Triggered yet? Applying a rationalist framework to emotionally charged “research” should be a priority for everyone, but too often we’re failing.

Dr. Vinay Prasad, MD, MPH, UCSF hematology-oncology maven and host of the Plenary Session podcast, returns for an authentic discussion on the LACK of authenticity in healthcare.

This is required listening for anyone pursuing a career in medicine. Dr. Prasad has written two books, Ending Medical Reversal and Malignant.

Check out our previous show together here.

Transcript Below!

[Dr. Z]Hey everyone, Dr. Z. Welcome to the ZDoggMD Show. Today I have a friend, he’s like a brother from another mother because we both are trying to bring reasonable discourse back to the world based on science, critical thinking and actual argument, actual civic engagement. Dr. Vinay Prasad, welcome back to the show.

[Vinay] ZDogg, thanks for having me. It’s great to be in the studio.

[Dr. Z]Dude, I know. Last time we did it on Zoom, right?

[Vinay] I know, it’s not the same.

[Dr. Z]It’s not the same. Just so people know ’cause they never know, you’re a hematologist oncologist at UCSF.

[Vinay] That’s right. I’m a HemOnc doctor and I’m an associate professor as well and epidemiology biostatistics.

[Dr. Z]Gunner, gunner. So let me see, okay, your parents are from India?

[Vinay] That’s right.

[Dr. Z]Like mine.

[Vinay] Yes.

[Dr. Z]How proud are they of everything you’ve done? I’m telling you.

[Vinay] I was just telling you that I think they definitely are probably happy that I became a doctor, but I don’t think they really understand what academics is all about and you know why someone might wanna do that. I think they’re more of the private practice mindset.

[Dr. Z]Are they the types, ’cause this is my parents, “Show me your paystub.”

[Vinay] Oh yeah.

[Dr. Z]Yeah, that’s what they care about, right?

[Vinay] That’s right.

[Dr. Z]Academic prestige and all that.

[Vinay] I would say the amount of money you make and your self-worth are exact one-to-one correlation in their worldview.

[Dr. Z]It’s a direct ratio only. One-to-one, one-to-one.

[Vinay] Direct ratio.

[Dr. Z]So Vinay and I have talked on the show before, you’re the author of a couple of great books. One is about ending medical reversal, how our science kind of changes course when we look at the study, and we’re like, “Wait, no, actually that wasn’t true.” And the other one is, remind me your other book.

[Vinay] “Malignant.”

[Dr. Z]”Malignant” about cancer research and research in general and cancer therapeutics. Ooh, there’s a lot to talk about there, but first.

[Vinay] All right.

[Dr. Z]I wanna pitch the fact that you’re, okay guys, this guy is one of the few medical communicators that doesn’t suck. I mean, it’s ridiculous, dude. Like I listened to your podcast, “Plenary Session”, which is ostensibly a podcast for HemOnc nerds and science nerds, and I was immediately going, “Who is this guy that speaks clearly “and succinctly about issues that are complicated “with a variance in your tone.”

[Vinay] That mirrors what I’m saying.

[Dr. Z]That mirrors what you’re saying, that isn’t artificial. I was like, “Nobody in medicine does this.” Like we’re used to those lectures where just like .

[Vinay] Oh, they’re terrible. But I think, you know, you and I both take pride in the fact that when you’re up there and you want to speak and you want to communicate information, that’s an honor that’s placed on you. And so you gotta take advantage of that. You gotta do the best job you can. And I don’t know about you, but have you been to many lectures that are God awful?

[Dr. Z]Dude, listen, what you just said, it just triggers this like burning.

[Vinay] Fuzzy feeling.

[Dr. Z]Burning anger in me because in medical school, even at UCSF, you would have these researchers who would come down from on high and would teach some lecture. It was so boring. It was monotone. And you know what it was? It was a crime against us as the learners. Like you said, it’s a gift to get to stand there and convey what your hard earned knowledge is. It’s a gift. Why would you squander it, abuse it? And these people are there giving their time. So, you know, what started happening is I stopped giving my time as a learner. I would just learn from the book. A wonderful teacher can teach you more in five minutes than you could get from books for a year, right? Why do you think it is man? What is it?

[Vinay] Yeah, I think people are rewarded for different things, but actually being a good teacher, a good communicator, that’s not one of the things we reward at all. We reward people for the number of papers they’ve published and where they published it. And so you get somebody pull ’em out of their laboratory, they publish exceptionally well, but they haven’t really practiced communicating. And they’ve never been judged for how well they communicate. If they were, they might not be giving a lecture. And I think that’s the problem of academia is that we don’t take ownership of the fact that we are gifted the students’ time, and we have to do the best thing we can with that which I think means the best content and the best delivery. It’s not just one or the other. That’s why I like your stuff so much because I think you take pride in it.

[Dr. Z]Well, it’s definitely something that I’m passionate about and you’re passionate about. So anyone who hasn’t checked out your podcast, check it out. Now, the reason I brought that up is I’ve been thinking about this thing that you talked about on your podcast recently which is the study recently that was talking about maternal and it’s child mortality outcomes, right?

[Vinay] Yeah, neonatal, yeah.

[Dr. Z]Neonatal outcomes in African American patients whether they are taken care of by a black doctor or a white doctor and purporting to show a significant difference in outcomes. Can you tell me what the paper was sort of on its surface showing? And then what, if you actually look at the paper, how we ought to really think about this? Because I think until we understand the problem, how are we gonna fix inequities in outcomes in this country? So let me know what you’re thinking here ’cause.

[Vinay] Yeah, so this is a paper that got a ton of press. I read about it on CNN, that’s how it came across my desk. And then I was curious and I wanted to find out what this paper is all about. So I gave it a deep read and it is a paper just as you say. It looks at one state, Florida. And it notes that in Florida, infant mortality at one year, it’s not terrific. It’s actually quite, lamentable. It’s about six per 1000 babies pass away which is exceptionally high, globally. It’s not where this country ought to be. That’s across white and black babies. One thing they did note was the outcomes are much better for white babies which we know. There is a great deal of disparity. And that is disproportionately burdened, or that burden is placed disproportionately on the black community and black babies have higher rates of infant death. The thing that the authors did was the next step. They wanted to know if the doctor that was linked to the baby, and we’ll talk about what that link means, if the doctor that was linked to the baby, if the race of the doctor matters. And they did indeed found that that was the case that if a black doctor was taking care of a black baby, that baby was about 1/3 less likely to die, something eight out of 10,000 to maybe it’s about a half. I think it’s about four per, sorry. That baby was about half as likely to die from eight in a thousand to about four in a thousand if there was a black doctor. And that is a massive effect size. If real, that’s really significant. And so that was sort of just on the face what the paper was saying.

[Dr. Z]Now, of course, what would you interpret, if you believe those results and took them at face value? You would say, holy crap. The white doctors are either behaving in a biased, racist way and harming these children.

[Vinay] Right.

[Dr. Z] Advertently or inadvertently, or the black doctors are just so much better at taking care of black patients that it’s not even close, the outcomes are so different.

[Vinay] Now it’s one of the other, or both.

[Dr. Z]Or both?

[Vinay] Yeah.

[Dr. Z]Now both of those things are horrifying to imagine because it means that our white colleagues are either complete, so biased that they don’t even recognize it or just overtly biased. Or we’ve missed something about the aptitude of a specific race of doctors being so much better at caring for this particular group of patients. Both of those things are really like, they ought to merit a whole bunch of research if it’s true, but what is actually true when you look at the paper?

[Vinay] Yeah, I guess I would say in addition to what you said, it also suggests that the power of one doctor that touches a neonate is so big. It’s almost as big as all of the injustice that’s been going on for hundreds of years, all of the differences in socioeconomics of poverty of premature birth, all of that, 50% of that can be compensated for simply by the race of the physician. So it caught my eye and you and I both know, as a clinician, and I think this paper was done by people who weren’t clinicians. But you and I both know as clinicians that when a baby comes in or any patient they’re really sick, how many doctors touch that patient? How many nurses? How many respiratory techs? How many people touch that patient? It’s not just one. It’s many, many people. And what they’re saying is just one of these people, if that one person were different, you get this big effect. So I found that on the face, probably, a bit implausible. And so we dug some more and we found out that in Florida there is this field on the form and it’s called physician of record. And the hospital gets to assign a physician for the baby. And that assignment doesn’t always happen before the outcome is known. Sometimes the baby could have already passed away and then they decide, you know, who to put on this form. And that assignment is not standardized. It could be any doctor. So a number of possibilities emerge. If a baby is sick and goes to the intensive care unit, are they more likely to put a NICU doctor on that form? It turns out NICU doctors are slightly more white than general pediatricians. If the baby does well, are they more likely to put the general pediatrician? If the baby does poorly, they may even put a doctor who was not involved in the care of that child. It could be the medical director of the unit. And that’s often done in some of these hospitals. Perhaps for some degree, that’s done for legal liability reasons. But whatever the reason the field they’re linking to the baby’s outcome doesn’t guarantee this doctor took care of the baby, and it certainly doesn’t guarantee that this doctor played a causal role in the baby’s outcome. And I just say one more thing. I approached this paper from a different vantage which is that I am the biggest supporter of having more black physicians. I think we desperately need more black physicians.

[Dr. Z] [Dr. Z] I agree.

[Vinay] It’s a crime that the ratio of the number of black doctors we have and the number of black people we have in this country, that’s a disparity that needs to be ameliorated. So I’m a believer in that. But what I had a question mark was is does this paper show what it claims? And that I’m not convinced. And I think you can have both those things. And I think some of the people who are proponents of this paper, they make a mistake which is they think in order to convince the public that we ought to have more black doctors, we’ve gotta show findings like this. But I think the moment you concede that you play a dangerous game because we need more black doctors. We need more female doctors. We need more under-represented minority doctors because that is a good in and of itself, not because it’s instrumental in any other outcome or goal. And I wanna draw that distinction in this paper. So I criticize this paper as an ally, as a fan of, you know, the need for more diversity in our ranks.

[Dr. Z] I think what you said was really important which is you are assuming based on the results of this paper, if you don’t critically evaluate it, that one doctor’s being assigned to this patient can undo everything starting at the original sin of slavery in this country, all the momentum. I mean, if we think about this, the way we exist now as we exist in the present moment, and we’re this fluctuating vibration in the present moment, that is the result of the conditioning of previous present moments. Starting at slavery till now the amount of negative momentum for the African American community is so you can’t even put it into words. If you had a super computer, you might be able to quantify it. But you’re saying that somehow then assigning a black doctor to a black patient is gonna undo all of that.

[Vinay] Yeah, 50% of that.

[Dr. Z] 50% of that. That was the plausibility question that got you digging deeper into it. And the other thing you said that was interesting is it came across your desk through CNN. That’s how a lot of stuff comes to doctor’s desks now. It’s no longer from society meetings and this kind of site, it’s showing up in your Facebook feed. And people are sending it to you going, “What do you think of this?” Outrage on one side or the other. I actually got a lot of people who are outraged, that they felt that they were being personally attacked by this paper as a Caucasian nurse or doctor. And they were emotionally upset because they said, “This thing is basically saying “that I am killing my black patients “just by the mere fact of caring for them “and the color of my skin.”

[Vinay] And we know two things can be true. Implicit bias can exist.

[Vinay] [Dr. Z] 100%.

[Vinay] But can it result in 50% mortality? I mean, if you’re saying that you’re making a really bold claim about, I think, how much implicit bias can play a role. And it’s a very, I think, negative claim, but I want to put that aside. I think that the paper itself is just not able to do this. You know, the doctor who’s being attributed to the baby is attributed after the fact and is not attributed in a systematic way. That’s a nonstarter for me. You can’t even use that data for any purpose. You gotta abandon this project until you get better data.

[Vinay] [Dr. Z] Yeah.

[Vinay] But I believe that it is a mistake to go down this path. The more we look at immutable, characteristics of doctors be it our skin color, our sexual orientation, our gender, our gender identity, and we try to link this to whether or not patients live or die, we’re playing a very dangerous game because we might not want to unleash the potential for discriminatory results that may come from this. It would be one thing if all the results show that groups that have been marginalized do better as this paper shows, and as other papers have shown.

[Dr. Z] The women doctor piece, right? Those doctors have better outcomes, right?

[Vinay] It showed that they did better.

[Vinay] [Dr. Z] Right.

[Vinay] What if you find a result that, in any of these groups, some group did not do as well. Can you publish that result? And if not, is this even sort of a sandbox you should be playing in? Because you’ve really created a scientific setup where only one set of answers are appropriate or not. And then the last piece of the puzzle is analytical flexibility. I know it’s easy to think that the people who do this research, that it’s very complicated and they’re very complicated formulas, and therefore the answer they’re getting is the answer. But there’s a really elegant paper that came out a couple years ago by Brian Nozick and colleagues. They took data of soccer players and getting red cards from referees, and they had the pictures of soccer players so they could score them on a scale of one to five based on their skin color. By the way, I’m not a big fan of this kind of scoring, but they did it.

[Dr. Z] Right, right. We’d score kind of low on that one if it’s scored that way, right?

[Vinay] Yeah.

[Dr. Z] On a scale of one to 10 how dark are you?

[Vinay] Is it post-summer or pre-summer right? Right, yeah I darkened a lot.

[Dr. Z] By the way, by the way, quick side note, do your parents yell at you for getting tan?

[Vinay] Of course.

[Dr. Z] Yes, mine do too. What are you getting so tan for?

[Vinay] Why are you in the sun all the time?

[Dr. Z] Such a caste system I tell ya, yeah.

[Vinay] So, you know, they scored these players, they have the data set. They give this data set to 20 plus research teams and they said, “Is it the case that referees “are giving more red cards to darker skin players?” And the answer was each of the 23 teams produced a slightly different estimate and it’s all over the place. Several teams say there’s no increased bias, there’s no bias. And a bunch of teams say there is a bias, and some teams say the bias is massive. And the point of saying this is true for all research enterprises. You wanna know if women physicians do better than men, black physicians do better than white physicians. You’re gonna get a range of estimates from just the flexibility in the dataset. But add the filtration pressure of the society we’re living in and what is acceptable to publish, the net result might not be any closer to the truth, but just might be what people want to hear or hope to hear.

[Dr. Z] Okay, and that is the world we’re living in now, especially 2020, pandemic year, politics, election year, cancel culture, outrage culture, QAnon on the right, cancel kooks on the left. It’s a disaster. It’s a shit show if we’re being completely honest. That’s the only curse.

[Vinay] I agree with that.

[Dr. Z] Word I’m gonna use in this episode. You can still share this with your mom’s people. But what I’m trying to say here is if that’s the culture you’re in, tell me about, there was this thing that came up on Twitter recently, an EP doc who did it a study and basically got fired. Can you tell me about this thing? Because it points

[Vinay] Norman Wang.

[Dr. Z] To this issue. Yeah, what’s going on?

[Vinay] Yeah, so this is the story of a Norman Wang, who is an electrophysiologist in Pittsburgh. And he wrote a paper that was peer reviewed and published in one of the cardiology journals, one of the prestigious cardiology journals. It is called a white paper which I think by that, he means a sort of a thought piece–

[Dr. Z] Yeah, what do you mean white paper?

[Vinay] I don’t think he means it as a discriminatory term. A lot of sort of papers in this space are white papers, policy papers. But it is a paper really about the history of affirmative action. And I think Norman Wang ends up in a place that I’m actually not in. I’m actually more on the political left here. I’m more of a supporter of affirmative action policies, and I believe that the current legal precedent as set by this right of central leaning Supreme Court is actually off the mark, and it ought to course correct to the left. That’s where I am. But Norman Wang, I think, he falls a little bit different. He falls right of center on this issue. He believes that some of these policies have not actually helped the contingencies, that they’re thought to help, under represented minorities. He thinks some of these other policies might be leading to, sort of, penalties being paid by Asian physicians and white physicians. That is the gist of his paper. It is a paper that sort of outlines the legal history of affirmative action through these sort of complicated Supreme Court rulings, and ultimately kind of falls, I believe, right of center where he is a bit critical of affirmative action, that it should be done, that it can be done. And I think he’s even critical that the way it’s being done right now may technically be a violation of the current legal precedent. And this paper was doing a fine job of what most academic papers do, which is being forgotten. No one was reading it. Nobody cared. Because honestly, nobody read these papers.

[Dr. Z] Yeah, they really don’t unless they show up on CNN or Twitter, right?

[Vinay] Unless they show up on CNN, Twitter, nobody reads these papers. However, in the current moment, people have a lot of time on their hands and they’re finding papers that have been published months ago, that there’s a perceived offense. And the perceived offense is that, of course, you know, if you have the attitude of Norman Wang, you might not be in line with, I think, a lot of the well intentioned and good efforts that are actually being done to increase diversity in this country. So Norman Wang’s paper met an avalanche of criticism. It was retracted, I think by the end of the weekend. And Norman Wang was asked to step down as fellowship program director of the EP fellowship which is what he did.

[Dr. Z] Wow, wow.

[Vinay] I do not believe he was fired, but he was asked to step down. And I’ve heard dueling reports about whether or not he’s allowed to work with trainees.

[Vinay] [Dr. Z] Oh my gosh.

[Vinay] And I guess my issue here is that I actually disagree with the guy. I think he’s wrong. I think his interpretation of law, although I think it falls within sort of an accepted interpretation of law, a right of center sort of a Clarence Thomas, John Roberts kind of scope of law. I think it’s not where we ought to move. It’s a perverse law that actually prevents us as a society of doing what is necessary to make this a better and fairer place. So I disagree with him. But I think the way to disagree with somebody is to defeat their arguments. Norman Wang writes a, whatever, 15 page paper that no one is reading. I don’t wanna retract his paper. I’m actually not sure it actually meets grounds for retraction. There’d been some claims that he falsified quotes. We will find out. Those claims have not been formally put forward. I’m not sure it meets the grounds for retraction. But I’m not sure that’s an effective strategy. When you encounter ideas that you don’t like which we all do. We have to do our best to engage with them, to argue with them, to defeat the ideas and change the minds of the next generation. We don’t wanna drive ideas underground ’cause the moment you start driving them underground, I think they can gain momentum of their own. People will silently follow that. I think you have to take some ideas and defeat them rather than deny them. So that’s sort of where I fall on this. I have mixed feelings about it. Should the paper have been retracted as somebody who follows the rules of retraction? I’m not entirely convinced it meets those rules. At the same time, do I agree with him? No, I don’t. So I’m sort of totally torn on this issue.

[Dr. Z] And this is the thing, you can disagree with the guy and then come out with arguments, and say, “Well, these are the reasons I disagree.” Why would you cancel the guy, you know? And I think that’s what’s happening. And the MedBikini thing was another version of this, a different angle on this actually. Those guys and they were guys. And I’ll tell you already, what’s gonna happen is even you and me having this discussion as two men, we’re gonna get crapped on. And Oh, as two Indian men. I’m a Persian Indian. You’re Indian. Oh, we’re the model minority. We don’t understand what it’s like to be a minority. Well, what do you think about that?

[Vinay] I think it’s a tough issue. You know, I said something on the internet lately, and, you know, people pushed back on me, and said that I was speaking from a position of privilege. And I guess like many people–

[Dr. Z] I get told that all the time by the way.

[Vinay] And when you tell that to somebody, I mean, that is a modern way of insulting somebody that is acceptable.

[Dr. Z] It really is, yeah.

[Vinay] I mean, it’s a deep, personal insult. And, I think, the challenge that I face is that, you know, you really don’t know what I’ve been through. You don’t know where I grew up. You don’t know what my home life was like. You don’t know the struggles that I faced. And for you to turn around, and just to assume that I’m taking this position. And usually my positions are not strong positions. My positions are pro debate, pro discussion. That’s where I fall. And to assume that I’m taking that position out of simply because that I’ve been blessed with some sort of magical life that you have ascribed to me that I don’t feel on the inside, I think that’s kind of wrong. And I think we would all do better if we talk less about the characteristics of the person with whom we’re having the dialogue and more about the content of the discussion.

[Dr. Z] Heaven forbid, I have nothing to add to that you pretty much. This is what I say when you’re a wonderful communicator. We need to be saying this overtly. People are scared. Why do you think medical people are so terrified to take any sort of public debate in the way that you’re saying. ‘Cause I’ve been in this position. Sometimes I throw ad homonyms around and then I regret it. And the more I kind of really introspect and kind of look at myself, and say, “You know what, “is this how you wanna be in the world? “Is this your legacy?” No it’s not, so I try to pull back on that

[Vinay] I know, me too.

[Dr. Z] It’s hard.

[Vinay] It’s hard. I mean it’s natural. Because when you’re kind of upset about something and somebody is saying something stupid, you know, you wanna point out that there’s a reason why they’re saying something stupid. But I think if you step back, you reflect, and it’s part of growing. We can all evolve. And it’s okay to, sort of, try to do better in the future even though you’re not always perfect in the past.

[Dr. Z] Right, right. And I think also accepting and putting your own biases out on the table is important.

[Vinay] Yes.

[Vinay] Full transparency. You know, we talked about implicit bias earlier?

[Dr. Z] Yes. I took an implicit bias test. I’ve told this story a few times about gender bias. And I failed it. Basically, I am so biased towards old school views of male female roles and it’s unconscious. ‘Cause the way the test tests you, you get the right answer ’cause we’re woke enough that we go, “Yeah, women can be CEOs too.” But that little delay where you make the decision is what the test is measuring. And so it’s saying, “Are you overriding an unconscious bias?” Now here’s the thing, you overrode.

[Vinay] I see, yes. At the end of the day you did come to the right answer.

[Vinay] [Dr. Z] An unconscious bias!

[Vinay] Yeah, so that’s good

[Dr. Z] You used your conscious awareness to recognize something conditioned into you by forces that you didn’t control. Growing up in the seventies with two Indian immigrant physician parents who really valued those gender roles ’cause they came from them. Even though both my parents were doctors, my mother still cooked and cleaned and—

[Vinay] Even though she’s working full time.

[Dr. Z] Even though she’s working full time, doesn’t matter. And you know, that was something that was conditioned into me. So now to hold that person as a privileged, you know, bad individual is a villainization of the person that is absolutely not justified. And what it does, is it then weakens the ability to have a discourse because you assume ill intent or evil. And it’s a polarization, and I think this has really flowered on Twitter.

[Vinay] Yeah, I think so.

[Dr. Z] You know, John Haidt wrote a book about it, “The Coddling of the American Mind.”

[Vinay] Brilliant book.

[Dr. Z] Brilliant book, right.

[Vinay] And a number of excellent points. But I just wanna talk about the med Twitter for a second ’cause you led with that. This is another article that it was doing a damn fine job of being forgotten which is what these articles do. No one was reading it. And it was discussed at a conference many, many months before, and it was brought out on Twitter. And somebody brought it out in a very clear way. They highlighted the portion of the article that said bikini and they threw it out with a tweet that said something like, “Here are some male doctors shaming women “for wearing a bikini.”

[Dr. Z] Can you remind us what the study purporting show?

[Vinay] Yeah, this is a study like, and again, I have mixed feelings here because I hate all these studies.

[Vinay] [Dr. Z] Yeah, they’re dumb. They’re dumb, bad datasets.

[Vinay] For 10 years, I’ve been writing articles about how we judge professionalism in medical school. I’ve argued that it is used as a weapon to sort of cudgel views that we dislike. And there are a lot of just shitty professionalism articles. And I’ve been interested in this topic of how do you define professionalism, who defines it, how they set the rules and how they use it to punish people who have different views.

[Dr. Z] And I tell you now, they better use your long shaggy hair as an example of unprofessional, okay? Don’t tell me about COVID.

[Vinay] I don’t wanna pull a Pelosi and get my hair cut anyway. But .

[Dr. Z] So, you’ve actually delved into this.

[Vinay] Yes, I’ve delved into this, yeah.

[Vinay] [Dr. Z] Tell me more.

[Vinay] Okay, so the professionalism literature is, you know, years ago people had these surveys and they said things like, “Can we link medical school behaviors “to longterm board disciplinary reaction “such as being disciplined by the state medical board?” And of course, being disciplined by the state medical board is a very rare event. It’s like being hit by lightning. I mean, I’m sure it happens to doctors who are not doing a great job, don’t get me wrong. But of all the doctor’s not doing a great job. I believe disciplinary action is probably still an infrequent event.

[Dr. Z] Tiny, tiny. In fact, there was the anti-vaxxer who just finally got it disciplined.

[Vinay] Finally, and you know you can get away with a lot of stuff for a lot of years.

[Dr. Z] You can get away with basically murder.

[Vinay] So that’s the background. And in some of these things, they said, if you take food from a talk and you don’t finish the lecture that’s considered unprofessional. And I’m like, “Come on.”

[Dr. Z] Dude, then I’m the least professional.

[Vinay] I know.

[Dr. Z] I’d be like, “Hey guys from Pfizer “funding the talk, thanks. “Yeah, NORVASC for life, bro.” And then take the sandwich.

[Vinay] What’s unprofessional is professionals giving a shitty talk so I have to leave.

[Dr. Z] Oh yeah, hello, exactly.

[Vinay] Okay, but these are the kind of little petty things. So anyway–

[Dr. Z] Ad hominems. Ad hominems.

[Vinay] Ad hominems.

[Dr. Z] Right, yeah.

[Vinay] So these are the kinds of petty things that have been in the field. Then in the last five to seven years, they’ve been a number of surgical publications where doctors have decided to go on social media and be snoopy and snoop around people’s profiles and look for photos of them drinking alcohol, appearing intoxicated. Somebody added along the way for a man wearing a swimsuit with no shirt on, for a woman wearing a bikini with no top on. That was added to this list of sort of picky things to complain about.

[Dr. Z] I’m not wearing pants right now, bro. I mean, this is–

[Vinay] I didn’t wanna tell them.

[Dr. Z] Yeah, exactly. So this was another in a series of it right?

[Vinay] Yeah, of a series of these kind of–

[Vinay] Yeah, a series of these Yes, yes.

[Dr. Z] Wonderful legacy, right.

[Vinay] And the person being who’s the first author is, of course, a medical student who wants to go into vascular surgery where this fell. And why is he doing the article? Why are all the authors doing articles? I think we should actually be honest about it. They’re doing articles because that is the coin of the realm. This student is probably doing an article ’cause he wants to get into vascular surgery and they told him, “You gotta do some article,” And he thinks, “What can I do? “I don’t know anything about vascular surgery. “I’ve gotta do some bullshit article.” And that’s why he does this classic in the genre of bullshit, you know, professionalism.

[Dr. Z] Ah, it’s perfect. I can’t believe I didn’t think of it. That’d have been the kind of article I would’ve done. You know, you need to do some research. I went and did fruit flies, Drosophila melanogaster like radiating flies.

[Vinay] What were you thinking?

[Dr. Z] Like what was I thinking? I had to run gels. I could’ve just gone of Facebook trolled some.

[Vinay] Snooped around. Yeah, just trolled around

[Vinay] [Dr. Z] In bikinis.

[Vinay] Yeah. I think that the interesting thing about the article is that it faulted both men for being, you know, topless in a swimsuit and women for wearing bikinis. And it was quickly labeled and received this big inertia that it was sexist.

[Vinay] Right. And I guess I would say, I don’t wanna that it’s 0% sexist, but I wanna say that there are bigger sort of failings, outlines than sexism. Sexism wasn’t, I don’t believe, the core driver of that. In fact, men and women in equal numbers were faulted for this stupid swimsuit thing.

[Dr. Z] Yeah, That’s right.

[Vinay] The failing is why are we making students jump through useless hoops to become vascular surgeons? Why are we incentivizing these garbage articles? But that’s not where I think, so it’s fine. It was labeled as sexist. Sexism was a component to it clearly. But what was the reaction? The reaction was they apologized. Of course, when you apologize these days on Twitter.

[Vinay] [Dr. Z] Oh, you’re destroyed.

[Vinay] You’re destroyed. You can never apologize to the satisfaction of the mob.

[Vinay] [Dr. Z] No.

[Vinay] And we have to really be cautious about that. If you create a situation where you will never win for apologizing.

[Vinay] [Dr. Z] You’re not gonna apologize.

[Vinay] And that’s what we have in a big office right now. You create a situation where people will never apologize again. So we don’t want that. We want to actually give take an apology when an apology is given even if it’s not perfect because, you know what, this kid I don’t think has gone to the school of how to give a perfect apology. And maybe he didn’t do a perfect job. That’s one. Two, he received hundreds and hundreds and hundreds of posts calling him, you know.

[Vinay] [Dr. Z] Horrible things.

[Vinay] Horrible things. And then I, honestly, wanted to know, is the goal of the people criticizing this kid. Do you want this kid to kill himself? And I think you have to ask yourself that when you are fueling a mob on Twitter. He’s apologized. The paper is retracted. Was sexism the biggest driver? I don’t know. Did all the people who were outraged by the paper actually read the paper?

[Vinay] [Dr. Z] No.

[Vinay] I don’t know about that either. But now that he’s apologized, that paper has rescinded, what do you want to do? You wanna be the comment 450 telling this kid that you’re a misogynist and it was all your fault? I don’t wanna be that person. And if he does kill himself, how will you feel about how you handled it? You think it was appropriate to spend half your day hounding this kid? I don’t know. So those are the sorts of thorny issues, I think, it lays bare, that it is labeled #MedBikini. The bikini part was just one part of a broader sort of, you know, list of nitpicky, stupid things to judge people on. It was a judgy paper. It’s in the genre of judgy papers. It was done because we incentivize students to do useless papers to get to the next step of being a clinical doctor which has nothing to do with papers, you know? So I think that sort of the full story of this MedBikini is more complicated and more nuanced than sort of that single, these were three sexist men. They might be, but there’s more to it.

[Dr. Z] You know, and no one, where’s this discussion happening? You can’t nuance that on Twitter. You’re going to get attacked by the MedTwitter mob, woke Med Twitter. And believe me, I’ve been the victim of this mob. And the great thing is I don’t give a fudge about these people. To me, they’re all non-playable characters. They’re just zeros and ones on an internet. When I sit down with someone in person or I go to a talk and I talk to people, I realize these are human beings and we can disagree and have a wonderful conversation in a way that there’s minimal ad hominems flying around. But then you actually get to the heart of it, and almost invariably, we each come to a higher understanding of the other’s position.

[Vinay] Yes.

[Dr. Z] But can that happen in a world where you score points on social media? It’s about how many followers can I get if I attack, you know, Eugene Gu or one of these ding-dongs right?

[Vinay] Total dingdongs, yeah.

[Dr. Z] Yeah Gu, that’s a whole other discussion.

[Vinay] But I think, in addition to what you said which is well put, I mean, on this issue, one of the things it sort of unpacks is there are a lot of actual doctors who might actually think it is unprofessional to post photos in a swim trunks with no shirt. They might think it’s unprofessional to be visibly seen drinking alcohol. Now I actually don’t feel that way. I’m actually like a very socially liberal person. That’s not my view. But they may feel that way. And when you create the mob inertia saying that it’s wrong to feel that way, where do they take those ideas? They’re not gonna to tweet it. They’re gonna go in someone’s DMs. They’re going to go an email. They’re gonna promote these ideas in a back channel way. So I guess what I think the added irony of MedTwitter is by being sort of a woke mob, angry about this issue, we are stopping a discussion that we really need to have. If you wanna change the hearts and minds of a doctor who thinks it is unprofessional to take pictures of yourself like that and post it on the internet. I don’t think that, but there are people who do. We have to recognize, we live in a country with a lot of people who don’t think the way we do. And they’re not so they’re not so few of them that you can just push them aside. They are potentially even the silent majority. Who knows, you know? We do not really survey these kinds of issues and we need to do our best to change the hearts and minds, not drive them away.

[Dr. Z] And, you know, I will even add to that and say, it is what Haidt talks about, a moral matrix thing. So the moral taste bud of sanctity versus degradation is something that, I think, you and I having been conditioned in the left as we come up in academics and all that, we ignore that taste bud. And it’s a very powerful one because it drives a lot of human behavior that is actually motivated by a sense of doing right. And so this idea that, “Okay, “I would not choose a doctor for myself “that is wearing swim trunks, “drinking a beer on a beach in Cabo “and tweeting it under his real name, going ‘Bro Cabo.” Well, you know what, honestly, I have some sympathy to that.

[Vinay] I know, a lot of people do. And the other thing is, you know, the relationship you have with a patient is a carefully cultivated relationship.

[Vinay] [Dr. Z] Yes it is, yeah.

[Vinay] You want them to view you in a light. And I think there are some people, that kind of picture will change the way they view you. That’s a discussion that needs to be had, not suppressed.

[Dr. Z] Not suppressed. And the truth is the fact that I’m even having this discussion, people are going to say, “Well, “you dress in drag, and do music videos, “and you drop F bombs, “and you’ve said terrible things on your show,” and all of that is true. I also don’t then bring that into my patient interactions. I’m a hospitalist. So patients don’t necessarily even know who I am or choose me. They’re often elders who are sick. But that doesn’t excuse it. So if patients were coming to me on mass and saying, you know, I saw your videos, I think it’s really unprofessional. I’m not comfortable having you as my doctor. I might change course on what I did if being a physician was my livelihood. It turns out it’s not anymore, but if it were. And that’s called using your judgment, right? So I think it’s worth having the discussion. And now the problem, like you said, it’s tinged with the sexist TS. There’s a lot of, I mean, the data set was terrible.

[Vinay] Oh, it was trash.

[Dr. Z] Yes, it was garbage.

[Vinay] It’s a garbage paper. I mean, it shouldn’t have been published for a different reason, I think, which is that it’s not really scholarship.

[Vinay] [Dr. Z] Not science, right.

[Vinay] And it’s in a genre that’s bad. Were they really three sexist guys set out to grind a sexist axe? I’m not sure of that. That was a narrative, that was a top spin put on the ball. And a lot of people played that ball. But they’re also people who are doing their best in a shitty system, and they made a mistake. And I think, you know, they own their mistake.

[Dr. Z] I actually saw the apology from the PI.

[Vinay] The PI.

[Dr. Z] And I thought it was reasonably well done overall. Now what was interesting is I watched the responses to that. Now a good number of responses were “Thank you for recognizing.

[Vinay] Yes, apologizing, yeah.

[Dr. Z] The garbage of this paper. And then there were the MedTwitter people that were just like, “You privileged, white, sexist men. “How dare you!” And at that point you’re like, well, this discussion’s over. If I were him, I’d be like, “Cancel this Twitter account. “And I’m just not gonna go on Twitter.”

[Vinay] In fact, I would have advised them to do that.

[Vinay] [Dr. Z] That’s right.

[Vinay] Because they didn’t have a lot going on on that Twitter account and it didn’t end well.

[Vinay] [Dr. Z] It’s nothing but pain.

[Vinay] It’s nothing but pain.

[Vinay] [Dr. Z] Right.

[Vinay] Yeah, but I guess I think it speaks something to the fact that, you know, you and I in our sense of sort of aesthetics and decorum, you know, we’re probably very similar.

[Vinay] [Dr. Z] I think we are.

[Vinay] Those kinds of things don’t bother. But it says something that when you are, I don’t know, on that view of the issue. And like I said, I hate all these kind of papers, but I still feel like, I think, that they were punished a little bit harshly by the mob. Mobs punish people in a very cruel way. And when everyone throws a stone at someone and they’re dead, who killed him? You know, something like that.

[Dr. Z] Yeah, yeah. They’re all NPCs at that point, non playable characters, because they’re all piling on. And the thing is, this is what we don’t. And you mentioned, you alluded this when you said, “What if this kid decides to kill himself?”

[Vinay] Yeah, what if he did?

[Dr. Z] Okay, why would that happen? Because human beings, when they are attacked by their own tribe. So let’s unpack that for a second because our own tribe, I take a lot of criticism from people that are not in my tribe. So if it’s an anti-vax activist who’s been delusional for a decade about science and is talking about, you know, radio waves and 5G and all this crazy stuff, I don’t see them as in group. It’s almost like it’s my natural tendency. And again, I’m processing this as I would with a psychotherapist, which I don’t have and probably need. I see them as out-group and I am willing to take their criticism and just let it go . Because it’s somebody that I don’t value their opinion. If another doctor criticizes me, it is like , and your immediate response is, “What did I do wrong?” ‘Cause I’m already afflicted with imposter syndrome. I already don’t think I deserve to be here. Now my own people are telling me you’re a bad person. Now imagine this kid who’s a medical student and a bunch of the tribe that he’s enter desperately these sacrifice.

[Vinay] Yeah, desperately enter. Doing this stupid paper, just to get in.

[Dr. Z] Just to get in. By the way my goal is to, at this point, we’re gonna harass the people who harassed him so much and we’re gonna affect them. But you know what I’m saying.

[Vinay] But they’re faceless. I mean, nobody will take it personally.

[Dr. Z] It’s a mass. Yeah, these people, like you were one of them. You’ve retweeted that, or you added your voice to them.

[Vinay] But the other difference, I think, that you and I have been gradually in the public space, in this space, how public it is is a matter of debate, at least in my case, right?

[Dr. Z] No, no, no. Your podcast is quite popular actually.

[Vinay] Among a certain brand of recluse . But we’ve been in the arena for awhile and we put our armor on slowly. This kid is going from no armor to gettin’ speared in the chest.

[Vinay] [Dr. Z] Right.

[Vinay] So I remember what it was like when I was, you know, the first time I got criticism was when I was finishing my fellowship, some paper we wrote, somebody said it was a stupid paper. I got in an argument with Milt Packer about paradigm trial which I think is a bad trial, and I got some flack on the internet. And then it just escalated every year that I was an academic because my papers and my writing got more notice and I got more and more criticism. And so I built my exoskeleton slowly, piece by piece. And why does it hurt? I mean, every person is susceptible to negative comments. We all don’t want to hear like we’re the horrible person. I think I have a lot of props for people like Hillary Clinton, you know? Can you imagine that kind of life where it’s just millions of hate comments to her and she’s built sort of something that keeps her self separate from that. But we’re not all there on day one. And this kid is on the other end of the spectrum. And he just did a paper that was really a cookie cutter paper of somebody else’s paper in a different field. And he just got harpooned for it. And he may even be thinking like, “My career is over. “I’ll never be a vascular surgeon.” So I do have a little bit of pity for this kid who I don’t think his intent was sexism. I think his intent was a paper to get into vascular surgery.

[Dr. Z] And, you know, intent matters.

[Vinay] I think it does.

[Dr. Z] But we act like it doesn’t. Like, if you’re intending to be a jackass and a racist, well then you should suffer some degree of consequences for that. If your intent was benign and you screwed up, someone should educate you. It’s like just culture in hospitals. You know, you don’t go, “Oh, you know, “you accidentally gave the wrong drug “and this patient had an adverse outcome “and you’re a bad person and you should die.”

[Vinay] “And you wanted to kill them. “Didn’t you wanna kill ’em?”

[Dr. Z] “You’re intent was to be “negligent,” and so then what happens? You have second victim effect where the person who made the mistake just beats themselves up. But just culture says, “No, let’s go through this. “Okay, was there malignant intent? “No. “Was it criminally negligent? “No. “Is there education that needs to happen? “Yes. “Should forgiveness happen? “Yes. “Shouldn’t apology happened to the patient? “Probably.” And if we did all that, it’s a very different thing now. And we have such a negativity bias. Tell me if this is true for you. Million positive comments, “You’re the greatest thing since whatever,” and then one comment, “Hey, you bald clown.”

[Vinay] Or in my case, “Get a haircut.”

[Dr. Z] Get a haircut. Exactly, right? Yeah, and you just focus on it.

[Vinay] I even heard Malcolm Gladwell say the same thing that there’s always gonna be a fraction of people who don’t like your your thing. It’s gonna be 1%. But when you get to his level, that 1% is a lot bigger.

[Vinay] [Dr. Z] It’s big.

[Vinay] It’s big. And we all anchor onto the negative comments. That’s why, I think, sometimes I don’t read the comments, particularly if what I’ve argued is something that I know is gonna get that sort of classic, you know, “I don’t really wanna understand your argument. “I just want to kind of voice “my discontent at what you’re saying.”

[Dr. Z] Well, you know, what’s funny? So now I have this proxy army of ZPac supporters who love what we do, they’re aligned with us. If they were all in the room with us right now, these 7,000 supporters, we would probably agree on 80% of stuff, and then 20% would make an amazing conversation. Good, motivated people. They get, I use the term butthurt by proxy. So they get hurt on behalf of me when they read some comments from the broader internet that are, you know, clearly just either they’re Russian bots or they’re just some dude in his basement goin’ “This guy sucks and he’s fat.” And they get really upset and they’ll attack those people or try to, and they’ll email me. They’re like, “You know, “this guy is saying some terrible things about you.” And I have to be like, “You know my children, “let me tell you. “We are all one and don’t let it bother you because.” You know, you really have to let those things go. And understand too, that the person making the comment is suffering their own kind of, in a way they’re suffering something that would provoke them to attack a stranger on the internet. So there’s some hurt there. There’s something that you triggered, inadvertently, but it’s hurt them enough that they’re doing this thing. So let’s have a little compassion and hold them in a little bit . Now what’s interesting is now I’ll do a show like say when I am ridiculed that plandemic.

[Vinay] Of course, but there’s a difference there. When you and I pick something to attack, it’s because we believe, and usually are correct that that force is teaching people a bad lesson.

[Vinay] [Dr. Z] The wrong thing.

[Vinay] The wrong lesson. You’re not going out there and goin’ to somebody who’s a violinist and saying, “You suck. “You’re out of tune,” you know? You’re not goin’ to him and slapping him in the face. You’re doing something because you believe there’s a net societal benefit for me pointing this out in this manner, which is an engaging manner that reaches more people than that boring article in the journal that’s no one’s going to read, right? So you’re doing it because you have a mission of sorts, but the people who like troll, I’m sure you get the same kind of trolling. I do probably to a larger degree. The troll on the internet, they’re not doing it with a bigger mission, I think. Sometimes they just don’t like the cartier suit.

[Dr. Z] Yeah, right, right, right, right, right. And again, I don’t care.

[Vinay] You have to not care.

[Dr. Z] But that takes practice, like you said, to build your exoskeleton.

[Vinay] You need to build it.

[Dr. Z] I like the analogy you use like this kid with no armor.

[Vinay] No armor.

[Dr. Z] Is now speared by the very tribe that they want enough. It just feel the sympathy for this kid. Now that all being said, now imagine you’re so conditioned by ideology. Let’s just say the ideology of the very left that says all power is a dynamic around race and control, and these forces are evil that are trying to keep people down and we need equality of outcomes, not equality of opportunity. Equality of outcomes.

[Vinay] That’s the far left position, yeah. The far left position, and say, okay, if you believe that, then you see these people doing this stuff and they are evil, they are the villain. And the same with the far right. They look at a me, who’s in the center actually, a centrist, and they call me this shit, “You’re a communist, sympathizer, like a Democratic shill.” I’m like, “Bro, I’m a registered independent.” I can’t even vote in the primaries.

[Vinay] I guess it makes me think of two things. One, I mean, I understand, and I sympathize with a lot of the views on the left because I hold a lot of those views. How capital has deformed our society, and how the sins of prior generations do perpetuate themselves. I hold a lot of those views.

[Vinay] [Dr. Z] Incentives matter.

[Vinay] Incentives matter, yeah. But one of the things about the left that I always thought was sacrosanct was that we on the left believe in forgiveness, believe that punishment should serve a purpose, rehabilitate rather than merely be retributive. But yet when you see people punishing this kid, are they really trying to rehabilitate the kid to get the kid to not be sexist? Or does it get a little bit out of control? And they just want to, I don’t know what they want. They wanna torpedo this kid. So I think those of us on the left, including people on the far left, who hold positions that I don’t think I’m all the way there, they are too cruel at times in the cancel culture mentality. They wanna get people fired from their job. Well, you know what, when you get somebody fired from your job in America, in this year, you not only deprive them of a livelihood, you deprive them of healthcare, you deprive their children of healthcare. That is a really bold thing to do. And yet you see that from people on the left who should have more compassion in my mind as someone on the left.

[Dr. Z] I think you’re getting at the heart of the moral matrix of left versus right. And how, you know, I think it’s been looked at, and maybe this data set is crap and I suspected it. But if you’re looking at like the big five personality traits, the left seems to score higher on openness to experience. That’s the main differentiator which makes sense because conservatives are like.

[Vinay] Let’s keep it chill.

[Dr. Z] Let’s chill out here. Get being practically naked, holding a beer is not very doctorly, right? Whereas the left is kind of like, “Well, maybe it is, maybe we need to change.” Maybe there’s this, you know. So left also values fairness versus cheating, and right lessened that, right? Loyalty versus subversion, sanctity versus degradation. These kind of pallets are a little more strong. So what ends up happening, what I’ve noticed is, so the left scores higher on disagreeableness. So they tend to be a little more poke you in the eye and try to fight a little bit. Whereas the right is much more polite,. Even though they disagree, they tend to be a little more polite. And I’ve noticed this in my travels around the country. So when I speak in Texas say, it’s a very conservative place, people are absolutely polite, they listen to ideas they don’t agree with, and they’ll gently argue back. But if you do the same thing in say, San Francisco, someone will be like, “Bro, you’re a fascist man. “You need to shut the heck up.” So it’s just a different kind of conditioning that I have just seen. Now it could be that I don’t have a big enough n number. But again, as someone who was sort of fledged in that leftist sort of crucible, it’s for the first time in my life I’m able to see both sides a little more because I was forced to doing the show that I do. And also I get older and I’m a little more libertarian, I’m a little. So it’s kind of fun to see that evolve. And now I try to make it a point of, okay, from the center what does this look like? And it’s important to have your belief, and really be passionate about it. But at the same time to recognize that others who have equally good intent can have different beliefs and then you can discuss it. This idea of shutting people down is just the worst.

[Vinay] You know, I think I come to it and the exact same conclusion you do from a slightly different way. I arrive at the same place which is, you know, in my career, I have, you know, a lot of issues that I care about. But one issue is how do we approve cancer drugs? How do we study them? How do we make sense of them? I quickly realized in my career that I was fighting against the current, that there are a lot of forces at play that were going the other way. Maybe even the majority of my colleagues, academic oncologists, the majority of the industry funding, there were a lot of forces going the other way. And so I quickly, sort of, did a course correct. I started to think I’m not gonna win this war by just trying to demonize them or shut them out. I can only win the war if I can change some of their votes. I need their votes. I need their minds. So when you have that perspective in whatever discussion it is from, you know, how we think about professionalism, what should affirmative action look like in a school. If your mentality is to win this issue, we gotta flip some people over to our side. The way you approach it is different, I think, than preaching to the choir. The way you approach it is thinking about what is the mental roadblock that they have in their mind that keeps them from seeing it the way I see it and what can I do to convince them, to show them that they are mistaken in that roadblock. And so in my academic work, I spend a lot of time thinking, like, “What does Dr. X in other university think?” Like, “Why does Dr. X not agree with me?” And I was like, “Well, Dr. X believes “that this is true about cancer drugs.” But I’m like, “That’s not true at all. “Let’s let’s study that. “Let’s show that to Dr. X.” And the other thing I think about is the youth. You know, there might be a thing to the fact that, you know, there’s inevitably a generation change in medicine. It’s really slow, but inevitably.

[Dr. Z] Medicine changes one funeral at a time.

[Vinay] Yeah, and I think that’s right because you need a changing of the guard to really change some ideas. So I spend a lot more time thinking, “How do you reach the next generation of HemOnc fellows “to let them see things this way?”

[Dr. Z] And that’s why what you’re doing in your platform is so important because I tell you, I’m rarely struck by, there’s so many people doing podcast, man. Like so many.

[Vinay] Somebody gave me a magnet that said, “I couldn’t afford a psychiatrist, so I started a podcast.”

[Dr. Z] Man, that’s so spot on. It’s so spot on. I tell you, most of my live shows are psychotherapy for me. You know? Like the other night I did one and I was just like, “Guys, “let’s just think for ourselves.” And I’m really talking to myself. Look over your biases, try to overcome them, and just think clearly. Don’t be an ideologic purist where you’re just checking the boxes of your tribe, right? So many podcasts and I’m invited on a million of them and they’re all very good people, but man, their podcasts are garbage. And I’m just being totally honest. I can’t sit through them. It starts with the quality being poor of the audio.

[Vinay] Bad audio, oh God. Don’t get me started.

[Dr. Z] And that’s the worst.

[Vinay] The worst!

[Dr. Z] The audio is the only thing that matters. Video doesn’t matter. It’s how good is that audio? And by the way, I learned that from you. I had a shittier mic. And then I saw you mic when we did our show, and I’m like, “I want his mic.” And I call Logan and I’m like, “Logan, what’s his mic? “Oh, it’s like the Shura SE7 beats. “It’s like a really good mic. “Yeah, how much does it cost? “Well it’s this much.” I’m like, “That’s not happening.” So then I went on my show and I’m like, “Guys, I’m raising money for some mics.”

[Vinay] But I’ll tell you, I’m such an audiophile about this because when I listen I wanna feel like I’m sitting right there at the table for the discussion. And that only comes when you got the crystal poppin’ microphone. But you’re right. The audio quality is crap. The content is garbage.

[Dr. Z] Garbage.

[Vinay] The person who’s speaking, let’s talk about this for a little bit. The person speaking is unwilling to tell you what they actually think. And, you know, that’s something that, what you have done in your program is you have always been willing to put yourself out there. Not only do you show your audience how you think about issues, you are willing to show them your artistic and creative side. You know, that’s a comfort that I don’t have with my audience ’cause I’m not gonna show them that kind of stuff. But you are. That’s what you want from the person you’re listening to. You want them to be able to offer themselves a little bit like that. And so many podcasts, they don’t offer themselves. So of course, no one’s gonna like it.

[Dr. Z] So what you basically described is authenticity. And you know what, now I’m realizing that’s what resonated with your stuff. That’s why I had you come back. That’s why we did our first Zoom call because there’s tons of people who are trying to get on this ridiculous show. They’ll send me their thing. And they’re like, “Oh, I wanna on your show.” And you’re like, you’re inauthentic. That’s what it is. You’re never gonna open up and tell me what you really think. The first time I listened to it was just a random podcast, I was like, “Did he just say that? “Oh my, and he said it with conviction, “and evidence, and support, “and articulately with a variance in tone. “Like .” I had man crush instantly. It’s so rare. Why is it so rare though?

[Vinay] I mean, this is something that we were kind of talking a little bit about before we started, but I find it so interesting that there are, you know, we were just having this national discussion about soldiers and what they mean to this country. And contrary to some political figures, I believe soldiers are, you know, the greatest thing. These are people who are willing to sacrifice their lives for a principle, for a country, for a vision of what we ought to be. What could be more meaningful than that? And we have these people in society that we revere, who are heroes, who sacrifice everything for an idea. And then you see physicians who are often unwilling to even tell you what they think because they’re so guarded and concerned about their potential for career advancement in this tiny little bureaucratic organization in this grand scheme of life. You know what I mean? They’re so reluctant to say anything outside of the narrow box they’ve painted themselves in. And I don’t fully understand that because, you know, those are the kind of people we need to take a little bit of a leap, to push people, to speak up for what they care about especially if they think that it’s an injustice being done to others who are less fortunate. We need them to speak up. And so I am always struck by how many people are so guarded about every word they say, who declined to come on my podcast ’cause they don’t want to tell people what they really think about some cancer drug ’cause they think the company won’t give ’em a trial in five years. You know, there are a lot of people who are reluctant to put themselves out there. But just contrast that with the soldier. They’ll give everything for an idea. You’ll give nothing for something you care about. That’s to me is an indefensible.

[Dr. Z] You know, I don’t know how much of our audience resonates with that the way I resonate with it. But it’s like an emotional issue for me. I feel like it is a crime against your existence on this earth that you will not open your mouth to defend what you believe, to speak, to communicate, to teach others, to connect with others, that you will censor yourself in that way for a game that is ephemeral. It means nothing. You said it, it’s a little bureaucratic world that people are protecting. And these are the kind of people that want to be on my show. The people who never ask are the ones that I have in here, you know? The problem, and this is the thing, so I look at myself and I go, “Well, “that’s the only thing I have is I’m willing “to say what I think.” I don’t have a big auspicious research history. I mean, that Drosophila thing though. Genetics, genetic.

[Vinay] That’s key, that’s key.

[Vinay] [Dr. Z] “Journal of Genetics.”

[Vinay] But you’re willing to say what you think and you know what you think. You interrogate yourself. You’ve reached an idea about some issue. There are a lot of people that don’t even do that first part. They don’t even, I think for issues, they not really sat down and thought about it. For instance, the PNAS paper. A lot of people just take the headline. That’s what I think about that paper. The MedBikini paper, a lot of people took the Tweet. That’s what I think about the paper. They read the paper, think about it, make their own decision. I think that’s another problem. But you know, one of the things this reminds me of is the track for academic leadership. I often hear people say something like, “Well, “if you really wanna make change, you gotta be the Dean. “You gotta be the chancellor. “You gotta be the provost. “Those are the people who can really make change.” And I wanna say, if the path to get there is a series of sacrifices. You sacrifice everything along the way. You didn’t speak up here. You didn’t speak up here. You kept it to yourself there. If that’s your whole life to get to be Dean, by the time you become Dean, you’ll have nothing left to fight for it. You’ll have lost who you are along the way. And I think that’s so often what many of us feel about the leadership in academia?

[Dr. Z] Oh man, you nailed it. That’s really what it is. And you can say that about political leaders.

[Vinay] Yeah, you can say that about them.

[Dr. Z] You know what else, I’ll say this, and I’m gonna say something that’ll trigger you for sure. But I think that’s why Trump is president because he’s the one guy who is just like, “I don’t care. “I’m gonna say whatever. “However offensive it is, whatever it is, “the people who agree with me will vote me in.” Whereas then you look at anybody who could run against that’s bred in the political mill, they’re gonna look like inauthentic pieces of crap.

[Vinay] Yeah, I think Americans and I grew up in the Midwest. I grew up in, you know, Indiana. I think Americans don’t like someone who has always aspired to be a politician. And for all his faults, which are innumerable, which you could have a whole couple of hours on, one of the things he does reek of is someone who I could care less if you give me this job or not. And I think at one point in time in the election 2016, he really could care less if he got it or not. He had other plans if he didn’t get it. And Americans like that to some degree because the person who could care less about having this title or this moniker, that might be the person who’s really willing to shake it up. Did he shake it up in a good way? I don’t think so. But there are people who are in this country who are hurting financially. They want someone to shake it up, and they wanna pick someone who they think has a courage to stand up to all the forces that say status quo. And to some degree they found an outlet in him.

[Dr. Z] It’s like, are you a “Game of Thrones” fan at all?

[Vinay] I love it.

[Dr. Z] So it’s like, when Daenerys says it’s time to break the wheel, right? And people think, okay, she’s the character to do that. And they’re desperate for it because they’ve dealt with conditioned servitude for so long and inauthenticity. And then when someone comes, who says, “No, I’m authentic as fudge. “I’m gonna tell you exactly what I think,” it’s a transformative thing. And I think you said there’s something specific about Americans too, that really resonate with that because the whole country was founded on, “I can’t function in England. “These people a-holes. “I’m going to go over here.”

[Vinay] So that courage it takes to do that, to say, you know, “We’ve put our lives on the line. “They could kill us for this, even having this idea.” And that’s the original idea of America were people willing to do that.

[Dr. Z] And I think that’s why it becomes urgent. This isn’t a intellectual exercise we’re having. This is why we get passionate about it because it affects everybody, this inauthenticity that’s bred into us out of fear, out of inertia, out of playing a game that really isn’t a game worth winning. So then you become Dean. Yeah, your gravestone says Dean of Stanford or whatever. Dean Lloyd Minor or whoever it is right now, right? Just to shuffle the deck.

[Vinay] The 22nd Dean who did the same as the prior 21. That’s what it’s gonna say right on the tombstone.

[Dr. Z] Right. Whereas if you’re a Dumbledore who kind of wanted the wheel broken himself, right? That’s a different kind of thing, but we don’t reward that. And in an academic sense-

[Vinay] And maybe we should talk about academics is in need for the reformation.

[Vinay] [Dr. Z] Yes.

[Vinay] We could talk about many dimensions, but one dimension is we don’t value people who provide value. Although one of the main goals, or thrusts, of academic institutions is to be a place that teaches the next generation to be bold and think boldly. We don’t reward the people who do the bulk of the teaching, who are the consummate teachers, the clinicians who take care of patients. We almost don’t reward patient care. We reward pipetting in a laboratory and publishing in “Nature”, “Cell” and “Science.” We reward getting grants and running a business. We reward, you know, a handful of things that are check boxes on a CV, but we’re not rewarding this thing that we’ve been gifted from society, the privilege of training the next generation to do better. And I think that’s what many of us in academics feel why you can’t become Dean with a road of a thousand compromises. You have to stand for something, know what you stand for and fight for it the whole way. And if you get there, you get there. And if you don’t, at least you died trying.

[Dr. Z] And you and I would probably agree with this we’re the teacher phenotype. And the teacher phenotype is one that values knowledge for the sake of being able to share it. And we don’t have enough of that in our academics. Like it’s really, it’s more the, the researcher phenotype which is the introverted science maven type which is like, “I know everything about this. “I will share a little with you “just so that I can know it better.” And that’s great. You need that. You need that. But that should not be the sole thing we value. My wife, academic chest radiologist at Stanford wins teaching awards like every single year she’s done the thing. And when I watch what she does at home, I’m like, “Why are you, what are you doing? “Like it’s nightly family, watching time. “We’re watching ‘Avatar the last Air bender.’ “Like, why are you on your computer “looking at these stupid images? “Work is over. “Your shift is done. “Like, what are you doing? And she’s like, “I’m supposed to do a lecture “for the students two weeks from now. “And I just wanna make sure it’s good.” And the amount of passion. She knows all this material, but she wants to teach. We need to value that.

[Vinay] We need to value that. There was a speaker I invited to Oregon where I used to work up there and he came and gave this lecture where he spliced the video in his PowerPoint and he had it timed perfectly, and he played it a loop, and he played a clip, and he dissected this video segment, he explained all the parts of it, and he had this really kind of good punchline at the end. In other words, he took a lot of pride in that craft. And at the end, I had asked a couple of students. I said, you know, “I heard this guy gives a good lecture. “You should come.” And they came and I asked ’em, “What do you think of that lecture?” And the kid was like, “Well, that was the best lecture.” I was like, “Yeah, it was good, right?” And he was like, “No, you don’t understand. He’s like, “That was the single best lecture “I have ever been to,” because the speaker took pride in it. And that’s the kind of thing that, in academic medicine, there are very little benefits to the person for spending all the time it takes to give a one hour lecture. As a case of your wife may be spending 10 hours, 20 hours on the back end. That’s gonna go on the CV as, “Gave class lecture,” you know? Which is in the section of the CV that people don’t read.

[Dr. Z] They don’t read it.

[Vinay] They don’t read. And the difference between that, all that effort, and somebody who just went up there and use the slides they did from the last talk, And, “Oh, it says 2017. “I know it’s 2020 now. “I gotta update these slides.” You know, there’s no difference in that in how we reward that activity. And I think that’s part of why I think it’s unconscionable we charge ’em what we charge ’em because I don’t think we’re delivering what we need to be.

[Dr. Z] I’m so with you, man. I mean, I stopped going to class mid, end of first year which was terrible because I lost social connections, I lost a sense of purpose because now you’re just reading from books. But sitting with the stage on the stage blathering on I’m like, “This is dumb.” And now kids just put the crap in their ears and play it at 3X. And you know, they think it’s gonna be like the matrix, “I know Kung Fu.”

[Vinay] I know it all.

[Dr. Z] Yeah, that’s not how it works.

[Vinay] So when were you in your career that you decided that this was what you were gonna at least grow or be a part of your career? How early on were you?

[Dr. Z] You know, I never knew it would be this early on, but I was teaching for an MCAT class right after college. So I rushed through college in three years at Berkeley, so I could take the fourth and do research in that lab. But at the same time, I was teaching MCAT to make some cash money. It was like their competitor Berkeley review.

[Vinay] Ah, I see, okay.

[Dr. Z] Great, great group because they were super intensive. They were like the gunners of the med prep, you know? The Kaplan were like amateurs. So the way that we have to teach was, it was a series of three, two hour lectures, two days in a row. And I had to do general chemistry which I knew nothing about. The guy was like, “Hey, you did decent “on your MCAT, you should come teach for us.” Well, I had to learn all that stuff, and then I was presented with an audience of my peers. These are still my peers. They’re equivalent. They’re smarter than me, a lot of them. And they’re super gunners. They all wanna go to UCSF where I had gotten in. And so that was the only credibility that I had.

[Vinay] Yeah so they idolized you.

[Dr. Z] They idolized me, but I knew no general chemistry. So how was I gonna survive? Learn to teach while entertaining while making it palatable while making it understandable for me ’cause I never learned it, right? Well, that then gave me the 10,000 hours, ’cause two hours a day, two days a week for like three years I did that with tough audiences. By the sixth lecture in that series, I had the comedy nailed, I had it all. And so that then opened this idea that teaching is something that can be done better than it’s done. And I think that then incepted me that eventually I would do it via video. And so that’s kind of how it. How did it happen for you then?

[Vinay] I guess I would say, did it happen? No, I guess I’d say–

[Vinay] [Dr. Z] You’re still employed. It couldn’t have happened, right?

[Vinay] I mean, I started making a podcast in 2018. That’s the most I, you know, that’s sort of my first foray into social media besides Twitter because Twitter was a place where you couldn’t put ideas out that were too hot. And let’s talk about my ideas. These aren’t ideas about politics or society. These were ideas about whether or not, you know, certain drugs should have been approved by the FDA with an uncontrolled study of 50 people. I mean, they’re kind of esoteric ideas. But even there, it was too hot for Twitter, and I’d get a lot of pushback and a lot of sort of vitriol. And I thought, you know, maybe, again, my thinking is why are all these people who I need to flip over and join me on this side, why don’t they see it from my point of view? And I was like, maybe it’s not explained to them at the length they need. And so that’s why I started podcasting to really kind of, let’s flesh out all the background. You know, let’s explain why is this approval problematic?

[Dr. Z] That’s awesome. And because the end point goal of yours is to flip people in something

[Vinay] That’s what I wanna do.

[Dr. Z] That is crucially important. And we didn’t get into this in this episode, but we’ll do it again future because your sort of passionate movement is, “Hey, we’re often approving drugs “that have no to marginal benefit, “harm on data that is crap data.”

[Vinay] That’s right. That’s my view.

[Dr. Z] And it’s incentivized by profit, of course, and money, which is how our US system works. And why aren’t we screaming from the rafters about this when patients, our mother who’s treated for breast cancer. And so that was the book “Malignant,” actually. So people should check, I’ll put links to all this crap.

[Vinay] Sure, and why is that my issue? Because that’s the issue I’m uniquely qualified to talk about, you know? That’s the issue that, you know, I’m the one who went to school for all these years, studying this random field. I’m the one who has this random background in epidemiology, but also oncology. I’m the one who spent all this time in regulatory affairs. They’re just nobody. I mean, there are other people who could do it, but they’re not many, let’s put it that way. ‘Cause I don’t want to take away from them. But so I’m uniquely qualified to do this. Are there other issues out there that I believe in wholeheartedly that I applaud people for working on? Yeah, absolutely. But I’m not uniquely qualified for that. It won’t benefit any extra from having me. I don’t know anything more than what anyone else knows about that. So that’s why this is my issue. But I did set out, as you say, you know, to flip, flip the minds, flip a few cards. If we get, right now, maybe we’re 5% polling, I don’t know what we’re polling. But if we get 15% then we’re in the debates, you know? It’s just that. It’s just a little step forward each time.

[Dr. Z] That is so awesome. You know what I love about that the most is that you recognize your unique position that these are the cards that have been dealt to you, very few other people have the cards including the communication aspect, so here’s what you’re actually gonna use those cards. So many people are living in fear to use the cards that they’ve been dealt.

[Vinay] That’s absolutely right. And whenever I talk to trainees, I had this student who worked with me recently and she’s like the best artist and like a really good musician. And you know, she’s thinking about what specialty to go into. I should have her talk to you actually.

[Dr. Z] Yeah, that’d be great.

[Vinay] But she is thinking like, “Well, you know, “the musician, the artistry, that stuff for the side. “That’s not my career. “I gotta think about my career.” And I said, “No, no, no, no, no. “Who knows what the world holds? “That stuff could be your career too.” And so I knew she was such a good artist that I thought of this paper that I had long thought of. But the thing we’re missing is we need somebody to illustrate this paper with figures. And these figures are like, I don’t know how to, I can’t draw this. Then I was like, “Oh, this is the person. “She can do this paper because she alone can illustrate it, “and her illustrations are like textbook illustrations.” So we’re working on this paper. So I think more students out there, whatever your talent is outside of medicine, inside of medicine, you gotta think about how do you bring all this together for your passion. Which for you is doing this stuff. Which for me is, you know, trying to take the cancer drug ideas and push it a little bit forward. But we all have find our own little, you know, thing that we think we can push.

[Dr. Z] That’s wonderful. That’s finding your calling. I talk about it all the time. Are you finding your calling? And the thing is you need your friends and family and people around you to support, but also challenge what you’re doing. Because there’s a thing called self-delusion self deception, where you see it all the time in a vocalist on “America’s Got Talent” or something, and their parents and their family have all been telling them they’re great, perfect, and the most talented. And they go up there and they suffer a humiliation that they don’t understand because no one has actually fed back to them that, “Hey, you need to work more on this. “Or maybe this is a talent that you want, “but it’s not something that you actually have.” And so my wife, I remember after our clinic turntable health closed in 2017, which was a big segment of my life there where we, you know, this was the movement and, you know, and it ended up our partners did the same thing elsewhere. So I was happy that the legacy. So that wasn’t a thing I needed to continue to do. But I told my wife, I’m like, “Now is my time to do this ZDoggMD thing like as a thing. “I think we can change a lot of ideas and minds “and get people to think critically and have fun. “And I think I can do it as a career.”

[Vinay] So among the people who go to medical school in terms of like the ability to take risk you’re like, you know?

[Dr. Z] But how was that? Because I’d not that taken the risk.

[Vinay] You built up stability.

[Dr. Z] Yeah, built up stability. So I did a fairly risk-free thing. The thing is that’s not without risk because you’re risking your happiness doing something that isn’t sustainable. When I started it I was very happy. Then I saw the writing on the wall. This career is not sustainable because of all the forces that we talked about. And so my wife sat me down and we were having lunch, I remember and she said, “So I just wanna make sure something here, “could you be delusional?” She asked me point blank.

[Vinay] But it’s the right question.

[Dr. Z] It’s the right question because I had to stop and go, “Oh shit, am I one of those people “that like just self inflates their ability “and thinks that this is some chosen path for them.” And I had to really go through and I took a while to answer. And I said, “I don’t think so. “I admit it’s a possibility, “but I have enough really momentum now “and experience that I think that no it’s gonna take work. “It’s not gonna happen right away. “But it’s gonna happen, “and it’s important for me to do this in the world.” And that is the first time I’ve said that about anything I’ve done, right?

[Vinay] Maybe what this kind of brings out is that all the things we use to pick who goes into medical school are doing their very best to weed out people who are willing to take the jump you took.

[Dr. Z] That’s true. That’s really–

[Vinay] They’re people who will jump through all the hoops. The hoop number one, the Berkeley prep, and that you’re gonna get the score. You gotta get your good grades. You’ve gotta do it effective. You’ve gotta volunteer a little bit. You gotta do, obviously, basic science lab. There’s nothing else you have to do, but the basic science lab. And then at the end of it, you end up like the student who wants to do vascular surgery, who feels like, “I gotta do some paper in vascular surgery, “get my name on it, first author.” And what’s the option? “Oh, we’ll troll some people on social media,” you know? But that’s what we’re setting them up. They just jump through this series, and these hoops are stupid.

[Vinay] [Dr. Z] They’re dumb.

[Vinay] They’re dumb. They got nothing to do with taking better care of patients. They got nothing to do with taking risks that actually allow yourself to do something that can entertain, engage, challenge, inform people in a novel way. Maybe all of the hoops that we’ve constructed are the wrong hoops. I think that needs reassessment.

[Dr. Z] Yeah, you pretty much nailed it. I’ll never forget going door to door at the life sciences edition in Berkeley, knocking on doors to try to find some basic science person that’d take me as an undergrad.

[Vinay] Yeah, you gotta check that box off.

[Dr. Z] You’ve gotta check the box. And I knew it was a box. I knew full well it was a box. In fact, it was the game.

[Vinay] And you had no real desire to Drosophila cure the world.

[Dr. Z] So just the crazy thing. I had no interest in research, but I went in there with, you know, that openness to experience. I was like, “Well, this could be interesting.” And so this old dude comes to the door and I recognize him right away, Professor James Fristrom. He taught the intro to genetics class that 700 people took. And he’s like, “Well, “I need someone to make fruit fly food and this and that.”

[Vinay] “You got arms and legs. “Get in there buddy!”

[Dr. Z] And I’m like, “I’m your man,” full of enthusiasm.

[Vinay] So then they took this like premed student who is charismatic and full of energy, and then the isolated you in a lab and sent you off to be alone for hours a day. And they’re like, “Why does this kid not like this?”

[Dr. Z] You know, that’s exactly what happens to most people. You know, what happened to me though, was something magical. It turns out I found a mentor in this case. Not so much on the science because he could tell. This guy was so smart, all right? He looked at me and said, “You’re not a scientist. “You’re a doctor. “That’s who you are.” And he’s like, “I’ll tell you what though, “You can do some science here. “You’re gonna learn this method, “and I’m gonna support you and you’re gonna support me, “and you’re gonna help this lab, “and we’ll support each other.” And he became this mentor, this kind of scientific father figure to me. He taught me how to critically think, and would never tolerate a second of my bullshit. If I started saying, “Well, you know, “when I think about it I’d like to help people. “Shut up. “You don’t like to help people “You like to think you’re smart, “and feel a sense of pride and accomplishment. “Am I right?” And I’m like, “Well, kinda, yeah, you’re right.”

[Vinay] So when you were a med student, your graduation lecture went viral. I think even before you’re doing the show, I think somebody had told me about your lecture. He was on YouTube very early, you know?

[Dr. Z] Yeah, it was one of the first things I put up there.

[Vinay] Yeah, so your class must have known you for someone who does this kind of stuff. Who’s entertaining, but also an astute observer.

[Dr. Z] You know, it’s weird because I’ve reconnected with some of my classmates since then. I found med school traumatic, actually. I found it socially traumatic because you go out of college where it’s just kind of chaos into a clique-ish high school environment where it’s the biggest overachievers in the state of California are there at UCSF, and they’re all trying to prove themselves.

[Vinay] Get a leg up on you, yeah.

[Dr. Z] They’re not imposters, right? And they’ve all done crazy important things. And I’m this imposter. And so it was so disconcerting. And so I would use humor as a coping mechanism. And I think a lot of them thought that I was just too irreverent and a little bit of an a-hole, and I was like a snarky, sarcastic guy. And then they had to vote for who their speakers were and they got two. So I was the like, “Hey, let’s just drop a dirty bomb on Zubin.” I don’t think they expected me to say anything woke or anything like that. They just wanted me to be a clown. And then the other person was a super woke, like social justice advocate, wanted single payroll, all this other stuff. And so they contrasted us. So then I went up and gave the speech that I gave that was with a lot of help of my good friends in medical school. I mean, that was a collaborative effort. And it went well and I felt good. I was like, “That was the message I wanted to give.” That’s what med school was to me. It was a lot of suffering and pain, but also a lot of joy, and opportunity, and connection, and the mentorship, and all that. So it was exactly what I wanted to say. Not a damn thing has changed.

[Vinay] Yeah, not a damn thing has changed.

[Vinay] 20 odd years, yeah.

[Dr. Z] And how about you now? So where’d you go to med school again? Remind me.

[Vinay] University of Chicago, Pritzker.

[Vinay] [Dr. Z] Nice, so it was a hard core.

[Vinay] It was a hardcore place. Is that nice? No, I mean, I remember I’ll tell you a little story. So on my surgery rotation, I think, the clerkship, the prior year they had gotten dinged for, I don’t know, maybe somebody student complained that they were mistreated. And so the surgical clerkship director was this neurosurgeon who took it over and Lord knows why he wanted to do it. It’s certainly not his passionate in life, but I think he needed it for advancement or something. So he was this guy from, you know, Eastern Europe originally, I believe. And he was cognizant of the fact there was mistreatment the prior year. So at the end of the clerkship, he said, “You know what, before you fill out your forms, “we are gonna talk about mistreatment. “So let us all sit in a circle. “Please sit down in a circle, “and we’re gonna go around, “and have everyone explain how they were mistreated. “Erica, please stand up, go first. “How were you mistreated on what rotation?” And so somebody gets up there and starts saying, “I was on this surgery rotation, “and the attending said, you know, ‘You’re stupid, “‘you’re stupid. “‘You’re never gonna amount to anything.” And it was like, this person getting obviously emotional because that’s not a thing you can say to somebody, it’s very inappropriate. And he was like, “Okay, okay, okay. “When they said that, were you doing anything incorrect, or?” I’m like, “Oh my God.” I was like, “This is not helping. “This guy just bash it.” And they get to me, and he was like, “Were you mistreated?” And I was like, “No sir, “I was not.”

[Dr. Z] No sir, I’m sorry.

[Vinay] That’s a little bit of the flavor. It was a place where people trained on the east coast. People were hardcore. People got angry. People yelled in the OR. I mean, there was a little bit of tension there. And it was a place where the students were motivated. They were gunners. They were pushing to come in earlier and stay later and do more. And that didn’t vibe with me because that’s not the speed I’m at.

[Vinay] [Dr. Z] Were you grades or pass, fail.

[Vinay] We were grades in clerkship. So we pass, fail for two years and then clerkship grades. And those grades determined everything. And so you had sleeper agents come out and they were hungry. They were hungry for the honors.

[Dr. Z] Bro, so can we commiserate for a second? So, so UCSF pass, fail. We’re super woke, left coast. We’re killing it, bro. What happens in the clerkship years? Pass, fail, honors.

[Vinay] Oh, pass, fail, and honors.

[Dr. Z] Yeah, there’s no grades. It’s pass, fail, honors. Well, how do I get into Stanford as a resident then? Well, you need to get honors in two thirds of your rotations.

[Vinay] Yeah, that’s what they said. You gotta get the honors, yeah.

[Dr. Z] And then you need a special thing on your Dean’s letter that says. There’s four adjectives. Outstanding, good, excellent, good, fair.

[Vinay] Code words meaning like-

[Vinay] [Dr. Z] Code A, B, C, and F.

[Vinay] And then they said we don’t give grades, but we have these code words.

[Dr. Z] Exactly, so what happened? The sleeper cells came out. These wonderful, wonderful people the first two years who were helping you and pass fail. And P equals MV, bro. Third year, they’re rounding on your patience. They’re bringing PowerPoint slides to class. They’re just basically out of control, and all that unconscious competition became conscious and open.

[Vinay] At the end of rounds they’re like, “Does anyone have time for a real quick lecture on?” I’m like, “What, the nephron? “How the hell this guy pull this out? “Where’d he get that nephron from?”

[Dr. Z] Oh, my God!

[Vinay] If they start talking about kangaroo rats, then, you know, that nephron, that loop of Henle is long dog.

[Dr. Z] I think that’s one of the problems with medical school is that you can’t do two things at the same time. You can’t really take someone and really teach ’em to make them aspire to be great at something, and judge ’em at the same time. There’s a fundamental tension there. And in a lot of, I think, medical training, the both are always tied together, and the trainee is always worried about looking stupid, not saying the right thing. And that hinders to some degree what they’ll learn, what they’re willing to ask, how they’re willing to challenge. And I think the best we can we gotta pull those two apart. I don’t have the answer there, but I think that is a tension.

[Vinay] Man, you know, that’s the thing. I agree with you. It is the tension there because you’re being evaluated. So if you’re just yourself, man, I tell you, and I’ve told this story a million times. I used to tell it in my talks. So there was this guy, Scott Flanders. And I say his name ’cause I no longer care. Plus, Scott is a really good guy. He is a hospitalist attending at UCSF. Now he’s at Chicago actually. And one of the founding like hospitalist academics, like really smart guy. Looked like a surfer dude, like blonde guy. And I was his third year on my medicine rotation at UCSF at Moffitt-Long, we used to call it the death star, right? ‘Cause that was like the academic heart. It was like, you know, Galadriel says, “Welcome to the heart of Elvendom on earth.” Like it was powered by the ring, you know, just this academic bubble, right? And I was on my third year rotation, I had to get honors in this rotation, or I was not gonna get an internal medicine residency that was gonna propel me to my GI fellowship that I thought I wanted to do. And Scott Flanders, I would say shit on rounds because that was me trying to cut the tension. Like, it’d be like, “Hey, you know, you guys “should take this urine to the lab and spin it yourself. “Because until you do it yourself, “you don’t know how it’s done. “You’re gonna think some nameless lab person’s doing it. “It magically comes back.” And I’m like, “That’s great.” And I go, “When we’re done, “we can all do shots of the supernatant.”

[Dr. Z] It just came out. It just came out and–

[Vinay] It didn’t fly. It didn’t land.

[Dr. Z] The team was giggling. Flanders just kind of looks at me and he goes, “Damania, you speak and then think. “I would like you to reverse that or better yet just think.” And you know what? He was right, but boy that hurt. I was like, oh, but then when we sat for our evaluation, you know, he was like, “You know, “this is the thing, man, you’re a wise ass, sarcastic, “you don’t like playing the role you’re supposed to play, “and that’s gonna suck. “It’s gonna hurt you. “It hurt you on this rotation “’cause I was like, ‘Who the hell is this guy?’ “But the truth is, I talked to your team, “I talked to your patients, I talked to the nurses, “you treat everyone like they’re “the most important person in the room “and you’re appropriately humble “in the face of what you don’t know. “So I’m forced against my better judgment “to give you honors in this rotation.” And I was like, “Oh, I screwed you Simon, suck it!” The other guy in the rotation.

[Vinay] But you know, that’s just the conservative core of this attending coming out because the truth is the students who make a few wise cracks, who tell a few jokes, who lighten the mood, they’re often the ones you want the most. And what they do to a team dynamic is hard to really.

[Vinay] [Dr. Z] Really hard to put in words.

[Vinay] Hard to put into words. But when you’re tired and you’ve been rounding for four hours, somebody makes a joke or two, it gives people a little boost of energy. I think, you know, it’s hard to quantify. That’s why I try not to be too old school like that. I’m sure I’d love to have like a student like that on my rotation.

[Dr. Z] You should bring a puppet. That’s what I used to do on HemOnc rounds.

[Vinay] Ventriloquism.

[Dr. Z] Do you know Steve Coutre here at Stanford?
[Vinay] I know the name.

[Dr. Z]You know the name. He’s one of the hematologists. So he was my Heme attending, and I remember there was this weird hobo puppet. I’ve kind of told the story before. Like some patient had given us this hobo puppet, like with a little bag on it. It was the creepiest thing you’d ever seen. So one day we’re rounding, we were miserable. It was a very hard service, young people dying of leukemia. I mean horrible stuff, right? I had built this like emotional wall around myself, so I wouldn’t feel it. And it came down later, I remember. One day, all of a sudden that wall just kind of. I was just like weeping in the corner. “Like, oh my God, those poor people,” you know? At the time though, I’d built the wall. And so part of the wall was humor. So Coutre, we were rounding. We were all kind of just, “Oh God.” And he goes, “Damania did you see,” bed three or whatever. I go, “Yeah, I did.” He’s like, “Well, you didn’t round on your patient. “You’re the intern here.” I’m like, “I didn’t, but, you know, Mini Z did.” And I pull out this puppet, and he starts presenting vitals just like super. And I tell you, man, to this day, Coutre like sites that as like the thing that saved that week and that month. Because these stupid little things, that shouldn’t save anything. It’s this idea that we’re humans and we are suffering and we don’t acknowledge it. There’s a communalization of pain that happens when you go, “Hey, I made a joke because we needed it.” It’s like, “Oh, you’re all acknowledging “that we’re hurting a little bit.”

[Vinay] Yeah, I think you’re right. You hit the nail on the head.

[Dr. Z]Man, we did a thing today. I mean, mostly it’s therapy for you and me. Let’s be fully honest. Like this is one of the most.

[Vinay] Hopefully nobody holds it against me.

[Dr. Z]Oh, you know, if you get canceled because of me, I will hire you on my team. I have no money to pay you.

[Vinay] Oh, that’s okay.

[Dr. Z] Because I had to raise money for these mics.

[Vinay] For these mics. Oh, come on. The moment you heard the audio quality you were like, “It’s worth every penny.”

[Dr. Z]Dude, and the thing was I did AB comparisons ’cause I’m such a nerd. I pulled out my old shirt a little, you know, SM 58, and I’m like “Logan, okay. “I put two clips in Dropbox for you to listen to.” Yeah, exactly, pulses everywhere, and just bad frequency response. And he’s like, “Well, I mean, it’s clear to me, “why are you still vacillating?” Because there’s a 30 day return policy on this very expensive mic and I might pull the. I’m so cheap, dude. It’s an Indian thing.

[Vinay] Of course.

[Dr. Z]I’m telling you. If we want to really be racist and go for the stereotypes, it doesn’t matter how much money you ultimately make the Indian and you will just not spend it.

[Vinay] We’ll be like, “Oh, gas is 10 cents cheaper “on the other side of the street. “Let me cross.”

[Vinay] [Dr. Z] This dangerous intersection.

[Vinay] I’m gonna cross this dangerous intersection.

[Dr. Z]That will take 30 minutes of my time to cross.

[Vinay] Yeah, just for the 10 cents.

[Dr. Z]Yeah, 10 cents only? Exactly. It’s a thing, you know, I think it comes from the frugality of arriving with nothing.

[Vinay] Yeah, really nothing, yeah. But I was just thinking about how journals, they do their podcasts, and you know, they have all this money. Some of these companies are making, you know, billions of dollars, these profit margins and their microphone is so crappy and their discussions are so bad. I’m like, “Oh, kill me. “Don’t put out a podcast.”

[Dr. Z] Just stop.

[Vinay] Just stop. Just it’s okay to say, “We’re not gonna embrace this technology”

[Dr. Z] It kills me. I die inside. And then they’re like, “Can you do my podcast?” It’s like “Bro, can you develop my app?” It’s like, “No, I’m not gonna develop your app. “I’m not gonna do your podcast. “I hate everything that you’re doing, but I like you. “You’re a good person, “but I hate what you’re doing as a communicator “to even be complicit in this crime.”

[Vinay] It’s aiding and abetting a crime, yeah.”

[Dr. Z] It’s aiding and abetting, absolutely. And every now and again, you’ll see me on a podcast that I was like, “Oh, I listened to it. “And I really like this podcast.” Even if it doesn’t get a lot of views, I don’t care. I have to reward the person who puts puts out good effort with my amazing presence. Because I just realized when I said that, I’m like, “I’m being an a-hole.”

[Vinay] We know what you mean, yeah. It means don’t waste your time.

[Dr. Z] But, I think, if it’s okay with you, I’d love to have you back.

[Vinay] Sure, I’d love to come back. We’re in the same area now.

[Vinay] [Dr. Z] So great.

[Vinay] Yeah, so easy.

[Vinay] [Dr. Z] It’s so great having a smoke and all that.

[Vinay] Of course, where else would you?

[Dr. Z] We’ve gotta hide in here where we’re efficient six plus feet from each other.

[Vinay] Easily seven feet.

[Dr. Z] ‘Cause you know there’s gonna be like, yeah, exactly five people who are like, “You guys aren’t wearing masks.”

[Vinay] Seven and a half feet apart.

[Dr. Z] That’s right.

[Vinay] We were PCR tested on the way in, obviously. Of course, we were.

[Dr. Z] Of course, we were. Nasal and anal.

[Vinay] We were antibody tested by the folks from Stanford. Just kidding, just kidding.

[Dr. Z] just said there was 100% prevalence of COVID. Last just toss away question which will follow up on another show. Masks, do they work or not?

[Vinay] Oh boy, that’s a toss away?

[Vinay] [Dr. Z] Yeah, it’s a toss away.

[Vinay] I guess I would say that-

[Vinay] [Dr. Z] What’s the state of the state on this?

[Vinay] I think it was reasonable to recommend, you know, that there was enough there and the precautionary principle to recommend. The studies, I mean, they’re just different types of studies. They’re studies of if you cough in a chamber where you measure droplet distance. Well, it looks great. Obviously it’s better than just having it explode all over the floor. There are studies that look at what happens to real people when they use it in real settings. And those are more mixed. And I guess I think that, and this is something that Margaret McCartney, a great piece for BMJ, where she talked about how this pandemic was kind of a missed opportunity to study some of these things we thought work a great deal a little bit more. That’s everything from masks to how should we reopen schools? Should we just have, you know, let Georgia do one thing and California do another, or should we think of a way we can test some stuff, staggered implementation. In Norway, they did a real quick study of whether or not it was safe to open gyms or not. They did a randomized study. We could have done a few of those kinds of things to learn a little bit more. And I think that was the missed opportunity.

[Dr. Z] I’m with you, I agree. I agree. I think that we should be, and I’ve said this, I actually have a merch that says this because I gotta pay for this mic. It says “Science, the crap out of it.”

[Vinay] Yeah, that’s the answer.

[Dr. Z] That’s what we should do and do it right. Yeah, I agree. Dude, Dr. Vinay Prasad, brother, this is one of the most enjoyable conversations I’ve had in a long time.

[Vinay] Thanks for having me. It was a pleasure.

[Dr. Z] And I’d love to have you back to go deep on the cancer drugs and things like that.

[Vinay] Let’s do it.

[Dr. Z] People care a lot about. Guys, I’ll put links to his stuff in the stuff as usual. Do me a favor, like share the show. This is, this is great. If you’re listening on the podcast, thank you. Please leave a review because it helps us a lot. check out Vinay’s podcast called “Plenary Session” because it is really good, you guys. Especially if you care about cancer drugs, but even if you don’t, everything he says is so well articulated. It’s a great way to use critical thinking. And how do you dissect trials and studies and evidence. Until next time, my brother.

[Vinay] Thank you, ZDogg.

[Dr. Z] Love you guys, we out.

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