my colleagues had been in opioid recovery for 20 years. Now, my best friend in high school ODed, and I was really, I didn’t, I’ve been angry at her for 20-odd, 30 years, because it really, I still was feeling like it was a moral failing. I just was angry that she had let herself get to this point, and so one of my colleagues comes to me and says, “Hey, I’ve actually been in opioid recovery. “I’ve been clean for 20 years. “I have to get a knee replacement, “and I have put it off for two years now “because I don’t wanna take even tramadol. “I am afraid to do this. “Do you think Buzzy would help?” And so I was like, I don’t know, let’s collect some data, and I made little data sheets for him to record, and at the end of it he’s like, “I’m so sorry.” I said, ugh, didn’t work?

– He said, “No, no, no,” said, “It worked, “but it hurt so bad that I couldn’t do it without Buzzy, “and so I didn’t collect any data for you. “I used Buzzy constantly. “I didn’t take any opioids, “but you definitely have something there. “You need to make it so you can plug it in, “because I had to replace the batteries eight times, “but this totally worked.”

– So N of 1 trial there.

– N of 1 trial, but we’ve been hearing this from people for years, with the arthritis, and the hip pain, and the elbow pain, and so that was the penny that dropped, that said you need to make fewer pennies, and quit practicing, and just focus on this.

– [ZDoggMD] When was that?

– That was December 15th. Plus, plus, true stories, so I’m thinking about this, and really stressed about it, and trying to decide again, anxious about what I should do, and my husband, the psychiatrist, says, “Sweetie, maybe you should think about going on Wellbutrin “because then you won’t be so sad all the time, “and maybe it’ll help your ADHD, “and it doesn’t make you gain weight,” and I said, sweetie, maybe you should think about getting a job with benefits so I can quit.


– So, that’s our knock-down-drag-out, so we blinked at each other twice, which is our way of saying, dramatic emotion going on here, and I went to the hospital to do my procedural sedation shift, and he called me about an hour later and said, “Look, Obamacare’s out there. “We can afford this. “Give notice.”

– Wow, wow, so okay, so you quit. Tell me about this VibraCool thing that you’re doing. Did she just blow continuity, Tom? She’s now got glasses. She had no glasses before. Now she’s got glasses, okay.

– Your mind and your continuity are blown.

– For those who don’t know, we just took a pee break and came back.

– What do you mean we, paleface?

– We meaning I did, ’cause my bladder’s like a peanut, except a swollen peanut that hurts.

– I know you so much better after this talk.

– Really, doctors get to understand each other’s bladder dysfunction almost instantly. We left off with your quitting the job,

– [Amy] Marital discord

– Marital discord, the getting Obamacare so that you could then pursue the second dream, which is VibraCool. Tell me about this.

– We decided that it was worth me going full time with the company to address the opioid crisis by making something that was bigger, and using external neuromodulation for, particularly, post-op and people that were trying to avoid opioids at all, and the name VibraCool was not yet developed. After our five minutes of intense marital discord that then resolved, we sat around the kitchen table going, how can we not sound dirty and talk about vibration and cold, you know: FreezeVibe, or VibraFreeze, or–

– [ZDoggMD] Icy Hot.

– Rightthat’ll, oh no, that’ll never take off, and came up with the concept of the name VibraCool. We wanted to be a little more descriptive. Buzzy had a number of barriers to coming to market, in that nobody knew what Buzzy was, and people looked at it and said, oh yeah, for kids, and so we wanted to distance ourselves from that, and be a bit more explanatory in the name, and took what was essentially Buzzy to a physical therapy show. We tried for a little while calling it Buzzy For Aches And Injuries. People still went, oh, for kids, or oh yeah, that’s for needles, for kids, and took it to a physical therapy show, got a lot of great feedback on, make it bigger, make bigger ice packs, make it so it’ll fit bariatric populations,

– Got it.

– and so the engineering part of this was not terribly difficult. The interesting part, from an engineering standpoint, was that all of the ice packs, and all of the gel packs for heat that are out on the market are full of antifreeze, so they absorb vibration, so that doesn’t work well when you’re trying to deliver two different sensations to the same place, so I calculated the thermal energy that would cause frostbite, and limited the amount of gel, and so we just have ice packs that freeze solid, so they are completely confluent, and that way you get more direct cold, and from a recovery or rehabilitation standpoint, a lot of the research on ice, the biggest drawback is that it decreases blood flow. Well, guess what high-frequency vibration does? It vasodilates, so one of the interesting things we found with Buzzy is that blood flows faster, and that, particularly if you’re comparing it to something like cold spray, there’s a three-times-higher first-stick success because you put Buzzy on, and it’s probably endogenous nitric oxide, but it’s like patting the vein, and it pops up,

– Ah.

– so when you’re looking at–

– That’s why we don’t use ice to start IVs,

– Right, that’s why cold spray is a dumb idea for starting IVs, because you’re putting ice right on the vein where you’re about to–

– You’re vasoconstricting

– Precisely,

– when you’re squeezing that.

– Probably, that study where there was a three-times-higher success with Buzzy was because the standard of care in that hospital was cold spray, so it was probably starting from a deficit. A study at CHOP with Buzzy found equivalent IV success, and one by Whelan, et al, found that 61% of phlebotomists said it made it easier. Nobody said it made it more difficult, but nobody else has reproduced that finding of easier blood draws with Buzzy. Many people have commented on faster blood flow, but you can see when you put it on, you see that the veins pop up, so from VibraCool’s standpoint, for recovery and for pain relief, the nice thing is you can still use ice and have vasodilation, so you get better blood flow, so it sort of cancels out the side effects, but the more important part as I began learning about opioid use is that we are, maybe it’s like a hierarchical society. We’re used to one solution. We’re used to this Y-chromosome-oriented this is gonna work better than this,

– How dare you?

– and I’m gonna use this, and what actually works for pain is that you have to address both the cognitive parts of it, and the impact of it, and the fear, and the physical pain itself, so the construct that I had used with Buzzy was teaching people you need pain, fear, and focus. Do something to address pain, whether it’s EMLA, whether it’s Buzzy, whether it’s injected lidocaine, whether it’s J-Tip, whatevs. Do something for pain, but do something for their fear, and then also, at the moment of the procedure, do something to decrease their focus on what’s happening, so take care of pain, take care of fear, and then, at the moment, take care of focus. When you have chronic pain, how do you take care of focus over the long term? That gets hard. The part that is very relevant to adult pain and opioid use is something called catastrophizing, and catastrophizing is a feeling. It’s very associated with depression, helplessness, hopelessness. This pain is stopping me from being who I am. This pain is stopping me from doing what I wanna do. I’m never gonna feel better. Opioids, and drugs in general, enhance these feelings of catastrophizing, because you take a pill because you’re scared that you’re always gonna hurt this much, and you can’t handle it. Well, because of the whole way that pharmacokinetics work, that pill is gonna wear off. The pain relief’s gonna wear off before you’re actually able to take another one, so you’ve got this period of time where, if you’re susceptible, then you have an increased anxiety, and a feeling of need for that pill because just due to simple pharmacokinetics, you’re not getting the pain effect, and you can’t take another one yet, and then you get scared. A really important thing, that Bob Tillman, who’s the head of the Integrated Pain Society, taught me was nothing does better than about 30% efficacy. They pass a drug with the FDA if your number needed to treat is such that 30% of people will get better with the drug, and so, consequently, we’re using a lot of medicines like gabapentin, even like opioids, where they’re only gonna work for about 30% of the people, and what we need is not this linear mentality of it’s this or this. We really need to look at this more in a comprehensive mentality of let’s layer, so mathematically, you got one thing that’s 30%, and you add another 30% thing, well, now your pain’s down to 50%, 52, and then there’s another one, and so now it’s down to 67% reduction. If you keep layering, then it not only reduces catastrophizing, because you don’t have this interim of, oh crap, I can’t take the pill. You feel like, oh, it’s starting to hurt again. I think I’m gonna get an ice pack. I think I’m gonna get a roller. I think I’m going to go do something to distract myself and watch a television show, but that layering is a very comprehensive approach.

– So it’s a yes-and approach, adding on different synergistic modalities to control pain, including the supratentorial, as we say, and we say that in a very dismissive way. We’re conditioned, a lot of times, well, that’s supratentorial, meaning it’s all in your head, above the tentorium. I say it in a very scientific way, which is there is the central perception of pain that is a component of, like you said, the anxiety, the fear, the catastrophizing. It’s interesting that you mention catastrophizing, ’cause we’ve been talking about it quite a bit on the show recently, as one of the cognitive distortions that has been plaguing people who suffer from depression, and that cognitive behavioral therapy and other modalities address, but also that it is one of the cognitive distortions that is being encouraged now in youth culture on college campuses and elsewhere, so in other words, they’re a series of distortions like everybody’s all good or all bad, dichotomous thinking, overgeneralizing, mind reading. I know you’re a bad person. I know what you’re thinking, and then going on social media and pounding on people for stuff, and this is a very human thing, but it’s a cognitive distortion that we’re encouraging on campuses when we create a culture of safe spaces and trigger warnings.

– Well, any kind of tribalism is artificial dichotomies.

– Any tribalism. Dichotomous thinking. In catastrophizing–

– I think the artificial dichotomies is really important, because I think that it is so much simpler, and it saves a lot of mental energy, and it’s probably adaptive to think about things as binary, and so this artificial dichotomy, I like the phrase of putting them together, because it reminds you inherently that

– It’s a construct.

– there are no true

– That’s right,

– yes, it’s a construct.

– It’s a construct.

– They’re not true dichotomies; it’s artificial.

– That’s exactly right, and actually we have a tribal switch in our brain, and we have an individual switch, and sometimes that tribal switch can help us. At a big sports game or something it’s great to have, or after 9/11 the tribal switch in the U.S. went on for better or for worse, where people were very united. It lasted about a second, but it did go on, but then the tribalism can be an in-group-out-group problem. Back to pain, I think catastrophizing is interesting because the perception of the significance of pain and our control around it seems to be such an important modulator of its perceived intensity and effect on our lives. I have this just terrible trigger-point-induced musculoskeletal neck pain that triggers tension-type migraines, that has been triggered over the last couple of months. I forget what I did, but it triggered it. Now, if I sit around thinking about it, and I go, you know, maybe I actually injured my cervical spine, and I have arthritis, and this is gonna be my new normal, and I’m never gonna get better, and what if I can’t do the show because I can’t, and then the pain gets worse, and then I get depressed. Whereas, if I just go, yeah, you know what? I’ll take something. I’ll watch my posture. It’s probably okay. Even if it’s forever, it’s okay. I’ll learn to live with it. It modifies everything.

– You can cut this part out because I don’t wanna be too commercial, but this works really well for occipital neuralgia. You look like a dork, but when you put it on like that you’re vibrating and having ice on the place where you’re spasming that’s causing the thing. My gift to you.

– You think I’m cutting that out. I’m going, that is staying in, because first of all, I got free shit now, which is key. Ah, dude, I’m totally gonna, so, well–

– Well, you do need to freeze it first.

– Well, so yeah, you gotta freeze it, ’cause it felt a little warm. I’m like, this actually makes me feel, so–

– But this, there’s a part that you just said about this is my new normal, and I think that this is part of why Americans take 90% of the world’s opiates. It’s because we don’t deal well with death or decrepitude. We deal much more, much more poorly? We deal worse than other countries because we don’t respect the aging population as much, so when you’re aging, you gave me compliments for looking young. We do value the youth look more, disproportionate to other cultures, and so this idea of this pain is something I’m going to have to get used to for the rest of my life means that the pain changes our identity, and it doesn’t do that in other countries, because what you’re capable of doing in other countries is not as important as who you are, and many other cultures deal better with death than we do, so I think that part of where our opioid addiction comes from was that we were an addiction waiting to happen. We have such a self-image that depends on our capacity to do, that we can’t tolerate doing things at less of a degree for the rest of our lives.

– I am 100,000% with you on this, and we’ve talked about this on the show as well, this idea that we have this cultural expectation of ourselves. It’s particularly in America, where this big city on the hill that is a beacon of innovation and all of this, but it comes at a heavy, heavy price, and the Europeans, people will say, well, they’re just a bunch of communists sitting around, and what have they done lately? Uh, they were happy, generally. They have, again, the way they treat their elders, the way they consider supporting each other on a social side, whereas here we kind of medicalize our social problems. Over there it’s totally the opposite.

– We were in Prague over Christmas, and they were astounded at how many medications we took. They’re like, Americans take so many medications, and I feel like, as doctors, we don’t tend to take that many medications, but ibuprofen, totally on that, inhaler for asthma ’cause of all their dogs, totally on that. Claritin to avoid having to take the albuterol for all their dogs, so I realized my kids, who are not very medicated, between all of us, we probably took five or six different medicines while we were there, and the whole time, none of them took any.

– Nothing.

– It was really, so it’s–

– It’s ’cause they’re drunk all the time.

– You understand that, right? Tell me, so this is effectively the Buzzy’s approach on a larger scale, aimed at both children and adults, right?

– Mm-hmm.

– You were saying the JRA kids with the hip pain.

– Right, right.

– Yeah, and it works on the same principle, so it vibrates, and it’s cool, and it doesn’t cause vasoconstriction because of the vibratory aspect.

– That probably causes some vasoconstriction, I’d have to imagine, but it causes less, and I don’t have any kind of quantification on that, but we do know that vibration and high frequencies vasodilates,

– Right, right,

– so you got that.

– so there’s a balance there, and so how is it, you’re studying it now, or how’s it work?

– They’re studying it for ACL repair, well, and here’s a frustration. There are now 28 randomized controlled trials on Buzzy. There is a meta-analysis in progress. It’s being done by Ballard, et al, in Canada.

– You have enough trials that you can do a meta-analysis.

– And I’m not doing them. I haven’t done any of this. I’ve done two studies, but because of conflict of interest it’s gotten frustratingly hard to publish, and it’s not worth it, because it’s so effective. It’s got an 80% of, or an effect size of 0.7 to 0.8, which means that you don’t have to have that many patients to do a Buzzy study, so every fellow, tons of nurses in Turkey, in particular, have done research on this, phenomenally good research. Italy, there’s a bunch of different studies on it, and then Deb Potts and Joel Fein did a study at CHOP that was the biggest one to date in the emergency department. Found it was equivalent to ELA-Max, but you got your IV in three minutes instead of 40, ’cause duh, you’re not waiting for the ELA-Max to work.

– Right, right, right, so it’s faster, so throughput, RVUs, production.

– I don’t have to do any of these studies, because it’s low-hanging fruit, and other people are doing them. What is frustrating to me is the A delta nerve that Buzzy blocks is the same nerve that you get for post-operative pain, or for injury pain, or for any other kind of pain. It’s not like the body has, it’s not like you have a stomach for ice cream and a stomach for your regular food, like my kids say, it’s all the same stomach. You don’t have a nerve for needle pain, and a nerve for bee sting pain, or a nerve for laceration pain. It’s the same nerve, so we’ve got all of this data that other people have done, that’s got a meta-analysis coming, and I’m trying to get physicians to realize, when they’re prescribing pain management, or PAIRS, or Centers for Medicaid and Medicare to go, look, it’s the same nerve. There’s all this data that it blocks pain, and you’ve got all of this data in TENS units that are using the same A beta that work when it’s really intense and cranked up. This is all the same physiology, so the extrapolation should be easy, and left as an exercise for the student, but it doesn’t work like that, so they’re doing a study on ACL repair and VibraCool at Emory right now, and I just put in, like I said, I just put in this massive grant, looking at, not pain as an outcome, but opioid reduction for low back pain using a vibration, cold, and acupressure device that I’m making, so…

– That’s awesome.

– It’s just very logical, and it’s multi-modal, and the cool thing is if you’ve got multiple different modes, so the back pain one is like our new VibraCool Flex. It’s got hot or cold. You can’t use them simultaneously, but some days you need heat, and some days you need cold, and with chronic pain you get better having options that you know you can try, ’cause it reduces catastrophizing, because it builds empowerment.

– The hope is that the endpoint of this is better pain control, less suffering, and maybe less opioid use, so lower area under the curve. Not getting rid of it, but lower area.

– Right, and hoping that through the concept of multi-modal pain relief, whether it’s external neuromodulation, whether it’s magnesium, whether it’s butterbur for migraines, whether it’s acceptance and commitment therapy, whether it’s this whole litany of different options, once you’ve accepted that some days vibration and heat feels good, and some days vibration and cold feels good, and you get a couple of extra hours of relief the more you do it, then you feel empowered to try other things, so my goal would be that people don’t look at this as a single solution, because there are no single solutions. It’s contextual.

– Ah, you brought it back to that feminine XX contextualizing. Why? Why do you do it? I don’t understand that.

– Well, what if we put an extra X? Will that make it more interesting to you?

– Triple X? Ah, the things I’ll do for my country. No, I think that is spot on. Now, here’s a question–

– Oh, why is the coffee always gone?

– Because there wasn’t enough, because it’s an espresso, and it makes like this much, but you were just in Prague, where it’s like just thick mud-water, right, the coffee. It’s very–

– You can eat it with a fork.

– [ZDoggMD] Eat it with a fork.

– But you’ll wanna use a spoon to get every delicious drop.

– Let me ask you a provocative question. Are you getting rich off this stuff?

– No.

– No?

– Well, I refuse to make it disposable, so that’s the thing. We have had many offers of investment, and people who’ve been interested if I make it disposable.

– [ZDoggMD] Why is that an advantage for them?

– Well, oh, that’s how you make–

– Yeah, ’cause you buy

– Here’s,

– a billion of them.

– here’s, so this is what I’ve learned. Here’s why we have such a bias toward pharma in the medical profession. When you get a drug approved, or a medical device approved, you have to have studies that prove that it’s safe and effective, you have to file the FDA’s 510k–

– 510k.

– Exactly, so you’ve gotta go through all of this work. Once you get a drug that works, it costs pennies to make more of that drug, and people are on that drug the rest of their lives, and you can sell it for $1,000. Once you make a device that works, they break. You still have the same costs, whether you’re making, I mean, you can get some economies of scale, but if it costs you $10 to make the Buzzy now, maybe it’s gonna cost me six when I’m doing a whole bunch of them. You don’t save that much money, and people expect that the device is gonna last forever. Whereas pharma, they’re making it for pennies and people are taking it all the time. The other part that is biasing our system toward pharma and away from non-pharmacologic is that you’re up on what you’re up on. In medical school, you are learning statistics on pharma studies, which are beautifully done, and very well-powered, and very well-written, because they have a lot of money to do really good science. There isn’t a magnesium lobby. There aren’t people out there looking at vibrating rollers for cancer pain. There is one study on it, actually. Vibrating rollers helps mastectomy lymphadenopathy afterwards, but my point is, we’re both trained on how to look at pharma studies. That’s our baseline, and we are comfortable with it, and they have more money to do really good studies, and so it biases us to not dig into research that people aren’t feeding us.

– So, making it disposable, you could crank the profit margin, you could be more like a–

– Sorry, yeah, I got on a soapbox,

– No, no, no, but see– but right, so if you got something disposable, then there’s a reason for the distributors to bother, ’cause if I want a medical device distributor to take this to a place, they have sold one for between 39 and $69, and that’s gonna last for a couple years, at least, and so they’re not selling any more, so there’s no reason for a drug rep to do that unless you’ve got a disposable aspect, and you throw these away all the time, but I have kids who are taking insulin, they’re doing their CGMs, they’re doing growth hormone, they’re doing Humira, they’re doing Enbrel, they’re doing all these things over and over every week, and it’s just crappy to intentionally make it disposable when I know perfectly well I can make it work and be reusable.

– And here we get at the moral injury that comes from trying to make money relieving others’ suffering.

– I am morally injured.

– [ZDoggMD] You are morally injured.

– I am annoyed, but I’m really happy doing what I’m doing, and at the end of your life, you don’t get any pleasure from how much you’ve amassed and accumulated. You get a lot of pleasure from having left legacy, and already on my tombstone there will be a barfing face, and there will be a bee, and so long as my kids’ college is taken care of, which they’re in Georgia, and there’s a really good scholarship program, at this point that’s not as big a deal.

– You are basically expressing, I think, what so many physicians feel about this kind of stuff, and you talk about doing well financially by doing good for patients, and you can do okay financially and still do good for patients, and still be able to sleep at night, and feel like you’ve made a dent in the universe, and the reason we did this is not to make money. I mean, let’s be honest. There are so many easier ways to make money than going into medicine. We do fine. We’re very privileged, but we care deeply about human beings, and I think when I talk about moral injury, and Wendy Dean and Simon Talbot’s idea of that, you think about stuff like this, because what will happen is, like Offit, if he makes the norovirus vaccine he’ll be accused of being a shill for saving hundreds of thousands of lives.

– Here’s a little digression. When I was 12 years old I wrote my hero science fiction author and asked if he would adopt me.

– Who was that?

– Robert A. Heinlein. He wrote Stranger in a Strange Land and, not my favorite, but Citizen of the Galaxy, and Have Space Suit-Will Travel, and they said yes. So they adopted me, and over the years it became real. These are actually their, what they used as their wedding rings. They’re his Annapolis miniatures, and they left all of their money to a prize to promote commercial space flight. They didn’t have any children, so when Grandma Heinlein died I was acting as the youngest next of kin. I mean, it was a very real relationship, and so I went through all the end-of-life planning, and that’s how I know that how much money you die with doesn’t make your quality of life any better. What made her life better was knowing when she endowed the chair of space engineering and space aeronautics at Annapolis, knowing there was gonna be that knowledge, the Heinlein Trust, which does the commercial space flight prize, knowing that she had endowed that, so what my husband and I’s perspective has been is, what is the lever that we need to build to be able to pick a fulcrum and lift humanity? I think that the fulcrum is suffering, and building the fulcrum is, building the lever is what’s most important right now. I’m not saying I don’t want money, because I do wanna build a fulcrum. I do wanna have something that can really leverage, just like the Heinleins did to leverage commercial space flight by giving a prize, I do wanna change the way we deal with pain and suffering, and I want to have money that I can use for that kind of philanthropy, but that’s not the end goal. It’s the means to an end of doing something that’s really big, so I had a fantastic role model, and I’m really fortunate to realize that being at the end of your life with a bunch of money and zeros in the bank is zero satisfaction, and I got that lesson in my mid-to-late 20s, and not everybody gets that gift. That was a tremendous gift to be able to give me the perspective that I have on, is it worth not practicing medicine and taking a monster pay cut to do this? Yeah, ’cause we’re comfortable. We’re really happy. We’re good, and you’re not gonna build a lever to put on an important fulcrum if you don’t change things up a little bit.

– I think I’m hard-pressed to outdo that as a closing statement for the show. I think that was beautiful. I think I’m in agreement. It came to me later in life, in my 30s, late 30s when I had that epiphany. I stopped chasing things and started chasing purpose and meaning, and I think you have highlighted for our listeners here a true path of purpose and meaning, and you’ve taught us about pain. You’ve taught us about ways we might look multi-modally at pain control, looking at even everything as subtle as gender differences, to the long-term effects of needle phobia on the broader suffering of human beings, ’cause it’s more than just the pain at the time. It’s the avoidance of care later on, and I would actually argue that some, a good percentage of the anti-vaccine movement is founded in a conditioned, unconscious fear of this, of health care people, and it’s not inappropriate. It’s an adaptive response, but it’s become maladaptive in our world, where these things are so important, so Dr. Amy Baxter, named after my fake email assistant, it has been a real honor to have you on the show.

– I could swap plasma arcs of verbiage and ideas back and forth with you all day long. This was really, really great, Zubin. Thank you.

– I love it. Really a pleasure. Take care, and we out.