In this episode:

Ivermectin, the latest Twitter absurdities, vacation without COVID, Will Smith, why medical conferences SUCK, NYC’s toddler mask policy, why so many academics leave for pharma, that 4th dose, and more!

Please subscribe on your favorite podcast platform and leave a review 🙏

Transcript:

– [Zubin] Hey, everybody, welcome back to the VPZD Show. We’re episode 15 now, VP, aren’t we though? Aren’t we, are we?

– [Vinay] 15, we’ve been going strong for a few months now.

– [Zubin] We’ve strongly been going. And I’m Dr. Zubin Damania, one of your co-hosts, a UCSF Stanford trained hospitals’ physician, and host of “The ZDoggMD Show,” and this is Dr. Vinay Prasad, who is a, what? UCSF Associate Professor of Medicine?

– [Vinay] Of epidemiology and biostatistics, it turns out, yeah.

– [Zubin] Ooh!

– [Zubin] And that makes you completely unqualified to talk about-

– [Vinay] Totally. Only a professor of epidemiology and biostatistics and a hem-onc doctor here at San Francisco General Hospital.

– [Zubin] So insufficient.

– [Vinay] And we are the co-hosts of this news show, medical news show.

– [Zubin] Yes.

– [Vinay] That’s primarily what we do. We deliver the hard hitting news, very little editorializing, mostly news and facts.

– [Zubin] 100% facts, exactly.

– [Vinay] Well, you know, to be fair, the news is no longer news anymore.

– [Zubin] That’s true.

– [Vinay] It’s all just two different versions of propaganda, so you have to choose.

– [Zubin] That’s exactly right, whereas we are a fax machine.

– [Vinay] We are a fax machine.

– [Zubin] We put out nothing but fax.

– [Vinay] At least we’re in the middle, you know?

– [Zubin] Yeah.

– [Vinay] These days, I can tell you what “The New York Times” is gonna say. I’m gonna tell you what “Fox News” is gonna say, you know. I know what they’re gonna say.

– [Zubin] You know automatically.

– [Vinay] You might not know what we’re gonna say. At least, there’s a surprise.

– [Zubin] Yeah, that’s true. And the thing is, people will say, “Oh, you’re not in the middle. You’re always on the contrarian side.” But I don’t think that’s true, actually.

– [Vinay] Of course not.

– [Zubin] If we were on the contrarian side, we’d be telling you not to get vaccinated.

– [Vinay] We’d be big into ivermectin and Vitamin D.

– [Zubin] Oh!

– [Vinay] And we’re not, we’re not. We’re not into that.

– This is good. Ivermectin, actually, we should touch on that before we get started.

– [Vinay] A large randomized controlled trial in “The New England Journal,” negative.

– [Zubin] Yeah, and it’s starting to look like things are not gonna bode well for the reputations of the physicians who’ve been pushing this as a cure-all and accusing other physicians of being incompetent for not pushing it as a cure-all when the data comes out and continues to come out.

– [Vinay] Let me say, so a total of 3,515 patients were randomly assigned to receive ivermectin, placebo or another intervention. 100 patients in the ivermectin group had a primary outcome event compared with 111. So, 15% v. 16%, and that’s sort of not statistically significant. I guess, I don’t know, I’ve heard people make up their usual things. They didn’t give it early enough, and you know, they didn’t give it with a cupcake, and they didn’t give it on a Wednesday, and you know, all these things.

– [Zubin] The goal post.

– [Vinay] But at the end of the day, yeah, the goal. I mean, at the end of the day, I think the reason, the core issue people don’t see is that biomedical interventions mostly don’t work. If you think they do work, you have to prove under what circumstances they work. You can’t ask me to show you that Santa Claus doesn’t exist. You have to prove to me that Santa Claus does exist. Find him and show his face. I can’t show you he doesn’t exist. And I can’t prove to you ivermectin will never work under any circumstances. That’s impossible. You need to prove under what circumstances it does work. So yes, did this trial do it one way? Sure. But if you believe it works on day whatever, zero, you need to run your randomized control trial and show it works. And it needs to be large, not some small study. It needs to have good data collection, not dubious data collection. It needs to be run in multi centers. You need to do that work. And the same is true for the masking toddler zealots. They need to do the work, too. They haven’t done it either, you know? It’s just one is the extreme left position, one is the extreme right position, but they’re both the same kind of core problem.

– [Zubin] And they would both say, “But nobody’s funding these studies, because pharma.” How do you respond to that?

– [Vinay] I mean, I guess I would say to be honest, there’s many more ivermectin studies than toddler masking studies.

– [Zubin] That’s for sure.

– [Vinay] No one’s funding the toddler masking studies, so we can’t…” But at least… But I mean, I guess I would say that the burden is on the people who wish to impose these things on others and wish to make recommendations, to prove their recommendations work, that the burden is not on the skeptics or the critics. And with toddler masking, I have faulted them so much. They have failed. They’re a failure. All the people who pushed for it, the AAP and CDC, they’re failures for not running that cluster randomized trial. And I’m happy to call them a failure to their face. They failed the human race during the pandemic by recommending something without generating evidence. And similarly, the people who recommend fistfuls of whatever supplements and minerals you think you’re missing, you’re failing, too. I mean, you can run those studies. To be honest, there’s more funding for that than there is on the other end of it.

– [Zubin] That’s for sure. I mean, honestly, it sounds to me like you’re in the pocket of big diaper. I’m pretty sure Pampers… Who’s paying you, Vinay, Pampers? ‘Cause it sounds like you’re really against putting cloth diapers on kids’ faces with no evidence. By the way, my daughter, my 10-year-old still has to wear a mask in her elementary school because they brought it back.

– [Vinay] Oh, Jesus, they’re still doing that?

– [Zubin] Because, you know, BA.2, BA.2.

– [Vinay] I saw some district brought it back because of gastroenteritis. Did you see this?

– [Zubin] That’s great! This is a new precedent. Anytime someone gets the sharts, like anytime a kid sharts in class, they have to wear a mask on their face.

– [Vinay] First of all, I don’t know what it has to do with gastroenteritis, but I mean, do you bring it back if there’s a drought? If the drought goes on long enough, do you bring it back? I mean, .

– [Zubin] Yeah, dude.

– [Vinay] Is it a panacea?

– [Zubin] The threshold, yeah.

– [Vinay] What I wanna say is that what I’m pointing at is, there’s a principle thing to say here. Here’s the principle thing. The principle thing is, if you think you can improve upon the state of nature, you need to prove it. The burden is on the person who believes in it to prove it to other people. And that’s true for masking toddlers, and it’s true for ivermectin. The burden is not on the third party to disprove it to you. And I’m a principled person, so that’s why I’m gonna hit them on, you know… And it just so happens to be one is the devout view of the left and one is the devout view of the right, or Covidian and Covidiot tribes, those kinds of things. But that’s just a coincidence, but they both are susceptible to the same sort of cognitive error, which is the pretest probability that these things work is very, very low. So, the burden is actually substantive and the burden is on you.

– [Zubin] Yeah, and I like what you said about, if you think you can improve on nature, because that’s the gold standard. Can you beat what the natural process is? I mean, this pandemic has unwound in a way that I think I would, if when we look at it with the retrospect-a-scope, we’re probably gonna think, “Ah, you know what? Nature did its thing and we had a very small impact. Until maybe vaccines came, we had a very small impact on the natural history of this thing beyond like maybe drawing it out or whatever. And I think it’s on us to prove that we did have an impact. It’s the same thing.

– [Vinay] It’s like, if you think about the human body, it has been evolutionarily conserved for hundreds of millions of years, billions of years, depending on how far back you wanna go. In other words, all of your ancestors did one thing right, which was they were able to procreate and have the next generation. So, there’s a huge selection pressure over long periods of time. And that’s true in health. That’s why the body works so marvelously well. It’s also true in illness. When we get sick, we generally do recover from most of the things that get us sick. Of course, there are all sorts of ailments that are so bad that you wouldn’t naturally recover. And medicine is about figuring out ways in which you can improve upon the body. But it’s very difficult to improve upon the body. And if somebody comes to you and says, “Oh, there’s this enzyme in the body, and if we just tweak it a little bit with this drug, you’re gonna be better off and heal better,” I think your initial response should be skepticism, because if that were really the case, it might have been selected for over so many hundreds of millions of years. And so I think that’s also born out in empirical data, that most of the things we try do not work in 50 years of drug development. Most of the promising things didn’t work. A few of those things did work. And how do you separate those two? You need data.

– [Zubin] You need data, that’s the bottom line. As far as being evolutionarily conserved, that’s why I as a male have nipples, because they’re so fucking useful. There’s no way I could have reproduced and had kids without male nipples. And you know what’s funny, actually, one last thing on this point before we move on to a Twitter thing that you saw. But today after this thing, I’ve gotta go teach a class, lecture to a class at Stanford on digital health. I was asked to do this by some folks at Stanford. And so I’m excited, because it’s gonna be a group of 40 hardcore-like enthusiasts in the medical school and business school. And I almost wanna tell them, so here’s the thing with digital health, it’s horseshit. Until you show me a single piece of data that a wearable device or some kind of monitoring system or something actually improves outcomes above and beyond tincture of time and our standard of care that we currently have, which is probably garbage, I don’t even know why we’re talking about it. I don’t know why we’re investing in it. I don’t know why we’re doing it. I would love to see the money go into actually studying, do these things actually work? Does having a Google Nest camera in your house listening for a particular type of wheeze, and then alerting your doctor that you have an asthma exacerbation, does that actually improve outcomes? You know, stuff like that. It’s fine to mentally masturbate over it, but without the data that it actually helps, all you’re doing is wasting money and time and diverting resources.

– [Vinay] And I would say that my guess would be, it’s not gonna work. And you might wanna call me a skeptic, but what you should call me is a realist and a pragmatist and someone who’s accurate, because they don’t work. There’s a recent study in “The New England Journal” I think this week about whether or not sending people with COVID with a home pulse oximeter improved outcome. The answer is it didn’t, sorry, those pulse ox they told you to buy. And I remember in 2020, they were like, “If you get COVID, stay at home and keep checking your pulse ox, and if it starts to drop, go to the hospital.” Well, it turns that’s no better than just seeing how you feel. And if you feel like you can handle it and stay at home versus you feel like you need to go in, that’s just as good as-

– [Zubin] Why am I not surprised at all? In fact, how many unnecessary ER visits happened because the thing glitched and said 88, and the person had a panic attack and showed up? It really is we do harm with these things, too. That’s the other problem. It’s not just money and wasted resources. There’s harm done. There’s iatrogenesis done every single day in the hospital. It’s the most dangerous place on earth, right? That RaDonda Vaught case, I keep telling people, I’m like, “If you wanna live, stay out of the hospital, as much as you can.” Anyway, so something happened on Twitter though.

– [Vinay] Oh, I saw this funny thing, and I was about to say something, but then I realized I was gonna go on vacation, and I was like, “I don’t wanna ruin my vacation.” Actually a few days before vacation, you don’t wanna say anything. You don’t wanna ruin it.

– [Zubin] It’s true, I made that mistake. Before I went on a meditation retreat, I put something out that created all this controversy. And I was like, “Oh-“

– [Vinay] I remember. I remember.

– [Zubin] I know. Yeah, you may have been involved in that. And I felt so bad when I came back and I looked and I was like, “No, what has happened?”

– [Vinay] And it’s like, you missed 2 million messages.

– [Zubin] Exactly. And 900,000 of them are furious angry and the rest are ambivalent angry.

– [Vinay] It started out positive and then it took a little turn.

– [Zubin] Yeah, it’s just standard.

– [Vinay] People have nothing better to do, nothing better to do.

– [Zubin] They really don’t.

– [Vinay] So, here’s what I saw. I don’t know if I should name the university, but it’s a university’s account. And they say, and I guess I shouldn’t actually quote it, I should just give you a paraphrase so no one can find it. But basically, some family donated a ton of money, and the amount of money is let’s say between 10 and $20 million, okay, to this cancer center. And it says, “Thank you for this family for donating all this money to this cancer center, we’re able to do all this great work.” And it has a photo. And in the photo from right to left, there are doctors in white coats, there’s the podium in the middle, and there are the members of the family who donated the money. In the background is the logo of the family name and the cancer center. That’s in the background and they’re on stage, and they’re in a hospital, in an atrium it looks like to me. And all of the doctors on the stage are wearing the mask and the family members are not wearing a mask. So it just shows you that for 10 to $20 million, you don’t have to follow the hospital’s masking policy.

– [Zubin] Money talks and masks walk, man. That’s an incredible story, and it’s not unusual. Like when the politicians, the one not wearing the mask in the elementary school and that sort of thing. So, actually, and that prompted my memory of this little Twitter thing that popped up. I don’t look at Twitter, but it was popped out. Someone pointed it out to me. Did you hear about this medical student who went on-

– [Vinay] Yeah.

– [Zubin] Yeah, you heard about it. Can we talk about it? Are you okay talking about it?

– [Vinay] I’m okay, I mean, yeah, I saw it. It’s something like the patient made a comment about the badge and this person said, “So it took a few extra blood draws.”

– [Zubin] That’s right, that’s right.

– [Vinay] Implying that they subjected them to payback.

– [Zubin] That’s right.

– [Vinay] Oh, yeah, you give the summary.

– [Zubin] Okay, this is the story and this is my take. So it’s a female medical student. She’s doing clinical stuff. She wears a badge that says, “These are my pronouns.” And her name is pretty typically a female name. So this patient, who’s probably one of our typical patients, asked the nurse and says, “Why is that person wearing a badge that says what her pronouns are when it’s pretty obvious what her gender is?” And I guess she overheard this or something, and so she was supposed to do a blood draw. So on Twitter, she says, “So this happened. And so it just so happened, I had to stick him a second time to get the blood.” Now we all know as a medical student, you’re gonna stick him a second time no matter what. I don’t think she intentionally-

– [Vinay] ‘Cause you’re not good at it.

– [Zubin] ‘Cause you’re not good at it. I don’t think she intentionally stuck him a second time. I think she was pointing out on Twitter, “Ooh, look, he got what he deserved for making fun of my pronoun, badge. It just so happened that I had to stick him twice.” Now there’s so much right and wrong with this. I mean, it’s beyond… Again, it just points out to the stupidity of Twitter and even being on there at all, if you’re a medical student. What the hell are you doing on there?

– [Vinay] So this person got suspended or something. There’s some punishment.

– [Zubin] Oh, so yeah, so that’s the thing. So outrage on Twitter, and then it was basically said, the medical schools basically said, “Okay, she no longer is going near patients,” which I don’t understand. As a medical student, that’s a equivalent to saying you’re not a medical student anymore, right? So, I don’t know what ended up happening, but I know that another… So she deleted her account. Another medical student basically said, defended her and said, “Look, you know, she wasn’t saying she stuck him intentionally. She’s just saying, ‘Hey, that’s karma.'” She had to delete her account for saying that, because like, what do you mean, karma? So, this is one of those great examples of why we should just, if you’re a medical student and you’re out there virtue signaling on Twitter, spouting off, you probably should just spend more time studying or forgetting about it, because it’s gonna lead to no good. The pronoun thing, I don’t care about it. The truth is if she wants to wear a badge and it makes her trans and LGBTQ patients feel better, that’s fine, there’s nothing wrong with that, right? The patient also can make fun of her if she wants. That’s fine, too. It’s just don’t go to Twitter and make a big shit show out of it, you know?

– [Vinay] So that’s one level of this really amazing point you’re making, which I think is that… And I do wonder, some people on these websites, I’m like, “What are you doing it for?” I recently saw the chairperson at some university who barely tweets and this person said something that got him in a heap of trouble, and I was like, when you’re a more senior faculty member, not familiar with the dynamics of these new websites, and also you’re very established in your career, and your career isn’t really the public communication of science or anything like that, why are you going outta your way? You can only get yourself in trouble. You’re not gonna have something zinger. You’re not gonna have some very interesting point. So, why is this old person on there? And similarly, I think, early in your career, yeah, you just don’t have the job protection yet. You haven’t really gone through all the training yet, Yes, you can contribute, but you also run a risk of getting yourself in trouble. And so, I’m not saying do it or don’t do it. I’m just saying you gotta be extra careful.

– [Zubin] A good rule of thumb might be, if you’re a young medical student, use Twitter as an inbound. Use it to learn as much as you can from your newsfeed and watch the madness. Again, because the cancel culture’s on both sides, right? Normally you think of cancel culture on the left. Now this side I was the right canceler.

– [Vinay] Well, it’s interesting because I think there’s a dynamic shift where, you know, I guess she probably has some supporters as well who thinks the way it was, you know. But there are also obviously other people who think that, you know, that… But here’s the point. So, I think it’s probably pitting two different cultures against, it’s pitting two different… It’s a culture clash. But here’s the thing I wanna say. There needs to be some, I don’t know what it is. We need to learn in medicine that… Or we need to teach perhaps better, you are inevitably gonna take care of people who you don’t agree with on all sociopolitical issues, okay? You have to treat them with dignity and you have to, I don’t know how to put it, take it easy with all the issues you believe in. I mean, no two people agree on every sociopolitical issue. Even you and I don’t agree on probably every single sociopolitical issue. We have a huge overlap. We’re friends, but we don’t agree on everything. Somebody who was born in a different background, different socioeconomic status, different part of the country, coming from a different region of the country, different time, different background, grew up in different circumstances, is older than you, different generation, you’re not gonna agree on everything. Back when I was training, the less you knew about other people’s full set of beliefs, the better, because you just focus on what you’re taking care of them for, what their values and preferences are. You don’t need to know everything. But I will tell you one story. Many years ago I was rounding, and this was during the heated 2016 election, Clinton verse Trump. And I’m in Oregon, and in Oregon, Portland of course is probably extremely liberal, so it’s like divided between Bernie and Hillary. But of course you throw a stone outside of the city limits and you’re in Trump/Pence country. That’s the nature of the place. And we were rounding and we passed somebody who was in the wheelchair and had a big Trump/Pence bumper sticker on the back of the wheelchair, right on the wheelchair. And we were talking to this person, This is one of our patients, but we run bumped into this person sort of just outside. And I was with the trainee, and then the trainee, and then this person said something about I think the election. And then the trainee started arguing with this person about the election. Obviously, the trainee is a Clinton supporter and obviously this guy is a Trump/Pence supporter.

– [Zubin] Oh my gosh.

– [Vinay] Yeah, and I was like just as quiet as I usually am, and I’m like, oh my god. I was like, “It’s okay.” I was trying to close the conversation, like, “Oh, well, we’ll see you later. Come over here, let me take you by…” I was like, “Come over here, let’s go.” I’m like, “What are you doing?” I wanted to say, “What are you doing? You don’t need to get into it. Yes, you don’t. Of course, he’s voting for someone that you’re not voting for. That’s okay. That’s not why he’s here. It’s not our goal to persuade him. We’re not campaigning for her, you know?

– [Zubin] Wow. [Vinay] Am I a Trump/Pence fan? No, okay, but is it my job in the world to talk about it every time? No, leave it alone, leave it alone.”

– [Zubin] It’s almost like they took social media and brought it into the real world. It’s like the guy was posting and she was disliking and arguing. And yet, it’s in the real world and she’s taking care of him.

– [Vinay] Correct, and that’s such a power imbalance.

– [Zubin] It really is a power imbalance. And you gotta imagine like, forget it. What’s funny now is it’s crazy, it took me many years, but now I don’t care what your politics are. Support whoever you want. It’s not gonna change my opinion. I’m not gonna get triggered. None of that’s gonna happen, because I just know everybody has different moral palates.

– [Vinay] Well, you know, my friend, Adam Cifu, you love this story?

– [Zubin] No!

– [Vinay] All right, so Adam Cifu, I co-wrote a book with him, “Ending Medical Reversal.” He’s a professor at University of Chicago. He’s literally the nicest human being. I mean, he’s won 25 teaching awards in a row. He’s in the teaching emeritus hall of fame. Students love him. He’s got a very sweet voice. He’s like, “Hey, how are you doing?” He’s got a really good voice. You instantly open up to him. He teaches you all this evidence-based medicine. He’s a consummate clinician. He’s just a great guy in the classic sense of the word, just a great human being. And he was asked I think by the medical residency program to put on a little fun debate for the residents, and he would be debating another faculty. And the debate was really interesting. The proposition of the debate was, do doctors have a duty to be political advocates?

– [Zubin] Ooh.

– [Vinay] Not, are you allowed to be a political advocate? Of course, they had all conceded that you’re allowed to advocate for whatever you want. But the question was, do you have a duty to be an advocate? And the other doctor debated the side, like, yes, we have a duty because to the extent socioeconomics drives health, and to the extent that we are the people who are pushing for better health, we have a moral duty to advocate for political positions that improve socioeconomic status of people. And Adam’s point was, well, he was tasked with arguing the other side, by the way. He’s not like he’s choosing. He’s literally asked as a debater to argue the other side, like a criminal defendant lawyer. And his task is to say that we don’t have a duty. You can do it if you want, it’s great. There are important causes. But to go so far as to say you have a duty to do it, that might interfere with at times the doctor/patient relationship, where sometimes you need to be neutral or not talk about these things. Right.

– [Zubin] Yeah.

– [Vinay] That’s his stance. Then he did the debate and it went well, ’cause it was in person and, like I said, he’s a charming guy. Then he did on Twitter some of his slides. And he was like, “Oh, here’s kind of my side of the debate. People might be interested.” Oh, and he got a pile on like nothing I…

– [Zubin] Oh my gosh.

– [Vinay] And they’re like, people were like, “Look at this white man doctor.”

– [Zubin] Oh, there it is.

– [Vinay] Right? It went to his race and gender, and it was about who he was. And I hate to say it, although I’m sure that some of these things are motivated or that there’s sort of a component of who’s the speaker. In his case, I mean, he’s just an earnest guy who’s just trying to do his debate. And I don’t know, his thesis isn’t even that strong. It’s a soft thesis. You don’t have a duty to do it. Is that so wrong? What are you talking about?

– [Zubin] Man, I think what you saw was how Twitter reduces complex, nuanced, in-person debates and arguments that are done in good faith to garbage, to trash.

– [Vinay] To garbage.

– [Zubin] Yeah, and that’s it. That’s the takeaway from that whole thing. Forget even the premise of the point. It’s like, here’s a good faith debate that was well received at the time on all sides and reduced to this gender-biased, power differential garbage. Yeah, I hate it, I hate it.

– [Vinay] Here’s the worst thing. I can tell you that, and I hope he doesn’t mind me saying, but my impression he is that he was really wounded by that.

– [Zubin] Yeah, of course he was.

– [Vinay] You and I have thicker skin ’cause we get-

– [Zubin] Barely though, I get pissed, too. I get really pissed.

– [Vinay] I try to.

– [Zubin] Yours is thick.

– [Vinay] I’ll tell you why that in a second, but I try to forget about it. But he’s a guy who really is earnest and really does always I think try to do the right thing, and he’s also somebody who likes to talk about ideas, which God forbid, there’s a few people left who like to talk about ideas, God forbid. He’s a guy who’s actually willing to change his mind if somebody came and wrote back to the thread, like, “Dr. Cifu, I appreciate this. But here’s why I think we do have a duty.” Like, whatever. I think he’s open to change his mind.

– [Zubin] Oh, totally, yeah.

– But I don’t think he’s used to just having a lot of people pile on and be really, I think, very hard and unfair. Because he’s not arguing this because he’s a white man. He’s arguing this because he was asked to argue this. And it’s not on the face of it an indefensible proposition. It’s an intriguing soft thesis. It’s a soft thesis, and so it warrants some reflection, and there’s some kernels of truth to that, which is like sometimes you do, you know, do I walk into a patient’s room and say, “What do you think about Vladimir Putin?” And if they don’t say the right answer, I’m not allowed to treat him? Is this what we’re doing in medicine? How many issues do I have to be an advocate for? Or, “What do you think about recycling? What do you think about Tesla? What do you think about Elon? Should Elon be spending all that fossil fuel and going to the Mars, should he?” What’s the right answer? What do I know about it? And then this is like a litmus test, and then here’s the treatment for you if you disagree. Like what is this? But now I think he’s self-censoring. There are lots of things he won’t talk about, and now we’re all losers for that, because now a smart guy is self-censoring and other people are self-censoring. Now I don’t think anyone on earth will ever touch that topic on Twitter.

– [Zubin] And once again, I will point to the central cause of all this, Twitter.

– [Vinay] It really is a poison.

– [Zubin] It’s just a poisonous place, but it’s also fun. It’s also fun to watch. But boy, I tell you, man, it is… It’s funny that it can be so much of our show talking about the crazy shit that goes on on Twitter because it’s that kind of a place, and it does… The thing is, it’d be one thing if it was just an imaginary space, like an imaginary number. It’s not, it has real world effects. The news reports on that shit. It’s really depressing, which-

– [Vinay] That’s what gets me. Ashish Jha, the only reason he is the COVID czar is-

– [Zubin] Is Twitter.

– [Vinay] Twitter, yeah, he tweets a lot. And then they always like, “According to three independent experts I found.” I was like, “Those are just the people tweeting! What the hell are you talking, independent experts?” And I was like, and by the way, how lazy have you gotten, reporters, that you just wanna, “Let’s open Twitter and see what somebody says?”

– [Zubin] Oh, man.

– [Vinay] And then sometimes the report is just a screenshot of the tweet.

– [Zubin] Yeah, I’ve seen that many times. It’s like, damn, dude, and you can even click in, click in so you can get sucked into that garbage. Which is great because we had a vacation last week. It was spring break for the kids, man, which was-

– [Vinay] Good transition.

– [Zubin] Oh, you see how I do those things? So here’s a funny thing. I’ve not been wanting to go and do public speaking anymore, just because I’m starting to feel like I’m enjoying virtual better in that sense, because I’m comfortable in my space and I can improv and it’s not contrived and it’s very authentic. But this week I went and I said, “Okay, these guys want me to come to Vegas to do a talk, and they’re a great group of people.” And I said, “My family, we have friends still and family still in Vegas, so we can all make it a trip.” So, we went for like four or five days, and this is what we found. We got on the flight. We’re having to wear masks. Everybody’s doing the usual Bay Area outdoor N95. And then the minute we land in Vegas, it’s like, it is insane. There’s like 5% of people are wearing masks, and they’re usually in the appropriate risk groups. They’re older people, et cetera, you can just tell, or they’re obese. They’re doing the right thing for them. They’re wearing a high grade mask and everybody else isn’t. It’s wall-to-wall people. We went and saw “O” at Cirque du Soleil. It was packed theater, nobody’s wearing a mask. We went to this exhibit, which is amazing, by Meow Wolf called “Omega Mart,” which I highly recommend. I won’t tell you anything about it. It’s just worth going. You have to go. And you can spend two hours wandering this warehouse of crazy shit, and nobody’s wearing masks. And it’s like COVID barely existed. And it was great. It was fantastic. And I’ll tell you that the hospitals there aren’t filling up, nobody’s dying in the streets. And so, again, the contrast between the Bay Area and there was remarkable. It was massively awesome. And then we came back and it was right back into it. But even the kids were like, “So this is how people are living outside of where we live?” It’s like, “Yes, yes, dear, this is how they’re living.” And they couldn’t believe it. So again, I think so much of this is cultural and political, and science, I’m not sure.

– [Vinay] The moment you get out of some of these urban liberal strongholds, it’s like Mardi Gras, it’s like 2019. You almost need like a field trip for some of these people to get them out, just so both sides can see the other side.

– [Zubin] Yeah, exactly.

– [Vinay] Show them what San Francisco outdoor, N95 looks like, and vice versa. Sort of an emergent therapy. But yeah, it’s amazing, it’s amazing. And at the same time, places like New York City still have… The mayor is fighting in the courts for the two to four-year-old mask mandate, because all the other rules are gone. They’ve dropped mask mandates on everyone. They’ve dropped vaccine passports. Even Kyrie can play, he can play now.

– [Zubin] Yeah, he can play now.

– [Vinay] But these toddlers, they’re not allowed. They’re not allowed to show their face, ridiculous. I listened to an interview with Mayor Adams. By the way, I saw him on Bill Maher a few months ago I thought he was like a legitimately smart politician.

– [Zubin] Right, right.

– [Vinay] He seemed charismatic. He seemed like he was a Democrat, but also centrist, so he could kind of hold us together and win an election. So I thought like, “Oh, he’s decent.” But now I see him acting like the stupidest person on earth. Are you stupid? Does anyone think that a two… I mean, even the people who think we should mask don’t think only the toddlers should mask. I mean, even they don’t think only the toddlers! I mean, this is the dumbest thing I’ve heard. Your advisors have to be the most incompetent people on planet Earth if your policy is only the toddlers mask, no one else masks. That’s the stupidest policy I’ve ever heard. And he should have some common sense to know that not only is that the dumbest thing he’s ever heard, politically you think it’s gonna help you to be known as the guy who only masked the toddlers? Are you outta your mind? Why do you want that to be you? They’re gonna hang that over you for the rest of your political career. Who is gonna vote for a guy who only masked toddlers in the pandemic? It’s a sign of… Yeah, go ahead.

– [Zubin] He’s in the pocket of big diaper, dude. Because these are cloth masks. It’s not like these are high grade. You can’t put an N95 on a toddler.

– [Vinay] There’s not even a such a thing, because it has to be validated and no one can…

– [Zubin] That’s right.

– [Vinay] You have to create a certain amount of compliance. I mean, I don’t even know where to start, obviously.

– [Zubin] It’s madness.

– [Vinay] The World Health Organization thinks it’s stupid to even try to do it. But to only do it to only like… It’s like if you a straining pasta and you decided to plug up one of the holes, I mean, even if you believe it works. But it’s more like not plugging any holes. What is he thinking? He lost the court battle, and then he’s like litigating it, and they won some appeal, and it’s like in the courts. And I’m like, “Why are you fighting this in court?”

– [Zubin] You know what? There must be a contingent of parents who are pressuring him. There’s no other explanation. Like really fucking anxious parents who don’t know science at all and are pressuring him. I mean, I can’t think of another reason a politician who’s reasonably intelligent would do that.

– [Vinay] Yeah, I mean, I agree with you that that’s probably it, but as you know, that in both political parties, there is a fraction of people who are totally crazy.

– [Zubin] Yes, a fraction.

– [Vinay] A fraction.

– [Zubin] Maybe a large fraction.

– Maybe a large fraction, but there’s a fraction. Okay, and the job of a good politician is to hide your crazy.

– [Zubin] Yes, yes.

– [Vinay] You need them to vote, so maybe you don’t wanna ostracize them.

– [Zubin] Especially in primaries, yeah.

– [Vinay] You need them to vote, but you don’t want to be seen as if you are only catering to that view. And I don’t understand why. There’s so many other sort of empty gestures he could do to kind of make those people feel better. I don’t know, it’s stupid.

– [Zubin] It’s like Will Smith level stupid, like, you know, go and ruin, go and ruin. By the way, how did you feel when you saw that? I’m curious.

– [Vinay] This is what people been waiting for, my opinion.

– [Zubin] Exactly, this is basically “TMZ News” right here.

– [Vinay] Well, I would just say that my opinion is very close to Bill Maher. He had a whole monologue on it. And I mean, the gist of his point of view is that, you know, you can’t resort to violence, obviously. You certainly can’t resort to violence against a comedian doing their job, making a very mild joke about your wife, okay. And then worst of all though, I think Bill Maher’s point that I thought was really excellent, was that he stayed, he won, and he got a standing ovation showing that the people in the audience are so unprincipled.

– [Zubin] Are awful people.

– [Vinay] They’re such shitty people, yeah. They don’t even have standards.

– [Zubin] Celebrities are garbage fucking people, period, period. They are.

– [Vinay] That’s true.

– [Zubin] Why do we care what they think? Why do we care what they do? Because they look good, fine. Look at them then, don’t listen to them, because they’re garbage people to do that. I was like, here’s a comedian who you oughta be protecting his free speech right to say whatever the fuck. He could have made a nasty joke about her and should never have been hit, come on.

– [Vinay] I mean, he’s a comedian doing it. I mean, that’s the whole job. You gotta go there and razz all the big players in the audience.

– [Zubin] Imagine if it was Ricky Gervais. He would have been murdered, murdered by Will Smith. Will Smith would have stabbed him to death. ‘Cause, I’m mean, Ricky does not pull punches. And you know what’s…

– [Vinay] Well, but-

– [Zubin] Yeah, go ahead.

– [Vinay] Go on. ‘Cause let’s be honest. Did you actually watch the Oscars live? [Zubin] I didn’t watch it live. I watched all the replay stuff, yeah.

– [Vinay] Yeah, I didn’t watch it live, the Oscars-

– [Zubin] Who watches the Oscars?

– [Vinay] Well, that’s another point Bill Maher makes and I think he’s really right about, which is that when in 1999 when “American Beauty” won, I remember the Oscars was the thing to watch.

– [Zubin] It was the thing, yeah.

– [Vinay] And now I’ve never heard of any of these films.

– [Zubin] Nope, haven’t heard of a single one.

– [Vinay] I never know any of them. I never know what the film is, I don’t know what it’s about, I never even watch it later.

– [Zubin] That’s right.

– [Vinay] I don’t know what happened, I’m not interested.

– [Zubin] It’s all mental masturbation for the celebrity set and like old people, that’s it. My mom’s like, “Didn’t you see the Oscars live?” I’m like, “I’m not 80. Why would I watch anything live?” Maher actually did say something a little bit interesting that I thought was vaguely worth talking about, which he said, “Listen, if alopecia is your big struggle in life, like, that’s pretty good. You could have cancer, you have leukemia, you could have all kinds of terrible chronic disease.” But the thing is then I think people who were defending Jada Pinkett Smith and Will Smith were saying, “For a celebrity and also a black woman, alopecia is more common. It is like a really big deal and she’s been public about it. So, she didn’t deserve to be made fun of. And here’s a black man defending a black woman, which you never see.” And so that was an interesting dynamic of that. That’s all fine and dandy and I see that perspective, but slapping a dude on stage because he made a joke about your wife, there’s no excuse really.

– [Vinay] You can’t, you can’t. I thought that they had a rule that you can’t hit people. Isn’t that assault and battery?

– [Zubin] Isn’t that just preschool, what they teach you in preschool? But it did tell you, too, that I think the pandemic has made us insane. It’s allowed this kind of like weird isolation to our emotions build up. We repress them and then they emerge in these very dysfunctional ways. We see it on airplanes. We see it on the street in traffic. Americans are apparently crashing their cars at higher rates than pre-pandemic because it’s full of road rage and distraction and madness. And we gotta count that cost when we think about the cost of what we’ve done during the pandemic. Again, has it influenced the course of nature that much?

– [Vinay] I opened Twitter the day later and then it’s like all the doctors I follow who are like experts in molecular biology are like, “My thoughts on Will Smith.” I’m like, Jesus. And then it’s like the same people talking about, they talk about COVID, Ukraine, Will Smith. I’m like, god, I’m sick of this. It’s just useless.

– [Zubin] Just useless. Of course, here we are talking about all those things. but yeah.

– [Vinay] Well.

– [Zubin] But that’s us, we’re better than them, Vinay.

– [Vinay] No, but I guess naturally came to it, but.

– [Zubin] Yes, well, we’re just two people having a conversation, okay? They’re shouting into the void. They’re like, “Look at me and care about my opinions.” Whereas we’re like, “Hey, Vinay, I’m actually curious what you think about Will Smith.”

– [Vinay] I don’t even know how we got on the topic, but.

– [Zubin] Yeah, it was me.

– [Vinay] I blame you.

– [Zubin] So, V, now you had mentioned this idea of masking and you said there was these doctors, like these doctors who go to conferences, like the ones that I saw at this conference, nobody’s wearing a mask. But the same doctors go home and they’re like, “We gotta throw masks on our kids.” What’s going on with that?

– [Vinay] Yeah, this is the one thing that I keep seeing. I see like this Mayor Adams, he’s like, “We gotta get these toddlers in the masks.” And then like the next tweet is like, “Hey, all the pulmonary critical care doctors are here at the conference!” In the aisle standing there.

– Maskless.

– Unmasked, maskless, and they’re like partying and like doing, you know. And then there’s like, it’s not even the regular conferences. Now they’re back to the pharma conferences and all these things.

– [Zubin] They’re all back.

– [Vinay] I was like, what? I mean, what are we supposed to tell… What is the message? Are we having a… There’s such a crisis going on now with COVID, the hospitals are full, things are so bad that desperate times call for desperate measures, and even though we don’t have any randomized data and it doesn’t make a lick of sense, we just gotta mask these toddlers. Okay, is that where we are? Or are we in the, hey, it’s Mardi Gras time for doctors. Okay, which one is it? Which one is it? It can’t be both. How can you have the frontline healthcare providers unmasked and partying in convention halls, flying everywhere, traveling, and then they gotta make sure we mask these toddlers. This is like the stupidest thing. I mean, it’s like a juxtaposition.

– [Zubin] Well, I will tell you what they will say. They will say, “Because we’re quadruple vaccinated and the toddlers can’t be, and we’re protecting our most vulnerable.”

– [Vinay] Yeah, but that’s wrong in every way. So, I mean, you could argue that because we are vaccinated, we are at lower risk of bad outcomes. But the truth is a four-year-old who’s unvaccinated is at lower risk of bad outcomes than even a triple vaccinated 60-year-old doctor. So they’re at lower risk of bad outcomes. That’s one. Two, I think you could say, well, we’re vaccinated, so we’re less likely to spread it. Oh, well, sorry about that. Once you get more than a few months outta your booster, your vaccine is not doing much to slow the spread. The third thing you might say is that, well, our conference is more important than their daycare. And the answer to that is, I’m sorry to tell you, your superfluous, industry-sponsored shindig conference is less important than a child’s early life education. Whatever you wanna say, there is no way to justify it. I mean, you could be consistent in one way. You could say, “I’m going to the conference. And by the way, don’t put the mask on those toddlers.” But you can’t say, “Put the mask on the toddlers and I’m going to the conference.” You’re hypocrite, and you’re the worst kind of hypocrite because you’re a disgusting hypocrite that prioritizes adult interests over kids’ interests.

– [Zubin] Okay, and you said something, these conferences are industry-sponsored shit shows of garbage.

– [Vinay] They’re shit shows of garbage.

– [Zubin] They’re shit shows. Even the ones I speak at, I’m like I look at the list of sponsors who are paying my salary by proxy as the speaker, and I’m like, “I feel so fucking dirty even just looking at this list of people that I would never directly take money from.” And it feels terrible. It’s another reason I’m not doing it after… I’ve committed to a couple more and I’m out, dude. It fucking sucks.

– [Vinay] Let me tell you, the oncology ones, my god. Their whole purpose is like all the drug companies come, they buy out the center hall, the carpet is like eight inches thick. You twist your ankle on this carpet, my friend. You’d break your ankle on that carpet, it’s so plush. And then they’re giving out cappuccinos. And these doctors who are making like six figures, you should watch the glee that they line up for free cappuccinos.

– [Zubin] For free shit, yeah.

– [Vinay] Yeah, and I’m like, what? “You make so much money, dude.” I was like, “You’re minting money. You need a free cappuccino so bad, you wanna wait 45 minutes?” And he’s like, “But they put a digital photo of your face on the top in foam.” I’m like, “Dude, just… I was like, “Get outta here, come on.” He’s like, “But it’s got my picture of myself in foam.” I’m like, oh my god, this is the kinda shit they’re doing. And then they go to the meetings and they’re like, “Oh, we got a new drug.” Oh, how does it work? “Oh, you know, it kinda works like in the cell. Anyway, listen, the drug is great. It’s just gonna shrink tumors up.” And then you’re like, “Oh, how did you choose patients for your study?” “You know what? We don’t have time for questions. We got patients in this study, the tumors shrunk. It’s a miracle game-changer, revolution cure. Okay, that’s it, yeah, we’re done.” These conferences are such shit. They don’t give you any methods. You can’t even do a video like, oh, here are the downsides of the study, because you don’t know anything to know what are the downsides of the study. I swear to God, I think the only purpose of these conferences is to seed the propaganda. If the first time I mentioned to you like, “Hey, Z, I’m selling this new pill. It’s called WX12.” And you’ll be like, “Oh, what is WX12? I don’t know. Should I take WX? What are the side effects? How much does it cost? What do you not know about it?” Right, those are your questions. But imagine you go to four years of conferences in a row and in year one, I’m like, “WX12 shrinks tumors in mice. No questions.” Year two, WX12 worked really well in this trial. No questions.” So you keep hearing WX12. By the time it comes around year four and five, you’re really kind of acclimated to it, you’re comfortable with it. I’ve shown you some cappuccino with your face in it. You think it’s sexy. WX12 is sexy now. Yeah, maybe you wanna prescribe it. Maybe you got fewer questions for me. And I think that’s why they do it. The whole existence of the conference is to seed and to get people to uptake these products.

– [Zubin] It’s a psychological manipulation, like anchor pricing, you know?

– [Vinay] Yeah.

– It’s like we were looking at the sushi place in Vegas and they charge $350 per head for omakase sushi, the fancy experience where the chef is right there from Japan. And he hands you like a live squirming shrimp. and he’s like, Hi!” And my wife and I were like, “Well, this sounds like an experience that we were really can’t afford, but let’s call and see if they even have reservations just to see what what’s involved.” So we call and they go, “Oh, so do you want the $350 omakase or the $500 omakase?” And we’re like, “Wait, there’s a $500 one?” They’re like, “Oh, yeah, it’s like super crazy. Like, there’s all kinds of stuff.” And then you go, “Well, god, that 350 omakase is not sounding so expensive anymore. Maybe we’ll sign up for that.” And so it’s this idea of anchor pricing. And it’s the same thing that you’re seeing at these conferences. It’s this desensitization.

– That’s also why if you walk into a Costco, they have all the diamond rings upfront, the laptops, and be like, “Get ready to spend, buddy.” And then you’re like, “Oh, everything else is so cheap! It’s practically free!”

– [Zubin] Gosh. I can get a 20-pack of brownies for like five bucks compared to a $2,000-

– [Vinay] Forget about the fact, can you eat that many brownies before it goes stale?

– [Zubin] Or before your kids get tired of it? Like the kids are like, “Oh, I had the sample and that shit was so good. Daddy, buy me the 27,000 pack of it.” And like five into it, they’re like, “Yeah, I don’t like this anymore.” It’s like, goddamn it, the novelty has worn off. Yeah, Costco nails that whole thing. But you know that Costco’s stakes aren’t high. like, I don’t know, cancer treatment. So maybe we oughta really look at that. But yeah, yeah, now-

– [Vinay] These conferences are all trash.

– [Zubin] Yeah, agree.

– [Vinay] I can’t tell you the time I went to a conference and I learned anything of value. And then the other thing is like, oh, my friend, he’s an expert in a certain one tumor type. I’m like, “Oh, don’t you need to go to the conference to keep up?” And he says, “If I go to that conference and anybody says anything I don’t already know, I’m not good at my job.”

– [Zubin] Yeah, yeah.

– [Vinay] I’m like, “Oh shit.” And then people are like, “Oh, it’s great for networking.” I’m like, “Yeah, I mean, it’s fun.” It’s fun for networking. Is it great for networking? I don’t know. I’ve always been a skeptic that people’s career trajectories are much different by glad-handing and networking, because I don’t think no amount of glad-handing can overcompensate for not having talent or having talent or vice versa. But you meet people and you go to drinks and have fun. All that said though, I think we have to acknowledge that, whatever, early childhood development is massively orders of magnitude more important than these conferences.

– [Zubin] Man. I’ve been wanting to take a shit on these fucking conferences since I was born, basically. Can I tell you a secret? In my entire practicing medical career as a hospitalist, I never attended a single conference. They looked like a waste of time. They were full of boring fucking people. The speakers were god-awful terrible. The whole thing was poisoned by pharma and by medical devices and by insurance sponsors and everybody. The whole thing looked like one raging conflict of interest. Then I go and I build a clinic and I learn about Health 3.0, and I think I wanna evangelize this to the world. Where do I get to do it? Who’s the only people who are willing to pay me to do that? Conferences. I then spent the rest of the time building my own platform so I would never have to rely on anyone to speak truth again. And now I’m finally at that point, and, Vinay, it’s still so hard to say no when someone says, “Oh, we’ll pay you this much money to come and talk to our audience about this.” And then you go there and you regret it instantly when you just even look at the fucking list of sponsors. And you’re like, “I feel dirty just even standing here.” And it’s not like the people in those companies are bad people. It’s just the whole structure of it is garbage. And even saying this right now-

– [Vinay] I wouldn’t know, because I don’t get those invitations.

– [Zubin] Oh man, we should do a trading places thing where you’re me for a couple months and you go and do these things. ‘Cause I mean, all these people are such racists. They’ll just think those two brown people look the same. [Vinay] Of course we could. It was like, if I could use your ID in college, I was sure I could buy. If we trade places, within one day, you will be like me on email, not being able to respond to all those emails they’re sending me.

– [Zubin] It’s true, it’s true, it’s exactly true.

– [Vinay] What did I wanna say about this conference thing? You were talking about how lousy they are and shitty they are, and it’s so true. Oh, I had an idea for it. Okay, I’ve gone to so many of these conferences, and sometimes you go to like an oral session. It’s like Friday afternoon. This conference is always like Thursday, Friday, Saturday, Sunday, the ones I go to, like four days.

– [Zubin] Right.

– [Vinay] Bonanzas. And then Sunday is like the key day. Then they also have a Monday or Tuesday, but that’s for like the dregs, like people who didn’t, you know, that’s like you really feel bad if you’re assigned to the Tuesday slot .

– [Zubin] Right, workshops, yeah.

– [Vinay] Workshops, yeah. So like Sundays is the big day, the plenary, like the big posters, the big stuff. I’ve walked in on Saturday afternoon, I go into some talk and it’s like, oh, it’s like the best of lymphoma or whatever. And I go into this talk. and you never know what you’re gonna get. You could get a great dynamic speaker, really interesting information. Or you could get talks so bad that you just wanna die.

– [Zubin] Stab your eyes.

– [Vinay] Oh my god, like you get bored even looking at your phone, that’s how bad it is. Why is this person jibber-jabbering in the background? I gotta look at my phone. I can’t even look at my phone in peace. It can be really painful. And then I thought to myself, “Well, why is this the case?” And this is because they’re picking the abstracts based on a 200 written word submission and not somebody’s slides and delivery and all those things that make a good talk. And then I was like here’s my idea. It’s like the NCAA tournament. It’s a conference. Thursday, everyone comes and everyone is assigned an oral speaking slot for 10 minutes. You get to present your work for 10 minutes. And you present it in hundreds of small rooms. And everyone in the room can vote on who are the best talks, and only one advances to the next round, Fridays, okay? Then Friday, round two, you present again. And then Saturday you present again. And then Sunday, it’s just the people who win the four rounds, like March madness. And the plenary is like the 10 best talks or whatever. And I think it would be great, ’cause you are guaranteed you go in on Sunday, every talk has cleared three hurdles, and it’s probably gonna be really good and more people get to see what’s really good.

– [Zubin] Dude, it’s “Oncology’s Got Talent.” That’s what it is. You have to keep progressing and you got these… Oh, that’s actually, boy. The only downside is you could imagine some bias being inserted, like the most entertaining presentation that may not be factually very correct. So, it depends on who you-

– [Vinay] Somebody said it penalizes people who have great science but bad delivery.

– [Zubin] Right.

– [Vinay] And I’m like, I mean, sympathetic to that, but if you have great science and bad delivery, then you should publish papers. But if you’re giving an oral talk, it is about the whole package. And then the other thing is, I mean, hopefully the audience is not so foolish that they can be bamboozled by a silver tongue.

– [Zubin] Right, right. Right, I mean, these are technically audiences of their peers, you know. It’s not like, you know-

– [Vinay] Presumably.

– [Zubin] Presumably. So what’s up with this woman who got fired in New York City, man?

– [Vinay] Oh, so it’s related to that… This is a woman who works in like the law department in New York City, and she confronted Eric Adams and said like, “Hey, you said you were gonna drop the masks in toddlers, but you got it on.” And then like that day, like later that day or the next day, she got fired.

– [Zubin] Ooh.

– [Vinay] She’s also a lawyer who’s supposed to defend in court the New York City’s whatever stupid policy. And she tweeted that, “I’ve defended a lot of criminals in my life, but I really feel bad trying to defend this stupid policy.”

– [Zubin] Ooh.

– [Vinay] And somebody was like, “Oh, well, see, you’re not allowed to do that if you’re a lawyer.” I’m like, I think you are allowed to do that. You’re allowed to say… She didn’t say, “I’m not gonna defend it.” She didn’t say, “I’m not gonna do my job.” She just said, “This is the stupidest thing I’ve ever had to defend.” Which is saying something.

– [Zubin] Yeah.

– [Vinay] Which is saying something.

– [Zubin] That’s saying something, especially in New York.

– [Vinay] And it is true, it is pretty stupid. I don’t know, this whole, everyone, you know, it’s the usual.

– [Zubin] Yeah.

– [Vinay] Take away their job. Somebody does, like, I don’t know, in a job you do like 100,000 things, but then one tweet, “Take away the whole job.” Nobody looks at the totality of the evidence.

– [Zubin] Again, I will say Twitter, Twitter.

– [Vinay] Twitter, in this case, you know, she did push him face-to-face.

– [Zubin] Oh, yeah, that’s true, so it’s a little different. Now, speaking of face-to-face, you were saying that, we were talking offline, apparently a lot of people out of medical training now are going directly to work for pharma? Or what are you seeing?

– [Vinay] Well, I think a lot of us are seeing, well, that is true, that a lot of people finish training and go to go to pharma, especially in my field of oncology, but also a lot of academics who are like 2 years in, 5 years in, 7 years in, 10 years in, not a week goes… You’re away for the office for five days, I come in, you know, and then somebody’s like, “Oh, did you hear? So-and-so’s leaving to go to this company. So-and-so’s going to AbbVie. So-and-so’s going to Genentech. So-and-so’s going to AstraZeneca.” I’m like, “Dang, who’s left, who’s left?” I was like, “We’re getting…” But they always find a way to get the fellows right out of fellowship and pay them an inferior wage ’cause they don’t know any better. That’s how they keep… I really feel bad sometimes. It feels like academic medical centers are a handful of people who’ve been there 30 years and then a whole slew of like first, second-year graduates until they burn them out and then send them off, and then burn through the next generation. It feels that way. But I was thinking, why are so many people going to pharma? And why does it feel as if it’s different than in prior years? And when you ask people going to pharma, they often say like, “Well, I just felt like I could do the work I’m interested in, clinical trials, but at a bigger scale.” And I actually think that they’re onto something, but I would rephrase it. I think what has happened is over the last 15, 20 years, we have made the job of being an academic oncologist at a university and the job of being a pharmaceutical oncologist at Genentech, the same, like they have the same mission. All they do is work on trials. All they do is deal with the company. All they do is advance scientific products. And so we have made the academic mission, the industry’s mission. And so then naturally, you’re gonna look and say, “My mission is no different than the mission over there. They pay you a hundred grand more per year or more. You have more flexibility, fewer hours to work, better benefits, more of your money comes as stock rather than payments. Why not do what I’m doing over there and do better for myself and less stress?” And I actually think what we should… The failure is that we’ve made ourselves just like the arm of pharma.

– [Zubin] Right, right, right. So academics needs to actually change back to its original configuration or mission if you wanna keep people in academics. And you should value teaching and actually really compensate people for good teaching and reward good teaching. And then the bench and clinical research that you do there is not just about developing products. It’s about expanding all the things that bench and clinical research is supposed to do. Yeah, I mean, at Stanford, this was an epidemic. I mean every single hem-onc person I knew went into, ultimately ended up at Genentech or somewhere. And a lot of the pharmacists actually left and ended up working in the pharma companies. Look, there’s nothing wrong with-

– [Vinay] Nothing wrong with it.

– [Zubin] Working in the industry, that’s fine. We need that, too. But the thing is, if it just becomes a thing, it’s just like here, everybody, UCSF, Stanford, everybody, all the med students wanna go work at startups or work for digital health companies or all this other vaporware that… And look, I’ll be honest, when I finished my residency at Stanford in medicine, I wanted to go into GI when I went into the program, ’cause I was like, “Oh, this is great, man. I get to play video games in people’s asses.” It was interesting intellectually, GI physiology for me. But then I did the rotation and I’m like, “I hate this so much. I don’t like my mentor. I don’t like anything about it.” And I had a panic attack. I’m like, “Well, shit, now what am I gonna do?” So I finished medicine and I took a year and worked in these two little med ed startups and thinking, “Oh, the grass is greener, I’m in the Silicon Valley, it’s 2002.” And what I learned from that was, wow, this is an empty, vaporous, garbage space. And all that energy and vulnerability that your patients would show you in that connection, all of that, that was all gone. And so it drew me right back into clinical medicine. But I needed to do that. I needed to go through that. But I think a lot of people never get the clinical. They never get hooked by that or never get the opportunity to be hooked by that, which is really a shame.

– [Vinay] You know, it’s really well put. And I think that your point I wanna reiterate is like, yeah, it’s not about… There’s nothing wrong with going to work for pharma. It’s a fine job and we need people to do it, and a lot of great people do it, a lot of very smart people do it. And there’s nothing fine with wanting to make a startup. A lot of smart people do that, too. I think I will flip it on and point to the academy. Academics, if they wanna keep anybody, they need to figure their shit out. They’re gonna lose everybody, because you’re not gonna be able to compete with these other people in terms of money. You’re not gonna be able to pay these people as much. You’re not gonna be able to give them a more flexible lifestyle, because patient care is inherently not very flexible. You can run, but you can’t hide. They’re gonna page you, they’re gonna find you. They’re gonna get your opinion. In my mind, I think the failure is that many, many talks and conferences I go to are all the same, cheerleading for drug products, cheerleading for drug products. Universities are making partnerships with drug companies, drug companies that are building… They’re working together to build a building on campus, to go into partnerships for different therapies and this. Everybody who works at a university is thinking, “How can I get the drug to market?” Where are the people thinking about, hey, is the drug cost effective? Hey, does the drug work in elderly people? Hey, does the drug work in people with lower socioeconomic status? Hey, what have happens in the real world when people dose reduce? Does it work? Hey, that clinical trial you ran, was the control arm fair? There’s nobody who’s funding that or cares about that at the university. And if you don’t do that, then you’re making the university basically the same job description as pharma. And as long as it’s that, people will keep going. You need it to be something different if you want people to stay. And I think they are failing miserably.

– [Zubin] Yeah, yeah, it’s a massive hole in the whole thing. You know what’s funny is last night I had a nightmare, a clinical nightmare, which I haven’t had in a while. I have them every now and again. It’s kind of like a residual echo of PTSD of my years in the hospital taking call Q for days with the residents and all of that. I was suddenly, it’s like “Inception.” How do you know you’re in a dream? Well, you can’t remember how you even got there. So suddenly, I was on call and was called to the ER and there was a patient who had elevated blood pressure. And for some reason I had sent him home, not knowing what was up. And then I looked after the fact at his blood pressure and it was 327 over something. And I’m like, “That’s a fatal blood pressure.” I sent him home. So I spent the rest of the dream trying to find this patient, like talking to the clerk and the clerk was spelling this patient’s name, and I was trying to write it out and I couldn’t get it right. I kept misspelling it and I couldn’t get it right. I couldn’t contact this patient. I started to panic. And then I realized, oh my god, I think my malpractice insurance lapsed. This guy’s gonna go home and die. I’m gonna be responsible for it and then I’m gonna be ruined financially. All these things are happening in this dream and I’m just starting to panic. And I wake up fucking almost screaming. And I realized, wow, that was 10 years of my life. That’s actually many, many times, not that, right, ’cause that’s absurd, but that’s what clinical medicine can be like. It’s very stressful. You’re always second-guessing. You’re always worried about stuff. It is inflexible and it’s exhausting. And so you have to really kind of, we’ve talked about this before, but if it’s enough to give me anxiety dreams years later, it tells you that we oughta really be focusing on supporting people who do that kind of work, too, and making the work more sustainable.

– [Vinay] You’re really onto something, ’cause there’s gonna be… The crisis is just gonna get worse, more and more. There are more and more up opportunities to be a doctorpreneur. I love that word.

– [Zubin] Ah, yes.

– [Vinay] Doctorpreneur, there are more and more opportunities to do other things. I think you’re onto something, which is that like what makes medicine great? Talking to people, thinking about the problems, thinking about what are the best things and then go forward for that person. That’s what makes medicine great. What makes medicine terrible? Paperwork, trying to actually get things to happen because they involve many, many clicks and opening browsers and two-factor authentication and all this stupid computer bullshit. And the way to solve this problem is to allow doctors and NPs and PAs, and pretty much everybody in medicine to do more of the job they want and get more support for all that nonsense that they don’t want or to eliminate the nonsense that they don’t want. I have a colleague who works in a clinic that’s really efficient. The colleague’s like, “The reason I’m able to work so efficiently is that I walk out of the room and I just tell this person who sits there what are we gonna do for this person, what’s going on, and what they need to order and set up. And then I walk away. I don’t have to type anything. I don’t have to put all these orders in. And somebody else is there to like, ‘Oh, the scan came back now, you wanna take a look at it?'” Like remind, like be a helper to this person. And I was like that’s what you need to be doing to make people wanna stay, to make it less stressful is to have proper support. But they don’t wanna invest in that, ’cause that just cuts away their nonprofits. Their nonprofits.

– [Zubin] Exactly, it’s gonna happen that people are just not gonna wanna do it and it’s gonna come to a crisis. It’s already there, and COVID has made it worse. There’s a term in business called capability and it’s just a wonky way of saying, do people feel capable in their jobs to do what they need to do and be morally at ease? And capability’s made up of having the tools, meaning the right technology, having the resources, meaning the team and the staffing and the support, and having the autonomy, meaning the trust and the support to make your own decisions. If you have those three things, and they’ve looked at doctors, right? If they score high in capability, the organization is more profitable, there’s less turnover, and there’s better outcomes. It’s like, well, why don’t we focus on capability? ‘Cause it it’s a doable thing. It’s a metric you can actually shoot towards. But like you said, it’s just like in the academy that everybody’s building these buildings and doing all that, that’s what they’re doing. They’re building extra wings with their money. They’re not actually investing in the only thing that matters really to their longterm success, which is their people and the clinical enterprise.

– [Vinay] And if you donate 10 to $20 million, you don’t have to wear a mask in the atrium. Masks are only for us poor doctors. By the way, I would be pissed if I was a doctor working there and I saw this donor get to walk around.

– [Zubin] Totally.

– [Vinay] I’m not allowed to walk around without a mask.

– [Zubin] Totally.

– [Vinay] I’d be so pissed.

– [Zubin] Totally.

– [Vinay] And look at this shameless cancer center, for $20 million, you can do whatever you want. How many more million and they’d probably let them come in with active COVID infection, cough everywhere.

– [Zubin] Oh, totally. His PPD positive spewing mycobacteria.

– [Vinay] For 100 million.

– [Zubin] Yeah, you can cough TB all over our staff.

– [Vinay] You can come in with febrile for 100 million.

– [Zubin] Why not? Why not? I mean, its…

– [Vinay] These universities keep prostituting themselves out to donors and things like that. It’s ridiculous.

– [Zubin] It’s another structural problem, yeah, is the need for cash in all these institutions and then the internal politics.

– [Vinay] Public institutions, by the way, I really do wanna know what does tax money go for? I mean, what are they doing with it? Because all these public universities apparently are like always trying to beg the nearest billionaire for a few bucks.

– [Zubin] Right.

– [Vinay] Don’t they have any tax money?

– [Zubin] Right, it’s kind of like, wait, wait, what? No, we’re actually spending all our tax money on the 101 freeway creating an express lane that charges your fast track so you can use the HOV lane. Did you see that?

– [Vinay] Is that what all the construction is?

– [Zubin] Yeah, and it says… They have the gall to put up a sign that says your tax dollars at work. So wait, so you’re spending my tax dollars to charge me money to ride in this lane? Come on, dude, this is ridiculous. And we have a what, a 12% marginal tax rate in California. on state.

– [Vinay] It’s 13.5.

– [Zubin] Sorry, you’re right, 13. I’m in denial.

– [Vinay] In denial.

– [Zubin] I’m in denial.

– [Vinay] And what’s that tax rate in Vegas?

– [Zubin] That’d be zero.

– [Vinay] Wow.

– [Zubin] Yeah. Moving back here was the biggest eye poke I’ve ever suffered.

– [Vinay] Dumbest decision you ever made.

– [Zubin] Dumbest decision in the history-

– [Vinay] It’s the toddler masking of your life. It’s the dumbest decision you’ve ever…

– [Zubin] Except I’ll say this. It was the smartest decision because it was for my wife to take her job back.

– I know, good point. And if your wife is happy, then you’re happy, so we did it. We took the hit for that and it’s actually been net positive. But god, I miss Vegas. I miss that zero tax. I miss the non-masking. I miss the food and the travel and the general sense of purpleness of the state. It’s a very alt middle place, which I like.

– [Vinay] And the sunshine.

– [Zubin] Oh, I can’t tell you how much that matters, right? You know, you were in Portland for so many years.

– [Vinay] we used to open textbooks to read about the sun.

– [Zubin] Yeah, man, you were getting Vitamin D by proxy, just through the book, just reading about it. Yeah, it really does change your attitude. I was much happier in general. And I get a little grim around here sometimes. Although, you know, the difference between where you-

– [Vinay] Oh, screw you, I’m in the city limits.

– [Zubin] Yeah, I know, I know, right? The difference between where you live and where I live, it’s like literally a 30-minute drive max, but it’s sunny almost all the time over here and where you are, it’s just like-

– [Vinay] I tell people that Portland is like three months of California and then it’s like nine months of sleeping in the produce section with that mister going. Nine months with that mister, and it’s not a heavy rain. You don’t always have to wear a hood. But you are getting misted, you’re just wet and mossy. But I’m a happy person. I used to bike a lot and that keeps your mood even higher. But when I came here, I felt like cobwebs were lifted out of my mind ’cause the sun is really nice.

– [Zubin] Yeah, when I moved from UCSF down to Stanford, it was like a massive shift in my mood. I was happier in residency than I was in medical school, which is crazy. I really was, yeah. Whereas my wife who trained at Stanford as a medical student and then stayed at Stanford as a resident had the opposite. She was miserable as a resident. So, I do think there was an element of weather change.

– [Vinay] Oh, you think it’s the sunshine.

– [Zubin] Yeah, I think there really was.

– [Vinay] I mean, objectively, residency is more work than medical school.

– [Zubin] Oh, by far. But it was just that whole climate at UCSF was just… In the inner sunset where I lived, it was foggy and grim, and you just never saw the sun. And you couldn’t park, which sucked.

– [Vinay] I remember. Do they still charge you for the parking at that gym?

– [Zubin] Yes, they still do, but I’ve managed to figure out ways to weasel, like I’ll park here, then I’ll move it here, all to save like four bucks in parking. But I won’t give Stanford my money, sorry. They can’t have it.

– [Vinay] You know, something that really irks me about coming to work and having to pay a hefty parking fee because it’s like, you know, I’m not here ’cause I wanna be here.

– [Zubin] Yeah, exactly, yeah, exactly.

– [Vinay] I’m not here ’cause I wanna be here.

– [Zubin] Once again, capability. Do you feel capable when you have to pay for parking? It seems like you don’t have the tools, resources, and autonomy to do your job if they’re asking you to pay.

– [Vinay] Also, they have like these… Sometimes you go to parking garages and there’s no spaces left. Why are they letting people in the bottom?

– [Zubin] Come on, close the shit. Vegas knows how to do that. They light it up green and red in those hotel parkings to what’s available and they tell you how many spaces are there. Vegas does a lot of stuff right. And a lot of stuff crazy wrong. But yeah, mostly right. Dude, so what’s up with this fourth dose and Peter Marks and all this stuff, by the way?

– [Vinay] Oh yeah, fourth dose. Fourth dose.

– [Zubin] Yeah, I know.

– [Vinay] Didn’t I always tell you it was a four-dose vaccine? Four-dose vaccine. Well, I think the fourth dose is controversial. European CDC said recently that they’ll only recommend it if you’re over 80 or if you’re dwelling in a nursing home. This country, Pfizer said, “Hey, please give us the authorization for 65 and up.” And Peter Marks and FDA said, “Hey, we’ll give you 50. We’ll just give you 50 and up.” And they didn’t have an ad com. They didn’t have the advisory committee before. And Peter Marks, of course, is the guy who’s taken over for the two people that have been pushed out. I think he’s got a big rubber stamp on his desk ’cause whatever Pfizer does, he’s rubber stamping. He’s done a lot of really I think bad decisions, like moving the booster up a month for Moderna, citing Pfizer data. He didn’t have an ad com for fourth dose saying it was an obvious decision. Nothing obvious about it. Europe is not doing it and a lot of people are critical of that decision. I just think he’s not doing a good job.

– [Zubin] Yeah, that sounds-

– [Vinay] He’s just doing a shitty job.

– [Zubin] How can you look at what they’re doing and not go, “Oh yeah, these guys are all just basically pharma cash registers at this point. Because, you know, again, fine, 80 and up, whatever. And you know what? Giving people the… Like if they wanna get a fourth dose, that’s fine. I’ve had pharmacists reach out to me and they’re like, “I can’t fucking believe they wanna do a fourth dose. Now I gotta admit minister a fourth dose to a bunch of worried well people that have no reason for it.

– [Vinay] A 51-year-old who’s running marathons is gonna rush to get the… And by the way, how many, I mean, if we’re talking about giving options, should they just give you the option of giving like the 90 doses, like that German guy got?

– [Zubin] Yeah, exactly, the German guy who took 90 and then like sold the passes or was forging them or something. I was a like, dude.

– [Vinay] How many doses should you be allowed to get if you want, 100? I mean, I don’t know. Shouldn’t there be some evidence that the dose helps you or is that like…

– [Zubin] Yeah, or at least evidence that it doesn’t harm you. And they’re saying, “Oh, what’s the harm? What’s the harm?” Well, you don’t know ’cause you haven’t looked at it.

– [Vinay] I saw somebody, somebody who’s a self-proclaimed public health expert, who’s gotten everything wrong, say, “There is no harm.” I was like, “Oh, there is no…”

– [Zubin] Yeah, we’ve heard that before.

– [Vinay] This is the same person who said masking toddler’s just makes… It has a lot of good science to back it up.” A lot, really?

– [Zubin] These are the people who were like, “Prophylactic aspirin for a myocardial infarction sounds like a great idea.” And then you actually look at it and you’re like, “Well, no, maybe not, ’cause aspirin isn’t harmless.”

– [Vinay] Oh yeah, they were, you’re right. They were the same ones who were like, “An aspirin a day keeps the doctor away.” Turned out, it didn’t. It didn’t keep the doctor away.

– [Zubin] It turns out it shows you end up in the ER with a perforated gastric ulcer. I can’t tell you how many people I took care of as a hospitalist who were the victims of casual NSAID use or prescribed NSAID use in the form of a daily aspirin who would come with a GI bleed. And they don’t count that cost, you know?

– [Vinay] Oh, yeah.

– [Zubin] Yeah.

– [Vinay] Well, now we have some new randomized trials and the guidelines are changing slowly, and so that is good, of what, ASPREE and we have these two new studies of aspirin.

– [Zubin] Yeah, so things will start to shift to more evidence appropriate practice. I like evidence appropriate. Do you like that?

– [Vinay] Evidence adjacent, not even evidence based.

– [Zubin] Oh that’s great. Oh yeah, Peter Marks, he’s evidence adjacent.

– [Vinay] He’s evidence adjacent, he’s not evidence based.

– [Zubin] The evidence is in the other room. He just hasn’t looked at it. But he’s adjacent to it.

– [Vinay] I mean, my only question is when he leaves FDA, is he gonna go work for Moderns or Pfizer?

– [Zubin] Right, which one, which one?

– [Vinay] Which one, that’s the only question I have, The only lingering question I have. He’s done such a bad job, I don’t know what to say. I hate to say that he’s done a bad job, but he has done a bad job. I forgave him the first 10 screw ups, but like, I mean, the 20th screw up, I don’t know. I mean, this whole… I’d be curious, you should try to get your friend Paul to come on and talk about this fourth dose. I’m sure he’s-

– [Zubin] Oh, he’s got strong opinions, I’m sure. I’m almost scared to have him on ’cause I don’t wanna get him canceled.

– [Vinay] I know, I know. I saw him, he was doing his best at the meeting yesterday. You can watch on YouTube.

– [Zubin] Oh yeah.

– [Vinay] He was doing his best to like, you know, not be too mean to them. I don’t know, man, it’s really… It’s depressing I think when I think about it, because I feel like… I had this guy on my show recently and he said that something like, “Most of the misinformation that’s been problematic during this pandemic didn’t come from Joe Rogan. It came from the mouths of public health experts.” And I think that that’s this whole thing that no one will acknowledge, or maybe they’re only reluctantly acknowledging, that most of the biggest screw ups were done by the experts, from school closure to, I would say, lockdown, to lying about mask data, to pushing it to toddlers, to just allowing Pfizer to just open our wallets and take whatever they want. Should you write your check on April 15th just to Albert Bourla or should you write it to the treasury?

– [Zubin] Yeah, and yet people are losing their Medicaid now because this funding is running out, but we’re giving tons of money to Bourla. 36 billion? 36 billion?

– [Vinay] No, no, no, actually it’s more. It says that this year Pfizer will make 100 billion. We’ve already bought 5 billion of Paxlovid. By the way, Paxlovid, there is a trial in vaccinated people, but they’re not releasing the results.

– [Zubin] Oh.

– [Vinay] I mean, come on.

– [Zubin] Wait a minute, yeah, ’cause they’ve really only looked at it in non-vaccinated people.

– [Vinay] Correct. Do we have any, like what is the risk reduction in vaccinated people? We don’t know.

– [Zubin] Wow.

– [Vinay] Again, this is like, you know, this is like Tamiflu. This is Pfizer just collecting money.

– [Zubin] Yeah.

– [Vinay] It’s bad.

– [Zubin] Yeah, yeah, yeah, yeah, yeah. I don’t know, man. I’m just hoping this thing burns itself out and we stop talking about it and can move on. But that’s maybe wishful thinking. The only thing I was grateful for in terms of Ukraine was that it distracted us from COVID and people stopped talking about it.

– [Vinay] Barely, these people, their Ukrainian flag in their Twitter bio is collecting dust. ‘Cause they no longer talk about it as much.

– [Zubin] Yeah, and yet it’s more atrocious than it was before, you know? Like what’s going on there? You just go, oh, this is bad. But it’s been bad for… I won’t talk about Ukraine ’cause I don’t know anything.

– [Vinay] Well, actually, I was about to say, I was like took a few days, relaxed, and then I didn’t read the newspaper, and then I came back and I was reading yesterday. And I was like, oh.

– [Zubin] This idea of unplugging on vacation is actually a very powerful tool. You can truly wake up and go, “God, what have I been doing?” I’m just poisoned. I’m poisoned by the sociest fear around me and this garbage device that I’m hooked to and addicted to and all of that. And it’s possible to unplug. I just released a video with my friend Angelo about…

– [Vinay] I saw that, Angelo.

– [Zubin] Yeah, about our meditation retreat. There really is something, like you come back and there’s an aura that lasts for probably about a week where you’re like, “I could never plug back in again and it would be just fine, unfortunately.”

– [Vinay] Your videos are a little bit less frequent. I really liked your video on daylight savings. I learned something.

– [Zubin] Oh thank you, thank you, yeah. You know what it is, is it’s actually reasonable to talk about as we wrap up. I really am feeling like I cannot make a video unless I really care about deeply what I’m talking about. And there’s a lot of pressure to make videos. You know how it is, right? You have a YouTube channel that’s very successful. If you stop, the algorithm starts to fucking hate you. I didn’t put out a video for a couple weeks or something on YouTube, and then I put up my meditation video and it’s like the algorithm’s like, what is this? Yeah, exactly, and I have to accept that that’s okay and not worry about it. Because I’m at a place now in whatever this arc of the thing that I’m doing, where I just can’t do anything that feels not authentic. It just starts to burn. It feels like kryptonite. Whereas before, it’s like, okay, I can do… I know this video’s gonna do well and it’s important. I’m just gonna do it, even though I’m not really feeling it.” And I can’t do it anymore. So it may be that my days are numbered as ZDoggMD, who knows?

– [Vinay] Oh my goodness.

– [Zubin] I may ask you for a job.

– [Vinay] I guess… I look forward to your videos because sometimes I don’t wanna do all that homework. I just want you to do it for me.

– [Zubin] That’s why I watch your videos, dude.

– [Vinay] I know. ‘Cause the daylight savings, you got into some stuff. You obviously had read about it a lot more than I had read about it.

– [Zubin] I cared about it, yeah.

– [Vinay] Actually, I listened to your podcast version of it when I was riding my bike. But very interesting. All I know is, I mean, I’m not an expert on daylight savings and all the biological consequences. I actually think that… I mean, you did a great job of sort of getting into it, but I think there’s all these second or third order things that could happen. I don’t even know.

– [Zubin] Right, right.

– [Vinay] For instance, I don’t know. I mean, if I was running a company, what I’d say is if it really was dark as shit for half the year in the morning, then I’d say, we’re just gonna start an hour later.

– [Zubin] That’s right.

– [Vinay] I’ll stick it right back to them. You change the clock, I’ll change my start time. Fuck you.

– [Zubin] That’s right.

– [Vinay] You know?

– [Zubin] That’s right.

– [Vinay] I’ll get you back, you know. But anyway, but I was learning about it. But I do have to say that if the energy policy of a nation, like the way we’re gonna fight climate change and tackle our energy is just to keep changing our clocks, I think we got some work to do. We got some work to do. You need to be figuring out how to get some better energy. Come on, not just change this clock. Just set it, change the clock.

– [Zubin] And people underestimate what this means. It’s a massive socioeconomic, ecological, psychological thing when you tamper with the social calendar. So, forget about time. Time is, look, we go around the sun the way we go around the sun, that’s not changed. It’s the social clock, like you said, “Oh, I’m just gonna move my start time later.” That’s what we’re doing when we move the clock is we’re saying we’re socially agreeing to move start times into the dark or into the light more, and borrow an hour from here and put it here. And that has massive second order and third order and fourth order effects, as you say. So again, you can’t just make these decisions lightly. And when Congress did it in ’73, they realized they done fucked up , and they came back the next year and they’re like, “This sucks, we’re going back.” They made daily time savings time permanent then, and then they undid it. So, we’ll see what ends up happening, but it’s worth talking about. So those kind of things get me all fired up. But like, I don’t know, if I have to talk about COVID on my show, like I love talking about it with you because it’s a dialogue. But if I have to do more rants about it, I swear I’m gonna stab my eyes out. I’m just not… See, this is like part of your general wheelhouse, like you study this stuff.

– [Vinay] Oh, I’m tired of it.

– [Zubin] But even then you’re gonna get tired of it.

– [Vinay] I’ll tell you what I get tired about is like, everyone’s like, “Oh, CDC’s got a new mask study.” I’m like, “Oh.” And then everyone’s like, “Oh, do you wanna read it?

– [Zubin] Yeah, Vinay.

– [Vinay] And then I look at the top line results. According to the CDC, masks stop 99% of COVID. I was like, oh, Jesus Christ, 99, you say? You’ve gone up to 99, okay, let me see. I suspect there’s something wrong with this paper. But then I have to find the things that are wrong with it. Its gonna take like 15, 20 minutes of reading. And do I wanna spend that every single day reading? And then they had another one. Myocarditis is way more common after infection.

– [Zubin] Yeah, I saw that.

– [Vinay] And then I looked at it. The first thing they were like, “We looked at anyone who was in our EHR system with a documented SARS-COV2 infection.

– [Zubin] Oh my god.

– [Vinay] And their rate of myocarditis was… No, no, their rate of a billing code for myocarditis was… And I was like, well, first of all, most of the people with the infection are not in your fucking system, so what are you even talking about?

– [Zubin] Your denominators totally fucked up again. It’s the same thing they always do. And it made the news, it made the news. Okay, final verdict, final verdict, CDC says X. It’s complete horse… So that kind of shit pisses me off.

– [Vinay] It really does. It’s like propaganda. And I’m like, are the people… I’m like, are the people doing this work that stupid that they don’t… I mean like, is it deliberate or not? I don’t even know. Is it deliberate or is it not deliberate? And if it’s not not deliberate, who has allowed these people to be researchers? ‘Cause if you don’t know the most basic things. And then I tweet that it’s bad. And someone says, “Actually, actually.” I was like, all right, so they’re still-

– [Zubin] Here we go.

– [Vinay] Here we go. Then I tweet again, even like more simply. Then I use an analogy, oh, okay. Then I made a video with a little graphic to explain. And then, I still think they don’t get it. And I’m like, I don’t know what to say.

– [Zubin] And what do you think of Rochelle Walensky as we wrap up?

– [Vinay] Terrible.

– [Zubin] Rochelle Walensky doing a review of the CDC.

– [Vinay] Oh yeah, she’s like, “We need to reorg.” She’s like, “Things aren’t going well, we need to reorg.” I was like, the only reorg is you need is my resignation letter on my desk. That’s the reorg I wanna see. Fuck reorg.

– [Zubin] Did you see what Redfield said, the previous CDC director? He was like, what did he say? He was like, “I couldn’t get to the metal detectors at the airport because of all the shrapnel in my back from when I was CDC.” So apparently, he was pissed that everybody else was taking a shit on him, all the previous CDC directors when… I mean, that is-

– [Vinay] He was… You should read that. There’s a good “Vanity Fair” article by I think Katherine Eban about lab-leak, and it’s really good, and there’s some good Redfield quotes in it.

– [Zubin] Oh, great.

– [Vinay] But I don’t know. She didn’t do a good job. She’s in the Peter Marks bucket of not so good.

– [Zubin] Right, right.

– [Vinay] Peter Marks, Jeff Zients, whatever this guy is, the current COVID czar. When you have a lower vaccination rate among elderly people than Brazil, I think you kinda dropped the ball.

– [Zubin] Oh, man. Hey, by the way, and what happened to vaccines for toddlers? Did that just go away? Or was the data so abhorrently bad? ‘Cause we know that it wasn’t working well from even a serological standpoint, right?

– [Vinay] You’re talking about the Pfizer.

– [Zubin] The Pfizer, yeah.

– [Vinay] Mums the word about Pfizer. By the way, normally when you run a non-inferiority study and it didn’t work, you don’t just get to say like, “Oh we’ll just add the third dose now. We keep trying. Then we add a fourth dose and then we add a fifth dose. We just keep trying.” Meanwhile though, Moderna has a press release that they have a success, but they’re talking about 25 micrograms times 2, 50 micrograms. That’s an interesting dose. I got some vaccine researcher from the United Kingdom email me is to say like, “Are you seriously considering if you have a four-year-old who had omicron and recovered, you’re gonna about to give him 50 micrograms-

– [Zubin] Of Moderna.

– [Vinay] Of Moderna. And then if they were five years old, then they get 10 times 2, they get 20. So that’s an interesting…

– [Zubin] This is odd. Look.

– [Vinay] Odd, odd.

– [Zubin] I think when omicron hit, I think I was speculating that, and again, you shouldn’t do this, but I was like, this is the beginning of the end of this thing, because everyone’s gonna get infected and we’re gonna have some mass of immunity and the next variance is gonna be less deleterious. And I think so far, we’re seeing that with BA.2. I think it’s like a nothing burger. It’s the predominant strain now in the U.S. At least until the immunity wanes, right, by the winter. But yeah, I don’t know, I don’t know, honestly. I’m living my life. That’s the best we can do. I’ve modulated risk for myself and my family the way I feel is appropriate and moving on.

– [Vinay] You’re not under the thumb. Nobody can mandate you do anything, huh?

– [Zubin] Well, they can, and then I’ll pretend to obey, and then secretly won’t. Actually, you can. Hey, by the way, here’s a tipping point in the Bay Area. The grocery stores are now only 25% of people wearing masks in an unmandated mask environment. So, something is starting to, as spring warms up, people are starting to open up.

– [Vinay] I hope that I can see somebody working in restaurants not wearing masks.

– [Zubin] That would be nice, yeah. That would be nice. We’re watching a lot of K dramas, these Korean dramas on Netflix, and even pre-COVID, it was just etiquette in food preparation that they wear this kind of face shield thing that prevents them from spitting in people’s foods and stuff. And I was like, wow, I’d love to see data that says that that actually helps. But it’s interesting. It’s a very cultural thing. I don’t know.

– [Vinay] The last thing I saw interesting was “The Dropout.” You watching that on Hulu?

– [Zubin] No, is it good?

– [Vinay] Yeah, it’s Elizabeth Holmes.

– [Zubin] Oh, that one, yeah. No, I haven’t seen it yet. I gotta check it out.

– [Vinay] There’s something, people have such a fascination with people who pull off these kinda cons for so many years, you know?

– [Zubin] Yeah.

– [Vinay] It’s morbid fascination.

– [Zubin] It really is. So I know a… Oh, just real quick, I know a Silicon Valley billionaire, who’s kind of royalty in the Silicon Valley in the healthcare space, and they told me they knew Elizabeth Holmes at the time and had this sneaking suspicion that she was schizotypal or had some personality disorder. This was before it all came out. And just would say that she was just a very odd creature on many levels, so.

– [Vinay] There’s something interesting there. And I think that when you watch the show, and even when I’ve read the books and I listen to podcasts and all this stuff, I still don’t have my finger on… Not only did she fool people, but she really put the hook in hem. They really believed that what she was saying is true. And it doesn’t even pass the most prima facies sniff test. Because it’s not possible that you could run all those tests off a single drop of blood, you know? And I think every single person who knew anything about blood testing was like, “There’s just not enough blood there to do that.” And yet she persisted.

– [Zubin] It’s basically like blood coin, you know? It’s like the cryptocurrency made of blood, like it’s one big Ponzi scheme.

– [Vinay] It is.

– [Zubin] I’m gonna get all these angry messages from crypto enthusiasts now. “What do you mean, blood coin? Crypto’s the future of currency, Bitcoin.”

– [Vinay] God, I don’t understand it.

– [Zubin] I don’t get it, but yeah. I mean, I can’t invest in something I don’t understand. That’s the thing. Unless it’s like hedge money. So I have a little bit of it, but it’s hedge money. It’s like kinda gambling money.

– [Vinay] What does hedge money mean?

– [Zubin] Meaning just I know nothing about it.

– [Vinay] Money you’re willing to lose?

– [Zubin] I’m willing to lose it. Because people talk about it, it’s fine. Maybe it’s the Dutch tulip bulb craze of the 21st century. I don’t care. Here’s a little gambling money, right?

– [Vinay] I see.

– [Zubin] Yeah, that’s how I see crypto, but I may be an idiot. I am an idiot, I know nothing about it.

– [Vinay] I’m an idiot because I don’t spend any time thinking about money. I need to focus.

– [Zubin] Well, no, actually what you’re doing is you’re building so much of your own personal growth that you’ll never have to worry about it because you’ll just do well at whatever you do, whereas-

– [Vinay] I plan on working until you find me at my desk.

– [Zubin] Oh, just coded.

– [Vinay] Just deceased.

– [Vinay] Yeah.

– [Zubin] Yeah. What are you gonna die of? What do you think? What do you think is gonna get you?

– [Vinay] Probably cardiovascular disease. I’m an Indian man after all.

– [Zubin] That’s true. But you’re an oncologist, which means you usually die of your own specialty, right?

– [Vinay] You think you have that premonition when you choose your specialty?

– [Zubin] There’s something, you know, it’s a thing, if “House of God” said it like, you just kind of die of your… You die of your specialty. So cardiologists have heart attacks, cancer docs die of cancer. My wife, who’s a lung radiologist, chest radiologist, she’s like, “Oh, I’m gonna get adenocarcinoma, like non-smokers lung cancer, I just know it. Or pulmonary fibrosis or something terrible.”

– [Vinay] Oh, I see, interesting.

– [Zubin] And I’m like, “Well, I’m not taking care of you if you get one of those up longterm lung diseases. So I’m just gonna sign a post-nup right now.”

– [Vinay] I think I play the odds. The odds are, with our background, we’re not used to this rich Western diet, you know?

– [Zubin] Yeah.

– [Vinay] And I follow your diet. Most days I probably don’t eat anything.

– [Zubin] Right, the one meal a day. I went off-

– [Vinay] And I exercise a lot.

– [Zubin] Yeah, you do, yeah, you do. I try to, too. I went off the rails when we went to Southern Cal a while back for a week. I was eating three meals a day for the first time, and I gained 10 pounds in a week. 10 pounds.

– [Vinay] Oh my god.

– [Zubin] Dude, and I lost it over two weeks, but man, it was brutal. My metabolism is adjusted to this sort of one meal kind of snake-like python, eat a goat and then digest it over the rest of the time.

– [Vinay] I can’t even eat. If I eat breakfast, I feel sick. I feel really sick.

– [Zubin] Yeah, I feel ill. Oh, I felt ill for the first couple days until I adapted. Then I was hungry all the time, ’cause my insulin secretion had just gone through the roof. Bad, dude.

– [Vinay] I also believe for exercise that, you know that feeling when you’re exercising and you feel like you’re gonna die?

– [Zubin] Yeah.

– [Vinay] I try to achieve that feeling every time.

– [Zubin] Where you hit the wall, yeah, oh man.

– [Vinay] Yeah, you wish that you were not even doing it, and the pain and misery is so bad. Maybe that’s perfect.

– [Zubin] That’s great. Now my buddy, Ron Sinha, who’s has been on my show. He’s an internist down here, specializes in South Asians, actually, in metabolic syndrome. He says that kind of exercise is actually bad because it raises your cortisol and makes things worse.

– [Vinay] Oh, everyone says all these things. No offense, but you know, I always hear. Everyone has always got some story to tell me, like, “Oh, you don’t wanna…” Remember, what did Trump say? He said any exercise is bad ’cause the body only has finite energy.

– [Zubin] Bill Gates used to believe that we had a finite number of heartbeats, and if you speed up your heart rate by exercise, you’re just burning through your life.

– [Vinay] But you know, the truth about all these things is like I’m sure that some diets change LDL and triglycerides and cortisol in deleterious ways and others don’t, and I’m sure that some types of exercise raise some of these inflammatory things and others don’t and these things. But what I have no idea is, is whether or not those proximate changes in metabolites actually predict longterm outcomes. And when you draw upon studies where they’re like, oh, people with, I don’t know, whatever high cortisol live long, live shorter than other people with lower cortisol, that’s not the same scenario. Because what you’re saying is those people just happen to have like a resting baseline higher rate. But it’s not the question of whether or not, if I do this exercise and if that’s the way in which my cortisol goes up, does that increase or decrease my longevity? I don’t think anyone has any clue.

– [Zubin] Nobody knows. Nobody knows at all.

– [Vinay] Nobody knows. Nobody knows anything.

– [Zubin] And all these are surrogate markers, too. And it’s kind of just like, what are we even doing? You have to find the right diet that’s sustainable, that you’re happy and you feel good and whatever. I mean, that’s it. And your exercise-

– [Vinay] My goal is so I can still fit in the pants I had since college, that’s my goal is, approximate goal.

– [Zubin] Yeah, so you have a very specific goal, right.

– [Vinay] I don’t wanna buy new clothes, I’m cheap.

– [Zubin] Hell, yeah. Hell yeah.

– [Vinay] I have some jackets I really like. I wanna be able to wear them.

– [Zubin] Dude, you got to wear one of them on my show. Remember that, the leather one.

– [Vinay] I didn’t have that that long. But you remember that jacket, but then you turned up the temperature.

– [Zubin] I know and you had to take it off, man.

– [Vinay] You smoked me out of it.

– [Zubin] And then Marty went all old school, old man on us, and got us all sweaty, too.

– [Vinay] And then he had some soup.

– [Zubin] Marty Makary is a American treasure. I’m just gonna say that. But you go out to eat with him-

– [Vinay] I really like… Oh man, he’s such a funny guy. I really like him. I was talking to somebody and they’re like, “Why do you like Marty so much?” And I was like, “You just have to have a meal with him.”

– [Zubin] Just have a meal with him, just have a meal with him.

– [Vinay] He’s a very funny, fun-loving person.

– [Zubin] He really is, and he doesn’t give an F.

– [Vinay] That’s what I love about him.

– [Zubin] Yeah, I love it. Like this waitress, the interaction between him and the waitress was just priceless. “So, this juice.”

– [Vinay] How come you haven’t learned from him? He won’t like us telling about him. Hey, how come you haven’t… So, I’ve actually learned something from him, which I feel like that I wonder how come you haven’t taken the lesson, which is that if you crap on Marty, it’s like water on a rain coat. It just beads right up. And then he told me, he was like, how like, you know, just never, never even think twice about it. Huh?

– [Zubin] I need to learn.

– [Vinay] I feel like I have digested that more than you’ve digested it.

– [Zubin] Yeah, you have, you have, you have. You know what it is? I think it’s just that I find that there’s an element of truth and criticism of me sometimes, because sometimes it is me just being a little bitch or being inauthentic and people are piling on. And I’m like, you know what? I never even should have said that because I don’t really care about that. So why am I even talking about that? So now I just try to stick to stuff that I care about now. If people criticize me about stuff I care about, then I’m interested in why, because I wanna learn. But then if I disagree, then I’m like, well… It is water off a duck’s back. And then there’s the whole process of meditation and awakening that is a separate thing, that at some point you get this realization that none of it matters. It’s just all happening, perfectly orchestrated, and there’s nothing that you can to change it. And then it’s just equanimity, but that’s an asymptote.

– [Vinay] Let’s close on that.

– [Zubin] Yeah.

– [Vinay] That’s well put.

– [Zubin] All right, everyone, it’s always a joy, man. I just love these conversations. You guys know what to do. Subscribe to the show. You can check out Vinay’s stuff. I’ll put the links in the show notes. And if you guys do, if you do subscribe on a podcast channel, please do and leave a review. It helps us actually grow our reach a lot. It’s important. And then if you wanna join either of our groups, Vinay’s on Substack, we’re all over the place.

– [Vinay] Substack, that’s the place. And for you it’s Locals.

– [Zubin] Locals, yeah, or anywhere, ZDoggMD.com/supporters. You can join our supporter group and you actually get .

– [Vinay] I’m supposed to be on Locals and they’re probably mad at me, but I haven’t had time.

– [Zubin] Oh yeah.

– [Vinay] I’ve been so busy.

– [Zubin] If you need any help with that, let me know. Local’s a great place because they can’t cancel you and it’s just a nice… You get a group of people who care about what you care about, which is great.

– [Vinay] That’s great, I gotta work on it. I’m behind on some things. Once I catch up, once I catch up, I keep telling myself, once I catch up.

– [Zubin] You’re kind of a, I don’t know, vaguely busy guy, clinically full-time professor, writer, guy.

– Tired.

– Yeah, it’s a lot. It’s a lot. Sometimes I look at you and I can’t believe the stuff you do, because at your age, when I was whatever, 38, 39, whatever you are, I was just… Actually, I had that kind of energy, I did.

– [Vinay] So, I know the future now. I know the future.

– [Zubin] Yeah, the future is fat, lazy, gain 10 pounds on vacation by eating a normal three meals a day. That’s your future.

– [Vinay] And on that positive note, we out.

– [Zubin] Yes, we are out.