Two docs talk about the dangers of absolute certainty in medicine, public health, and social media.
Vinay Prasad MD MPH is a practicing hematologist-oncologist and Associate Professor of Medicine at the University of California San Francisco. He studies cancer drugs, health policy, and clinical trials and better decision making. He is author of these academic articles, and the books Ending Medical Reversal(2015), and Malignant(2020). He hosts the oncology podcast Plenary Session, and runs a YouTube Channel VinayPrasadMDMPH. He tweets @VPrasadMDMPH.
Dr. Z: Guys, welcome back to the show. ZDoggMD, Dr. Vinay Prasad. You know who he is. You kinda know who I am. We’re just gonna talk about stuff and things especially the madness around Coronavirus and our response to Coronavirus.
Dr. Prasad: Thanks for having me back, yeah. I came here just to… I really enjoy our conversation. Even if it’s just you and I actually–
Dr. Z: It’s true like now, ’cause we’re… We’re not really neighbors. Like we’re actually enough out of the way that we have to make a point of you coming by but I always just look forward to him. Like, you know, I’m just gonna hang out with a dude that I agree with. You know, what’s funny? So somebody called me out.
Dr. Prasad: Oh boy.
Dr. Z: On, I don’t know if it was Twitter or Facebook. And they were like, I’ve noticed that most of your guests are Indian. Is this a racial bias issue towards your own tribe? And I’m like, Indians don’t even accept me because I’m actually a Zoroastrian, we’re like a minority group in India. And then I looked back and I was like, it was you Monica Gandhi, Jay Bhattacharya. I’m like, something’s happening here?
Dr. Prasad: Where you’re profiling?
Dr. Z: I’m profiling. You know, it’s like reverse… I’m like a TSA agent, I only pick the brown people to go deep on.
Dr. Prasad: I’m scared to even laugh at that joke.
Dr. Z: I know, right? You’re gonna get canceled just for laughing. Yeah, so what’s been going on, man.
Dr. Prasad: Just so for the record, I’m just laughing to make you feel good about that joke. No,
Dr. Z: Yeah, ’cause you can’t even make a joke on Twitter now about anything without the danger of being canceled.
Dr. Prasad: I think people are in a quite humorless state if you asked me, yeah. I mean, I think that people are, tensions are high, nobody wants to admit it, but of course everyone to some degree is suffering emotionally, I think. You know, with quarantine with month after month, the pandemic. And when tensions are high, humor is is a lacking commodity.
Dr. Z: It’s a lacking commodity yet, we can employ it to disarm However, now, it’s like, you cannot, everybody’s on pins and needles. Like, am I gonna say the wrong thing? Am I gonna offend such and such and so-and-so and such and such and so-and-so. Like someone tried to cancel the White Coat Investor on Twitter. Like when that starts… when you’re canceling a financial dude, who’s like the most boring person on the planet, like how are you gonna cancel some… You know we’ve reached peak madness. And I think COVID is contributing a little bit.
Dr. Prasad: COVID is, I mean, there’s something in the air that says you know, when you’re cooped up all day at home, you know I think like the Romans in the gladiator, what did they do? They had those Coliseum events and somebody got killed at the end of the day. And the modern Coliseum, the modern gladiation is, you find somebody who said something wrong and off with their head, you know? One way or the other either through their professional, their employment, through public shaming, something like that. It keeps us all engaged. We all are having popcorn. Like, well, I hate to be that person, even though to some degree, some of us should have a little bit of sympathy because you know, to judge somebody based on one comment they made that may or may not be taken out of context, I think is quite cruel actually. I strongly disagree with this culture that we’re in.
Dr. Z: Yeah, this culture is, I like that term gladiation, ’cause that’s what it is, we’re about scoring points in a ring for entertainment and for credibility and for reputational points. ‘Cause humans are reputational creatures, you know, we’re built around, what’s our public reputation? How are we seen in the tribe? Because it’s life or death for us. If we say the wrong thing and our reputation is damaged, we don’t get hunting privileges. We don’t get to have sex. We don’t get to get food. So historically it’s hardwired in us. And so we’ve weaponized it through social media and then COVID descends like a pall on the whole thing. And weaponizes it further because everyone’s like we’re hyper emotional, we’re deprived of physical contact with people. And which gets me to this whole… We live in California.
Dr. Prasad: Yes.
Dr. Z: It’s starting to feel a little bit insane now because the pendulum swings from, hey, let’s open up. And no, you can’t go outside on a trail with a mask. You can’t have outdoor dining. How are you thinking about this?
Dr. Prasad: Yeah, so I think for the listeners who aren’t immersed in California, we’ve had a number of new restrictions come through in the face of rising case counts. And of course, you know, I think you and I would wanna do whatever’s reasonable necessary to keep cases under control. But some of the things we’re doing just don’t make a lot of sense. One of which is closing playgrounds. One of which is I think closing outdoor dining to be honest with you.
Dr. Z: Absolutely.
Dr. Prasad: I mean, I don’t see clear and convincing evidence that those actions are going to bend the case curve downward. And that’s important. I mean, I think this is something people don’t understand. You only get to make so many rules. There’s only so much energy out there that you can get people to comply with whatever you want them to comply with. Beyond that, you’re blowing your energy, your political capital and you’re not getting anything back. And so I think you can have irrational, excessive policies. I would say closing playgrounds is probably top of that list. It’s just gonna piss off parents. It’s gonna make everyone frustrated and we don’t have good evidence that that’s where the virus is spreading, so why are you doing that? I think it’s really something that has brought a lot of people out of the woodwork, public health experts to say what are you doing California?
Dr. Z: It is the opposite of harm reduction. What you’re doing is you’re creating a kind of pandemic fatigue, you’re creating authority fatigue, and you have no respect now for the authorities because you’re like this just makes no sense. Like Scott Adams, who wrote Dilbert used to say, you know if there’s a rule, like a business rule that makes no sense, like it really causes straight demoralization, and Elon Musk took it the next step and was like, listen if there’s something that makes you feel like you’re in a Dilbert cartoon, maybe we should readdress that rule. Well, so, you know, not being able to go on a trail, not being able to eat outdoors, first of all it’s punishing these small businesses. It’s economically devastating and there’s no science behind it. So why? But then they’ll say follow science.
Dr. Prasad: Follow the science, but this is, I think is not science-based right. You know, can I tell you a little story that you remind me of? Many years ago, I think I was like a fellow at the NIH. I used top do a rotation in Washington DC and you gotta get like a DC training license. And I remember you had to do a lot to get this training license. You had to fill out all these online and submit them. And then the last step was you have to go get fingerprinted. And so I like filled out all these forms and the last step was like, book your fingerprint appointment. And I was like, booked it for Tuesday. And I go down there on Tuesday and I got my fingerprint appointment. I sent in all the forms and I get there, and the guy’s like, I’m sorry sir, you can’t get fingerprinted. I was like, what do you mean? He’s like, well, we haven’t received your forms. I was like what are you talking about? It’s on electronic submission, like you have them. And they’re like, no, see what happens is the forms go in, it goes to a printer, it gets printed out. And then I opened this folder. I put the forms in the folder and only after the folder has been opened and you have the forms in the folder, can you come and get fingerprinted and added to the folder. And so I said, let me ask you, why can’t you just take one of those folders put my name on it, fingerprint me, put that in the folder. When the forms print, you add it to the folder. You see what I’m saying? He was like, oh, we can’t do that, we can’t do that. And I was like this is why people’s heads are gonna explode. Like what sense does this make? And you and I know there’s so many things in life and in medicine where you feel that frustration where you’re like, okay, why are you so adhering to rules that make no sense at all? And I think I’d put this in that category. Playgrounds closed, that’s not gonna bend the curve on the pandemic. It’s just gonna fatigue your populace. It’s going to lead to resentment, and meanwhile, there are places in this country where they’re going the other direction. They’re not even doing basic things.
Dr. Z: Like Florida, right?
Dr. Prasad: Florida, I was just talking to a friend of mine in Florida, who was telling me, you know, this gentleman went out to lunch and I said, oh where’d you eat? And he was like, I had lunch with my friend indoors. And I was like, what do you mean indoors, indoor dining? Like, yeah, we have indoor dining in Florida. And I said… He’s like, well, don’t worry, we have to wear a mask if we get up to go to the bathroom. That’s gonna stop it.
Dr. Z: ‘Cause that’s when it happens.
Dr. Prasad: That’s when happens.
Dr. Z: When your bladder is full. It’s like, oh, you know, that’s what the science is–
Dr. Prasad: That’s when COVID leaps.
Dr. Z: Follow the science.
Dr. Prasad: Follow the science, yeah.
Dr. Z: See, the reason I like talking to you, the reason we hang out at all, professionally, is that I think we fancy ourselves just rationalists. Like, let’s just actually use some clear thinking. There’s no political bent here. It’s just, hey, but yet everything’s politicized now. Everything is weaponized. And I think what happened was early on, I think, LA times had a piece on this this morning that I thought actually kind of captured the zeitgeist of this. I’m not even using that word right. But I’m gonna use it–
Dr. Prasad: I think you are.
Dr. Z: It’s a big word. All right, I have the blessing. So it said early on when like the administration was kind of blowing off, Hey don’t worry about this thing, when everything’s fine, whatever, the public health authorities decided well to counter that, we’re gonna get like really absolutest because we need to say, hey, no, and no certain terms you need to do this, this, this, this, this, this, all right fine. And the problem was then both of them are speaking in relatively absolute terms, which the public is gonna have a very short patience for, especially when you’re gonna do a lockdown, but you’re not gonna support the businesses, or you’re not gonna support essential workers in a way that is meaningful. So you do a half-ass lockdown initially with absolute public health messaging. That’s just this! And then it changes. No, oh, actually masks. And then now what you’re doing is the public health guys still are in that mindset And they’re like, okay, it’s just say no. Like it’s just like drugs, complete abstinence. So we don’t want you socializing, we don’t want you traveling, we don’t want you gonna Thanksgiving. we don’t want you gonna Christmas, we want you to sit down, stay home and bend the curve because otherwise, lives.
Dr. Prasad: Yes, and, you know, I think you’re putting it so well that it’s getting worse and worse. And I think it started out perhaps well-intentioned, there were some people came out there and said, let’s do some sensible things. This pandemic is coming. Gosh, we’ve gotta get ahead of this. And then there were a few people out there who, maybe were frank COVID denialists, 5G causes COVID or there’s no COVID, right?
Dr. Z: There’s no COVID.
Dr. Prasad: There’s no, COVID.
Dr. Z: That’s my favorite one.
Dr. Prasad: That’s my favorite, yeah. He has no COVID, okay. Well, all right, well, that’s a tough one to–
Dr. Z: Come talk to my friends in the hospital.
Dr. Prasad: Yeah, that’s something where I don’t know where we’re gonna start this debate. But in response to that, I think on the other end there were people who said, it’s not enough. That COVID is extremely lethal in eighty-year-olds extremely lethal in seventy year olds and sixty year olds and 50 year olds. It’s not enough that it’s really bad in older age groups. And for people with comorbidities, it’s gotta be the worst thing imaginable. And so they started escalating. And so now, one of the best things about COVID, thank God, was it’s not very lethal among kids but then they said, well, you know, it causes Kawasaki like syndrome or causes, this-
Dr. Z: MIS-C.
Dr. Prasad: Right. Yeah, but what’s the denominator? I mean, yes, of course, but what’s the denominator? It’s a risk, it’s rare, it’s horrible, if it happens, you don’t want it to happen but it’s still quite unlikely to happen, thank God. They started talking about myocarditis. The 20 year old, even though they recovered asymptomatic well, on MRI, on T2 weighted MRI, oh they’ve got some spots on the MRI. And so, you know, what does that mean? I don’t know, but it doesn’t sound good to me. It sounds scary.
Dr. Z: It’s scary, and the thing is we don’t MRI everyone who’s had flu or Coxsackie virus or whatever it is.
Dr. Prasad: If I put you in an MRI every day, I promise you you’d be missing some organs by the end of the year. You know, like you can something, and then somebody’s gonna be trigger happy to say, cut that out I don’t know what that is.
Dr. Z: Adrenoloma, something else
Dr. Prasad: Of course.
Dr. Z: Incidentaloma, they call them a thousand percent and you know, it’s funny. So I was talking to Paul Offit And we had a great conversation and he really elucidated a lot of good ideas around these MRI vaccines that are coming out and he’s sitting on the committee and, you know, wink, wink, the data I’ve seen. And it’s a positive vibe coming from the dude which is interesting because I know early on he was quite skeptical because he’s made vaccines and he’s like, we’ve never made them like this. And it’s gonna be insane if we see it within a year, and now we’re gonna see it within a year. Which means that–
Dr. Prasad: Greatest success story of the 2020.
Dr. Z: It really is. And he’s willing to say that he’s like, hey, I give the administration credit, I give this… And he’s like, that’s a scientist. He did say something though that I think was new for him which he said, this is a scary virus. We don’t know how it’s… With these children with this inflammatory thing, these long haulers, this and that. And I think he was saying that to try to make a case that you should get vaccinated even if you don’t think you’re gonna die. Now he would not have said that, I think, and again, I don’t mean to–
Dr. Prasad: No, no, no, go on, yeah.
Dr. Z: I’m just using this as an example.
Dr. Prasad: He would not, had there not been people denying it
Dr. Z: Had there not been people denying it, and had it not been about a vaccine, if it was about just let’s open schools he would have said, well, actually on balance, schools being open is better for the health of children than the detriment of being infected with COVID. So it’s all contextual. So he’s a very nuanced communicator and thinker, but the way our public health apparatus works is it’s just catastrophization or just straight minimalization. If it’s, you know, Atlas or someone.
Dr. Prasad: And if you’re on social media and you start to toss things out in this space, catastrophization, minimization or something in the middle, as you start talking, you’ll just see yourself being rewarded for the worse it is more tweets, retweets, more likes, worse it is, worse it is. And you see people just drifting in that direction, or somebody starts drifting in the other direction towards this is a nothing burger, this makes, you know… So you can watch the rewards pull people to polls. The people in the middle who take it seriously, wanna do reasonable things but don’t wanna be excessive, want to properly budget how much energy people have for restrictions, that is something that’s very difficult to build, it’s not rewarded, I think it’s a deep problem.
Dr. Z: I agree, and what’s interesting is that, that’s a social media construction. When I’ve actually met people, cause people will come up, well, you’re a doctor. So you think this COVID things a hoax, right? I mean, I read this and I read that. I mean, what do you think about it? You can have a nuanced conversation with someone who’s been weaponized against COVID being real with five minutes, you can, because you’re person to person and you understand you can vibe on the body language and go, this person not trying to fool me this person’s not a bad person. Yeah, they’re just… They’ve been confused online and that works but we don’t get to do that on Twitter because you get rewarded for exactly the opposite. You get rewarded for catastrophizing, like, you know, stay home and then, you know, # you’re a loser, if you don’t wear a mask and it’s like, well but actually that’s not helpful. That’s just a say no argument.
Dr. Prasad: So I recently tweeted and got a little backlash–
Dr. Z: Oh this is gonna be good–
Dr. Prasad: I recently tweeted that… It was a link to a news story about rising cases in Miami-Dade County. And I said, my friend tells me that you can have a lunch indoors in a restaurant in Florida. Meanwhile, we’re one step away from a mask mandate in the shower in California. That was funny too.
Dr. Z: That’s comedy.
Dr. Prasad: I thought it was good.
Dr. Z: This shower mask mandate.
Dr. Prasad: The shower mask mandate. But you know, it’s a joke but it’s not that far from things we’ve seen. There is a mandate in Washington state for children who are playing outdoors to wear a mask while participating in outdoor sports activities, which is, I don’t know if you’ve been to Seattle this time of year but let us say, they don’t get the sun that we do. It’s a pretty damp state. So that really is a water based mask mandate, which is, I would say unlikely to be effective or useful at anything other than frustrating children and parents who are trying to keep the mask on the kids. So anyway, so I made my joke, Oh boy, and then within like… And then somebody texted me, he was like, oh people aren’t gonna like your joke or something or people aren’t liking your joke. And I took a look ’cause I’m actually quite disciplined about… I try not to look at what these people are saying back to me. ‘Cause I don’t want it to affect me.
Dr. Z: What do you mean “these people”, Vinay?
Dr. Prasad: These people, I mean–
Dr. Z: Yeah, that’s racist.
Dr. Prasad: Well, thankfully people of all races, shapes, and sizes–
Dr. Z: Hate you.
Dr. Prasad: Hate or love, that’s right, one or the other, depends on the day of the week. But yeah, I try not to let the emotions of the most vocal among us guide my internal compass. I try to keep it based on like discourse like this–
Dr. Z: Rational discourse, yeah.
Dr. Prasad: So I looked into it, like all these people like, oh, this is so objectionable. This is bad, you know, I’m like, oh my God, you know like can’t you take a joke ? And there’s some truth in the joke. Actually, if you really think about the joke like all good jokes, there’s a lesson to learn. And the lesson is you should do what matters. So maybe we shouldn’t have indoor dining, you know with mask on the way to the restroom. But maybe we shouldn’t close playgrounds. Maybe we shouldn’t have those masks in outdoor, wet environments, recommendations that just sap our morale. And so it’s a joke that rings true to a lot of us.
Dr. Z: It’s perfect, yeah. In my mind, it’s the perfect satirical comment, right? You’re saying, listen, I’m gonna point out through humor what is true and make you look at it. And the fact that people are upset is interesting to me because I think, and this fits your typical… ‘Cause you said something right in the beginning of this which is I got a text. Now, this is usually my threshold. When I get a text about a tweet or some social media posts that’s when I know it’s like, you know in The Matrix when agent Smith in the second movie, he escapes from the matrix and starts causing havoc in the real world. That’s when you realize, oh something has escaped from the Twitter matrix or the Facebook matrix and is out in the world, texting me which means now I have to take the seriously which is upsetting because this is just dumb on Twitter. And then now it’s like, oh this is somehow gonna affect my life. Because something I said has triggered an audience primed to try to get social points by attacking back. And it’s hurt no one, it’s a joke. You can disagree and you can argue with it but why cancel the person, right? ‘Cause if you were with me you wouldn’t wanna cancel me ’cause you’d realize I was a decent person.
Dr. Prasad: Of course. and it was a good joke.
Dr. Z: It was a good joke, yeah, exactly.
Dr. Prasad: And there’s a lot of truth in that. I guess. I think we have seen several examples, I think of people getting attacked personally. And you know, if we would try to put like specific concrete to what it means to be canceled, I think it means to complain to someone’s employer, to seek out people they know in the real world and bad mouth them and try to get them facing some sort of sensor or punishment or retribution in the real world for something said online. You know, it’s absolutely fair to reply to the tweet and say, I disagree with this or this doesn’t me laugh. Or you know, something that somebody who’s not funny would say, but if you wanna do that, that’s fine. But if you start to bring it into the real world, I think that’s where people think the threshold should be extremely high. And one should wonder if by doing that, you’re actually helping some cause. In this case, I don’t know what they would be thinking they’d help, but I’m actually not too worried about this because I think any sensible person would understand that I actually have quite a point, I think. And I’m happy to defend that point and argue about that point to anyone wants to dialogue about it.
Dr. Z: This idea of affecting people in the real world for their opinions, for their speech is fascinating. Like it’s one thing to cancel, like say, okay, I don’t want as an advertiser. I don’t wanna put my name on somebody who’s saying something that I fundamentally disagree with. Okay, then you’re voting with your dollars, that’s fine. But what’s happened to me in the past, which is fascinating. Like I’ve said things like, you know I think everyone should practice at the top of their training. Okay, that apparently is a dog whistle for give nurse practitioners and PA’s independent practice apart from doctors, which I’ve never said. And I actually don’t, I don’t agree with that. Yeah, so that whole thing. So I said something like that and then a bunch of doctors started attacking me. And these are doctors that are on these very weaponized Facebook groups, like Physicians For Patient Protection. They have these very elegant names like that. And what they decided was they get together they form a mob and remember they already don’t like you so there’s always some preexisting–
Dr. Prasad: That’s what I wanted to bring up with you. Yes let’s talk about that.
Dr. Z: Yeah, let’s talk about it because there’s a preexisting… I’ll tell the story, then we’ll go into that because there’s like any mob, there’s a preexisting grudge. So, oh, such and such did this to me once or ZDogg once made a video that offended me, or I just hate that guy because he doesn’t have to see a patients all day to make a living and I do.
Dr. Prasad: Or he’s successful at what he does.
Dr. Z: Even worse.
Dr. Prasad: Not but I mean, that is a common grudge people do bear is that they view you as a successful person. I think all of us view ourselves as some degree of success in some degree of things that we feel like we have yet to succeed in.
Dr. Z: Abject imposter syndrome.
Dr. Prasad: Yeah, everybody has that. No matter how successful they are, I’ve talked to people who are deans are, you know presidents of the university, they all feel like, well I should have gotten… You know, everyone has that feeling but somebody else may look at you and see somebody successful, and they may resent you simply because of the success that they see in you which I think is a very petty emotion. It’s very childish emotion.
Dr. Z: And then also very human. It’s common and reputational. So what ends up happening is they then leave the matrix and they start calling up people on my website where I’m gonna be speaking. And they’re like, we’re doctors and we think this guy is a poison and so on. And so these people will then call me and say, you know we have a bunch of doctors complaining about you. We’d like to cancel the talk that you were scheduled to do. Which, I mean, this is how at that time I was monetizing all of this. Like that’s how I paid for all his equipment before we had a Supporter Tribe. And so it would be like a direct financial hit, like you’re being canceled. Except that in my contracts, I always put that the 50% deposit is nonrefundable which means I just got paid half of the talk to not do anything.
Dr. Prasad: It’s the dream.
Dr. Z: That is the dream. So what I’m saying is you can immunize yourself a little bit about against this, but you also have to say, listen, I’m willing to die on my sword financially to say something I think is important.
Dr. Prasad: Yeah, and I think to your point, which is that when one investigates beyond people who are critical of somebody online, one often finds a pattern that these two individuals have interacted before and disagreed on a number of diverse topics. And what does that say to me? That says to me that some of the disagreement in the moment maybe disingenuously applied, it may actually be preexisting grievance or disagreement. Why is that important? I think if we wanna judge someone fairly based on whatever they did, even if we disagree with what they did and wanna punish them for what they did, it should be based on the merits of that individual instance and case and not based on how, you know, Tom treated Tim, four years ago on some other topic. And they’ve got some beef between the two of them but you don’t see all that on social media. And many of the people who cast the first stone are people who have all preexisting grievance.
Dr. Z: You know, what’s funny it’s no different than middle school politics, weaponized. And that’s why I think middle-school girls have such a hard time now with social media, they’re more anxious, they’re more depressed, they’re more suicidal because these little grievances like such-and-such and so-and-so, and gossip now become truly a thing that you cannot escape from no matter where you are. So you can be at home and it’s still happening because it’s reaching you through the phone.
Dr. Prasad: Yes and there’s no distance and yeah.
Dr. Z: None of that.
Dr. Prasad: Yeah, you brought up the interesting question about should nurse practitioners practice independently and somebody might Google me and see I’ve written actually in support of that practice. And I’ll tell you my 2 cents argument.
Dr. Z: Oh, we’re gonna get so canceled. I’m disavowing anything he says right now. No, keep going, keep going.
Dr. Prasad: Okay, I mean, just in my argument is that all practitioners exist on a spectrum from people who are extremely savvy and very independent and highly competent and people who need some assistance, needs some guidance, some supervision. And I think that we focus so much on the median differences between groups of people based on their training background, be it NP, PA or MD or DO, we focus so much on those median differences, we forget that the variability within the group is often quite large. And I would say we probably need a system that would think about both ends a little bit more clearly. So by that, I mean, the people who are lagging whether that’s they’re an MD or a DO or an NP or a PA, who need a little guidance and supervision we probably need a system where we better detect that and provide them that guidance and the people who are the all-stars in whatever field, you know, more freedom, more flexibility, more independence. Of course, the system we have now, it uses the degrees as a 100% surrogate for this, for performance on the job. And I would think that probably… So just my argument is that I think many NPs and PAs, should have independent practice authority. There needs to be some system to say, who should or shouldn’t have it. MDs, of course they all have independent practice authority but on the MD side, maybe we’d say that there’s some people on the backend who… We do a bad job in medicine of picking the low performers and, and remediating them. We have malpractice suits and things like that. Those randomly pick, somebody who did something often egregious and give them the death penalty. But the average person doing a poor job is just like skates undetected for their whole career. And so that’s the gist of how I think about it.
Dr. Z: Now see, this to me, what you just did, was you described everybody should practice at the top of their ability.
Dr. Prasad: Which is what you said.
Dr. Z: Yeah and I said, “training,” what I should’ve said is “ability” because that… When I talk about this Health 3.0 idea, it’s everybody on the team practicing at the top of their abilities in service of not just the patient ’cause that’s narrow; in service of each other as well. So that means that if you have an all star PA, and we all know that PA or that several PA, they ought to be given as much meritocracy based license as they can, whereas the idiotic MD, who went to a top school, who you wouldn’t let touch your dog. And we all know that person, you know, Dr. Death, the, what is it, Hands Of Death And Destruction? And those people get to do whatever they want. And we don’t have a process like pilots have where they mentor each other and they test each other. Instead it’s CME, which is nonsense and board re-upping, which is just a way to make money for these companies like ABIM, which is a total scam.
Dr. Prasad: And built into sort of, I think what you’re articulating I would even say that there are a lot of really good doctors, really good NP’s who just get burdened with paperwork and menial tasks in part because hospital systems and help systems profit more from burdening these providers. And I think your philosophy would say, take away that menial tasks that we can offload it to other entities and let them really thrive. Because one of the things about being a doctor that we love is when you get to do what you’re really, really good at. And that often is making those critical medical decisions, sitting down with people having a long conversations. I don’t think it’s necessarily doing the stupid billing and then the paperwork. And let’s not say that those four letter word, EPIC, but…
Dr. Z: Well, again, what you said is exactly this, everybody should practice at the top of their ability. Instead, what we do is we make them practice like a clerk or a data entry analyst, or… And so we do all this, and when I talk about Health 3.0, I say, we are technology enabled, but never enslaved. And what that means is we’re not serving the technology. We’re not serving EPIC by data entry. EPIC is serving us to take that off our plate so that we can do what only we can do. And there’s some things that only a absolutely highly trained physician with 10,000 hours and speciality training can do, nobody else can touch them, let them do that.
Dr. Prasad: Like neurosurgery.
Dr. Z: Like neurosurgery. You’re not gonna have a neurosurgery PA do the full surgery ’cause it’s just not within the parameters, right? But could a primary care nurse practitioner, or a family nurse practitioner do a lot of stuff, good in the world with their training? Absolutely, especially if they’re good, right? And this is the thing. And so what I found is… This is what bothers me is the people who are really activist on both sides of this. So there’s activist, nurse practitioner and the activist doctors, all of them are practicing at the bottom of their license. Like the doctors are angry because the nurse practitioners are taking their money.
Dr. Prasad: Yes, I know.
Dr. Z: It’s like, what are you doing?
Dr. Prasad: I mean, I think you’re hitting the nail on the head that it’s really sort of similar to all the issues we’ve discussed where there’s these polar extreme views that everyone no matter what your license, should have full authority to do everything. Or I’m the only person should ever do anything is an MD. And what we’re talking about is something in between that acknowledges that people have different strengths and weaknesses and different people are more or less capable than other people. And the system should find some way to evaluate things and make the same decisions we make for patients, individual and personalized decisions about what people can and can’t do. And actually we’d be better off for it, because right now, I think we’re failing because there is really no oversight for huge chunks of medical care that if somebody looked through, they’d be like, what the hell is going on?
Dr. Z: Exactly right. And you know, I think there is this idea of not knowing what you don’t know.
Dr. Prasad: Yes, that’s true.
Dr. Z: And I think a lot of doctors who are on the side of, hey, don’t give them independent nurses. You know, they say, well, they just don’t know what they don’t know. And I think those, those representatives are the loudest in the let’s have independent practice conversation. And you worry about that. The ones that are like, I’m not sure we’re ready for independent PA or nurse practice yet, they’re the ones that you wanna give independent PA nurse practice, because they probably are. They have a degree of imposter syndrome, which is a good sign. They have a degree of self-introspection, hey, medicine’s hard which means they’re careful, they’re thoughtful, they ask for help.
Dr. Prasad: And the same… I think that’s a well put. And I think the same is true for doctors because the longer I practice, I’m more and more comfortable with telling the fellow, you know what? This is how I’ve been taught and trained and how 75% or 80% of doctors would approach this problem. But I think we need to delve a little bit deeper into why that has become the case, either historical or scientific. You know, it reminds me of something. I was recently trying to explain how some, I dunno a new cancer drug works. And of course I was talking about some boring molecular pathway. And at some point I got a little bit stuck and I was like, oh, shoot. I don’t know if I know exactly at this molecular level, how this drug works. Because again, I’m not a laboratory biologist in every single topic. I mean, certainly I think I don’t have that qualifications. And then I think the trainee with me was like, well, isn’t understanding this very deep level of understanding how the drug works, molecularly, the thing that distinguishes doctors from mid-levels? I said, whoa, oh, that’s a bold claim. I would say, I think that’s not actually it. I mean, I know people feel that way or may feel that way that our basic science training is somehow what distinguishes. I guess I would say that I think that there may not be an absolute distinguishing characteristic and that what may be the real thing that you wanna talk about is what distinguishes good healthcare providers from those who are merely mediocre. And I would say, regardless of degree program, the thing that distinguishes good providers is they’re always humble, they’re always willing to say what they don’t know and try to improve upon that for the next year versus people who I think are going in a bad direction where they think they know it all.
Dr. Z: That’s it, that’s, it that’s, it that’s all it is. And we’ve done videos on Dunning Kruger effect. Yeah, and this idea that when you don’t know what you don’t know, you cause trouble and you overestimate your knowledge. And when you know a lot, you underestimate your abilities or you overestimate the abilities of others, and I’ve fallen sometimes into both traps. And what you see, sometimes we’ll say, for example, let’s just say a floor nurse. All right, so they have a certain education in immunology, et cetera. They can be very persuaded by anti-vaccine sort of online propaganda, because it uses just enough scientific language that they know just enough to… But they don’t know what they don’t know. So they can’t dig into the deeper rationale if you know, why that argument totally doesn’t make sense. Like the syncytin thing. Have you heard this thing about…
Dr. Prasad: I haven’t.
Dr. Z: This is an amazing one. Now they’re saying that the anti-vaccine thing is, all these MRMA virus vaccines are creating a cross-reactive antibody with placental syncytin which is this, you know, some compound in this placenta. And so therefore getting vaccinated, if you’re a woman will sterilize you. Yeah, right, it makes you laugh right away. And yet there’s a plausibility. You’re like, wait, this could happen. And then you have to think, okay, let’s do two more steps of imagination. The wild type virus, which has by now infected, tens of millions of people has not created a case of females sterility that’s been documented and that’s gonna have the same antibody production as this spike protein that’s purified and plus some. Convalescent plasma doesn’t cause… So again but they can… But if you don’t have that degree of abstraction, you can’t make that. So again, you’re in that Valley of Dunning, the peak of Dunning-Kruger where you’ve overestimated your ability and therefore you make a mistakes. So this is what we ought to be teaching people is how to think.
Dr. Prasad: Yes, and it’s the poorest taught thing we do. And I mean, along those lines, I mean, let’s just talk about medical education. There are some people you encounter in your medical education, who you ask questions to and you don’t get a lot of answers. You get a lot of hostility. Remember those people?
Dr. Z: Oh yes.
Dr. Prasad: My theory has always been that people display hostility when they actually themselves, don’t know the answer.
Dr. Z: Of course.
Dr. Prasad: And it’s a great compensatory mechanism to get somebody to like, never ask you a question again. And I do think that that is, you know, and I’ve written about it many times, but like how do we restructure medical education? I think that the core aspect of medical education is reasoning under uncertainty or partial certainty. And how do you think about that situation? Because a lot of our situations, there’s some uncertainty. And how do you interpret clinical trials and how do you interpret pathophysiology? And how do you make decisions when those two are at odds? I think it’s the poorest taught part of medical training. And, that’s my interest in of course the class that I teach.
Dr. Z: Yeah, see the nuance and the gray in not knowing everything, having uncertainty is paralyzing for some people and it can be taught. It can be taught how to deal with that. I always enjoyed it, the fact that you just don’t know everything. So let’s see how we’re gonna wind our way through the logic mill and you thinking rationally and clearly, and then throwing a little emotion to make the final decision because sometimes it’s a toss up. So how do I feel in my gut now? It’s 50 50 or Imma go with this and see if it’s right. If I’m wrong, then it reprograms my emotional gut for next time, right? People are so uncomfortable with that. And in fact, even even my wife was uncomfortable with that in medicine. So she trained in internal medicine with me. We did three years together. She’s board certified with me, Stanford, internal medicine. And she’s like, I hate this. Why do you hate this? Because it’s so gray, we don’t know anything. I like radiology. It’s there, the answer’s there.
Dr. Prasad: Or it’s not there,
Dr. Z: Or it’s not there. And so she did another four years of radiology. And now she’s like this world-class chest radiologist at Stanford because she saw what she was comfortable with.
Dr. Prasad: I wonder actually, if you interviewed her again after practicing chest radiology for a long time she’ll actually say, you know, it’s greater than I thought it was.
Dr. Z: She will tell you, ’cause I’ve had this conversation with her. I’ll say, I think a computer is gonna replace you in five years. And she’s like, it won’t happen in 50. And I’m like, why, you have no idea how gray that’s what she told me, how gray radiology is. But the beautiful thing is I feel like I have the tools to navigate the grayness. In medicine, the grayness was to her a fog because it’s more human based.
Dr. Prasad: I see, I see, it connects with the domains of uncertainty that she likes and she’s good at.
Dr. Z: Yeah, that’s right, that’s what it is.
Dr. Prasad: I mean, as somebody who spends a lot of time staring at radiographs, trying to make decisions about whether or not things are getting better or worse. And you think about, you know, the story you heard how people feel, the laboratory results and the radiograph and you’re putting it all in, and you realize there is no like Oracle you can appeal to. At the end of the day, it is a judgment, it’s a decision. You hopefully get better at it as you go through your career, but it’s an important decision. I think it’s a decision that I find very interesting and appealing and I like to talk through, why I’m deciding, what I’m deciding.
Dr. Z: And as a cancer doc, as a hem-onc doc, this is the apex of that sort of human synthesis of the uncertain with all these pieces. ‘Cause you said, how does a patient feel? What are the labs showing? And what’s the radiograph showing, and then synthesize them through the filter off your experience with this particular malignancy and your experience with this particular patient, so you know–
Dr. Prasad: And to tie it back to COVID, back when we’re talking about it at the beginning, it has been my observation, although I have not empirically proven it and maybe I should actually try to sit down and study it; that some of the people who get pulled to those draconian polls, the absolutist, stay in your room till 2022 or the, that doesn’t exist at all, they don’t have practical boots on the ground experience in this uncertainty quagmire that clinicians find themselves. And probably, you know, people who go to Sub-Saharan Africa to bodily Ebola or find themselves in. They can often be, I’ll give you one example. I mean, I think there are people who do wonderful work on air ventilation and systems, and aerosolization they often have very strong and dogmatic views about how we should mitigate the air. But you know, those views may not actually mesh with sort of empirical data. There are people who may be doing epidemiologic modeling for many years and they may have a very precise, I’ve seen some estimates predicting how many people are gonna get COVID to like the person, you know, 422,242. And I’m like, oh God. I’m like, okay, you get… You’re not gonna be right on the dot, but okay. All right, I get your point. But they have very dogmatic views. And then there are people who come into the debate about how mandates and policies work. And they may not know that anytime you mandate something and make a policy, the intervention isn’t the perfect world where everyone does what you say, it’s what your recommendation does when it goes out into the ether. And one of the things you could do is it could piss off a lot of people. So you start taping up playgrounds, you piss them off and then they start slacking on other fronts. But we who spend time in medicine, I think we know it very viscerally. You know what it’s like in a primary care appointment you see somebody for the first time… Can you imagine if you talked about all the things that primary care doctor is supposed to talk about on visit one, they ain’t gonna be a visit two, right? You know, so we get some sense of what is realistic, what is practical? What is pragmatic and what is really kind of unattainable?
Dr. Z: Yeah and it factors in multiple variables in a complex situation. And COVID is the perfect example. Anyone who tells you, they know the answer, anyone who’s giving you a black and white absolute, you should be very skeptical no matter what side they’re on. And yet we, we aren’t, we actually tribalize towards those lines of reasoning. You know, we’re in the Osterholm Group on this, or we’re on the Monica Gandhi group on… Actually Monica is beautifully nuanced on most things. Yeah, she really is. And then you have the, you know, the opposite group the Scott Atlas group, which is like, hey this is all economic, this is economic. And, and again, we talked about this last time. I actually think they’re all from a place of, hey, I have a strong intuition about this based on my experience in these domains that are not the broadest domains, they’re these domains, and I’m gonna apply it to this. And I’m gonna apply it in a very absolute way because I think this is… I feel so strongly about this.
Dr. Prasad: I got one topic for you that I don’t know if you read about. Healthcare worker anecdotes in the age of COVID, have you seen this article on Wired?
Dr. Z: No, but it sounds right up the alley of what I beget every single day.
Dr. Prasad: This was a story about, I think, a nurse who said that many of the people, as they’re in their final throes of COVID and dying, they say, I can’t believe it’s a real or something like that.
Dr. Z: Oh yeah right.
Dr. Prasad: And Wired investigated, like, is this true or not? And they talked to other people in this hospital and they’re not vouching for the fidelity of this story. And they really raise questions about whether or not the anecdote was faithful. There’s another example. I think some ed doctor talked about how he cared for a patient with COVID. He was a Jewish physician. And when they took the patient’s shirt off he had a swastika tattoo on the chest and SS tattoos on the arms.
Dr. Z: This was Taylor Nichols, yeah.
Dr. Prasad: And I saw some internet sleuth. Did you see this Zubin?
Dr. Z: I didn’t see this.
Dr. Prasad: Some internet sleuth has identified several instances in the past where he has tweeted a very similar description of a patient he took care of, a year ago, two years ago, and something beyond, I believe you can go find that thread. And I guess it raises the question of whether or not there are multiple said people with these unique constellation of tattoos or whether or not there is something about the present story that may or may not be fully accurate.
Dr. Z: Can I tell you something? So that’s amazing. I didn’t know that, like, I’m really kind of shook right now because that guy who’s now held as this big hero of like, oh, this patient with a swastika and he still took care of him, but it tested his compassion as a Jewish physician and so on and compelling story. He has tried vigorously to get me canceled on Twitter for a video I did about abortion where I dared to say, hey, I don’t think we should legislate a woman’s right to choose these things. However, here was my experience when I was a medical student witnessing abortions and how difficult it was for me. And he said, “Oh you don’t even understand “you’re giving power to these anti-abortion activists.” and so on and so forth. And I said, I told him that I made the video that I thought was–
Dr. Prasad: You’re speaking to your own–
Dr. Z: Speaking to my own experience and also still advocated for what you’re advocating for. But he was unrelenting. We had private conversations, he threatened to make those private conversations public. Oh yeah, which is a good sign. Which I would have said, fine, go ahead. I told you exactly what I think of you. And so it’s interesting. So again, it pulls it full circle to what these social media platforms are. They are ways for people with no power and no recognition to suddenly have a perceived power and recognition at the expense of people, other human beings.
Dr. Prasad: I think your story is quite interesting about how we’re starting to live in a world where, you know, your story is your truth to yourself. And at the end of the day, it’s your experience. I mean, no one can tell you how you felt when you were witnessing X, Y, or Z. Only you can say that. We live in a world where everyone wants to play four chess moves ahead. So the thought is, well, you know it doesn’t matter that you’re saying what’s true to you, how might somebody interpret that? And what might that mean? And what might that mean? And what might that mean? We’re not good at this game as people, we’re really not good at it. I think a lot of COVID has been the same way. It’s not just, you know, well, if you say there’s seasonality to the virus somebody might say, it’s not real, they may not wear the mask and that would be bad. So therefore we shouldn’t study whether or not there could be a seasonal component. We shouldn’t even talk about it or study it. That’s not a way to operate in the world. You gotta be able to talk about this and have a dialogue. And then to your next point, I think the other point about social media, it has been a way for a lot of people to get a lot of attention. And that is always a double-edged sword because attention when directed at the right front is very powerful but we all know. I mean, I can make up a story right now that I can guarantee you will get like–
Dr. Z: A billion likes.
Dr. Prasad: A billion likes. We all know that there has long been a streak in humanity for confabulation, for just coming up with a story that, you know, in every culture, you know since the dawn of time there’s always been sort of confabulation and that can be done for very powerful effect. And I think it can be problematic. I mean, I think it is problematic, if the core elements… When a doctor tells a story, no one expects all of the facts to be true, because it would be very identifying, but the core elements have to be true. Like somebody had to come with, you know, Nazi tattoos and they had to have had COVID. Those are like two core elements of this story, right? Those have to be true for the story to have integrity. And I think if those core elements are not true, a guy who denied COVID saying, I can’t believe it’s real as they’re dying, that has to be a core truth for the narrative to have the impact it does. And it’s very important that it should. And so the Wired article is very good about this, investigating is this possibly true? Social media makes it very difficult to verify a lot of these accounts and it incentivizes people to have such accounts. And I think it’s a deep risk.
Dr. Z: Ah, man, I can’t tell you how many people send me these accounts. Did you hear patients are denying on their deathbed? Did you hear a guy with a swastika came in and was demanding care, whatever it was. And I’m like, yeah, I have. ‘Cause about a thousand other people have sent it to me. And yeah, I have, because I moderate my discussion groups and I see what people are posting. And social media, God, you know, it really sometimes hurts me to think that this is how I spend my time is on social media, putting content out. I don’t actually sit and troll social media.
Dr. Prasad: That’s what I was trying to explain to one of our… Somebody we both know who spends a lot of time on social media. This person was like, well, you know you’re so critical of social media, but I think it’s good. And I was like, what you mean by social media and what I think most of us mean by social media, it’s not the same thing. Very different. I mean, you are basically a television station. I mean, of sorts, right? You’re producing content and you’re putting it out there. And, that’s really what I do mostly ’cause I’m doing a podcast, different medium but the same thing and this person that we both know is sort of in that business too. That’s not what people are doing on there. People are… It’s their whole lifeline to the other world. It’s the place where they’re putting their most flattering pictures up. And they’re putting out a version of themselves, projecting a version of themselves that they wish they could be or aspire to be. And I think it’s quite dangerous. I mean, all these times we’ve talked, which has been I guess several times we’ve talked this so far, we’ve talked about the dangers around ideas, how ideas get polarized, how ideas… We haven’t talked as much about the dangers of your personal integrity. You know, I’m somebody who never says anything personal on social media, right? You don’t know anything I ate or drank. You don’t know any restaurant I’ve ever been to Z Dot. If you ever wanna go, you never gonna know.
Dr. Z: And no one can contact trace you man.
Dr. Prasad: I mean, I’m not comfortable living in a world where you can, like what I do on the weekends you know, I’m not gonna play that game. You know, I think I just… And I think it’s bad, it’s corrosive. We all lived, I think it was more common a few years ago. Or maybe when I was on Facebook where I would just see like people tried to, it almost feels like they’re trying to travel to beautiful places and post all these pictures to show that they’re living in an enviable life. And then some of those people I know, have later gotten divorced.
Dr. Z: Miserable.
Dr. Prasad: Miserable. They were not in a good place when they posted those pictures. It did not reflect
Dr. Z: Absolutely, you’re doing it for the gram as the kids say. And I tell you, like, I don’t do that. Like, that’s not what… Like you said, I’m a TV station. But what I do is actually part of the appeal of this TV station to some is that they see the completely authentic me. And more so behind paywall, which–
Dr. Prasad: Where you actually talk more freely.
Dr. Z: I mean, so the 8,000 odd people that support the show on Facebook, YouTube, and now we’re doing Locals which is completely off that grid. It’s like, you know, it was started by like Dave Rubin because he got canceled on Twitter. So I’m like a little worried, it’s a little righty tighty.
Dr. Prasad: You’ll let the audience tell you.
Dr. Z: Exactly, they’ll tell me. But the thing is, it’s totally off the social media grid. So the incentive is what people are paying to be there so they can have authentic conversations. And they may learn a little bit about my personal life. They may see my kids and stuff, but really it’s about I’m gonna tell you, no, you’re gonna get me. You’re not gonna get some that I portray or anything. And that’s the power and the potential of the technology. But social media, you nailed it. We’re always got fear of missing out. We see our friends doing these crazy things and you realize they got divorced or then worse, they’ve hurt themselves or something like that and, it’s really a–
Dr. Prasad: But I just wanna like agree with you about the strength of the technology, which is that, you know, 40 years ago some associate professor of hematology, oncology is not gonna have a hour a week podcast where he talks to you about a trial, his thoughts and impressions of it. I’m glad we live in a world where you can… That’s a television station. That’s what I’m running. You know, I talked about Keynote 177. But you know what I mean like that’s a very unique television station. There are few people who wanna tune in and thanks for tuning, no. And I have stations that I listened to that would never have existed long time ago. And you’re putting out a program that is a blend of you know, entertainment, thoughtful commentary. And as you say, I’ve said before, trying to strive towards an alt-middle which is something that boy do we need.
Dr. Z: Yeah, yeah, yeah.
Dr. Prasad: And that’s the strength. But I think the downside of it is that a lot of people are still figuring out who they are and what they believe. And we talked about this before. I pity them in living the social media world where really fantastic stories get a lot of traction. So of course, wouldn’t it be great if a fantastic story happened in your ER? Really provocative things get a lot of retweets. So wouldn’t it be nice if a dying patient said, “Oh I can’t believe it’s real.” or something like that to your ear. And, that’s problematic. And I’ll say one more thing. I mean, I don’t know if people know this about me but I actually don’t believe in using anecdotes to really drive policy arguments. I spend a lot of time to remove anecdotes and try to do like an empirical study to show that like on average, when you look at this situation this happens X percent of the time. Because I think we are as people overly persuaded by the anecdote and we don’t do a good job of stepping back and actually confronting our biases. And actually I’ve had a paper that I was trying to write, where I have a strong feeling and intuition about a topic but then I asked my research assistant to say, you know what, before I write this go look at 30 examples and let’s see how often this occurs, ’cause shit, I might be wrong.
Dr. Z: See that is what I call growing the Rider, the intelligence and the thinker above sitting on this elephant that is our emotional, intuitive self. And that elephant responds to anecdote and stories as a story-driven creature. But the Rider can either go along for the ride or it can take a space and go, oh elephant’s saying this, Hey, RA, go and research this and see if my offense is just off base. Yeah, ’cause I have a recall bias or I have a… There’s a million biases that I could have and we see it. And, you know, what’s funny is takes someone like a Dilbert writer like Scott Adams to write a book that he called Loserthink which was particularly provocative ’cause he’s like a Trump booster. But the thing is, he’s actually a clear thinker. So he wrote the whole book about there are cognitive biases and he’s like if someone attacks you on Twitter or social media and they’re showing one of these biases, you have my permission to take a screenshot of the page in the book and share it with them. In a non-judgemental way, just go, you know this is interesting. Here’s an example of a bias that you might be a victim of here.
Dr. Prasad: That’s very interesting.
Dr. Z: It’s really interesting.
Dr. Prasad: I mean, I’ll just give you one example of something where like this RA actually gave an interesting answer was I was once in an argument, you know, for years I’ve been arguing with the high and unsustainable price of drugs and somebody came and threw in my face that say you know, you’re strangely reticent about the hospital charges and you work for a hospital, don’t you? And I was like, oh, am I strangely reticent, I don’t know. And they’re like, in fact, as a profession, we talk so much about drug prices. We don’t talk about prices in proportion to their expense like hospitals and imaging and things like that. And so I said, shoot, is this person right or wrong? And so we collected a set of like, I forget so many articles and we asked how often do the authors specifically fault higher prices in healthcare on these five different things or six different things? And actually we found that if you look at the global landscape, that there did not appear to be a bias it was actually roughly in proportion to the spending. So it kind of surprised me. And so I thought it was so interesting because like I didn’t look at myself personally and maybe I am particularly critical of pharmaceutical drug prices in part, because I’m a cancer doctor. So of course it’s like a huge expense in my field and my line of work. But, this person had a skewed impression of the world too because this person felt like they’re picking on pharma companies, they must be disproportionately picking on pharma companies. And that turned out not to be empirically the case. And so it is funny that we all view the world through our own lenses. And sometimes the only way you can settle something is ask a third party, as I did, I asked some people worked for me to to really look into something without telling them too much about what you’re really after.
Dr. Z: You know I’m gonna tie this idea of bias back to the original… Remember in that we started the show, I’m like, I’m only interviewing… Someone told me I’m only interviewing Indian people. And they’re like pretty tribal, isn’t it of ZDogg? Since you’re South Asian male. And actually, I had to take a pause and be like, wait, no, that’s entirely possible. Could I be doing this and not know it, ’cause I’m not doing it consciously? And then I thought, okay, so what are… And this is Scott Adams talks about these failures of alternative explanations that people don’t even try to come up with. They just assume they use the mindreading fallacy. So they assume they know your mind, and then they apply it to you without thinking, okay, what else could be happening? So I had to do the experiment with myself. I’m like, okay, so let me see. So the last three guests I’ve had are all Indian. All right, let’s look at the other guests I’ve had. Is this even true? Oh, it turns out it’s not because, oh, it’s just like saying, oh, you only interview men. Okay, well, why is that? Well, okay. The last three were men, so there’s a recall bias, or proximity bias or whatever it is. And then I said, well, wait a minute. What if it’s true? What if the majority of the people that I interview are Indians? Okay, let me look at where I live. I live in the Bay Area. What’s the proportion of immigrants that are in healthcare, it’s quite high.
Dr. Prasad: I mean, I would say that it is possible that of course all of us are motivated by something that we don’t see potentially bias. But I would say the things that one would think about is proximity. You tend to interview people who can physically come to your studio.
Dr. Z: Correct.
Dr. Prasad: Overlapping interests. You tend to bring people in healthcare.
Dr. Z: Correct.
Dr. Prasad: The denominator of what people’s gender and race and ethnicity are. And they’re very likely are a lot of Indian… I don’t know if this is gonna be controversial but there are a lot of Indian physicians in the Bay Area.
Dr. Z: Go to Fremont, it’s 100% I worked there for a while.
Dr. Prasad: Well, I always tell people that, you know, I used to sit on the wards. This is not a joke, this is a true story. I used to sit on the wards when I was attending. And I don’t know if people know this about me but when I attend, I almost always wear a suit. And that happened because I was in attending when I was 32.
Dr. Z: And you had to look older and a certain age, yeah.
Dr. Prasad: I wouldn’t dress in a suit and all I would hear is how old are you, how young are you, when do you become a doctor? Doogie Hauser Enough of this damn, patronizing me, ’cause I’m young looking. I was like, okay, fine. And then I started wearing a suit. And then this, puff, gone, overnight, gone overnight. Nobody ever said, you look so young. And so I would go on the wards and I sit there in my suit waiting for my fellow to come or something like that. So we could round and I swear many many times people would walk up to me and hand me an EKG. It’s like, can you read this? I say, I think so. But you know, I’m not a cardiology. You’re not a cardiologist? I’m like, is that so much of a stereotype? I’m like hematologists, oncologists and they’re like…
Dr. Z: What an Indian hem-onc doc? Oh my God dude that’s hilarious. I mean, I even made a song called One Sikh which was a parody of “One Week” by the Barenaked Ladies where I went through all the stereotypes and they’re stereotypes for a reason because it’s just numerically, you could probably do a study. Now you should do this study. Looking at the bias. You know why I grew up thinking that?
Dr. Prasad: Because of I grew up in Cleveland area and my parents were friends with a lot of Indian cardiologists.
Dr. Z: Me too, me too. To this day, they’re like, why didn’t you become a cardiologist? You know there’s so much money. You’re just put in the stent and whether it works or not, it doesn’t matter. You’re get paid either way. So, you know what’s funny is I wanted to come back to something that you said, which is you dressed in a suit. Now, okay, I’m gonna give props to a colleague of mine who hired me actually at Stanford back in the day. He came back to medicine as an older, like he had an MBA at some other stuff. And so he was like one of the older students that came back. So he was in our residency a couple of years ahead of me or something and he reached out after I’d been working in tech for a year after residency because I’d just been so burned out and he’s like, you need to come back and do this and that. So he was always looking a little mentor to me in terms of the practicalities of how to be a doctor. And he used to tell me, ’cause I was young looking in those days, he would say always wear a shirt and a tie and a white coat and so on. And the reason you do that it’s the reason I let my hair go gray, is that patients are looking for an authority figure. And if you project professionalism and authority that will help with the relationship. Yeah, and they’ll listen. So that was one thing that I thought was interesting. The other thing is that he has all these pearls over the years that are similar. So one thing he just texted me this morning. They are getting crushed right now with COVID at the hospital. And my old group is like, half of them are in quarantine because they’ve been exposed. And so it’s hitting the fan. And he goes this is what I’ve started doing. He goes, anytime I text a nurse with some requests especially if it has a negative valence like it’s something difficult, like put in a Foley or take out the Foley you’re gonna be changing, always say thanks with an exclamation point at the end. And it changes the valence of it because it’s become a courteous thing where you’re acknowledging that they’re doing something for you and so on, even though you don’t have to do that, it helps a lot. So these little things are about our interface to interface connection. So it is important. It has nothing to do with bias and all that but it’s our perception makes reality.
Dr. Prasad: And I guess not to be a stodgy old man, but I will say that sometimes I do notice a lot of people on the wards in the ward du jour of the scrubs and the white coat. And I wanna say, you know I got nothing against it and like, I’ve been a resident and I wore a lot of scrubs, but I will say, I will encourage people to do their own investigation. Randomly assign your days and wear a suit and tie or a very professional dress or wear scrubs and see how you like the response you’re getting. And maybe it’s even in your own mind, maybe it’s in my own mind. Like I have more confidence because… But I do think anecdotally and I think there are some studies, it’s been awhile since I looked at that literature. I think there are some studies about the physical appearance of a doctor and how patients respond.
Dr. Z: Yeah, and we could get canceled for this, right? ‘Cause this is like a #medbikini 2.0. Yeah, I mean, just, I think… And again, you’ve said it, well, I don’t sound like a curmudgeonly old doctor at 37 or however old you are. That the truth is I say it all the time because I found it empirically to be true, but you’re right, if we studied it carefully–
Dr. Prasad: Just let people do their own experiment.
Dr. Z: Let them to do their own AB experiments.
Dr. Prasad: And if you hate us, then you hate us. You can’t hate me, it’s your experiment. You run it the way you want to.
Dr. Z: Go run it.
Dr. Prasad: Adjudicate the way you want.
Dr. Z: Find out.
Dr. Prasad: Yeah, find out.
Dr. Z: One day wear like just this really formal garb and the next–
Dr. Prasad: And then wear your wrinkly scrubs you know, they’re always wrinkly.
Dr. Z: They’re wrinkly they got some stains on ’em they’re tied up at the wrong part of your abdomen. So like, it shows either too little or too much muffin top. I mean, I’ve done all these things Vinay. Every single one. I’ve lost every single battle with fashion that could be lost. But yeah, I did notice it, it was absolutely… And especially I had a patient population the span of the socioeconomic strata. And what I found actually really interesting was also show economic strata patients responded, I felt to a professional attire. Now again, you could let your guard down on the weekends. You could come in with something, dressed down a little. And then what was interesting is they actually felt, I got this feeling. And again, this may just be perception on my part. Like you said, you need to study it. That they were like, oh this guy’s kind of a human.
Dr. Prasad: Like, if you dress down on the weekends, I find that people are more likely to ask you a question they wouldn’t ask you on the weekdays. Like, oh, what are you doing later today?
Dr. Z: Right, a more personal like human to human kind of thing.
Dr. Prasad: I don’t know, people should do what’s right for them. What’s right For me is to wear a suit. Once I started doing it, I really liked it. And also makes my life simple ’cause they don’t think about what to wear.
Dr. Z: Yeah, yeah, yeah, yeah, yeah, yeah. Yeah, so John Cunniff was my friend who makes these recommendations. I’m gonna have him on the show at some point. ‘Cause he has a little chair that folds up that he carries and it looks like a little cane and what he does, he comes into a patient’s room and he unfolds, the chair, sits down and– He gets it level and he’s there and he shows that he’s present. And it’s these little perceptual things, right? And it’s part of the healing thing. Jim Dody was on the show, he’s a neurosurgeon. And he was talking about, you know, patients seem to do better when a surgeon leans in, holds their hand tells them, hey, this is how healing works post-op they have seen better outcomes. I don’t know, he had some data that he was citing that I haven’t looked into.
Dr. Prasad: I’ve seen also another thing people make a lot of calls for is the bedside presentation to have the resident present the patient at the bedside in front of them. And offline, ’cause I’ll never say this publicly but I had a story once where–
Dr. Z: Wait, so you want me to edit this out?
Dr. Prasad: Yeah you can edit it, no, you can keep this part. I won’t say the part that’s–
Dr. Z: Okay, good, good.
Dr. Prasad: I had an attending who felt very strongly and we went to the room and my sub-I, I was a resident at the time, my sub-I said, for this patient I would strongly advise we don’t do this. And the attending said, no, let’s do it. I promise you, it’s not gonna be as bad as you think. And it ended up being the absolute worst. Like the worst moment I’ve ever seen in my life. And then we walked out of there. And I told that attending, I was like, you know, you win some, you lose some.
Dr. Z: Oh my God!
Dr. Prasad: Just ’cause you’re older and wiser so.
Dr. Z: That is brilliant. That’s a good–
Dr. Prasad: I didn’t tell you what actually happened. And I will take it to my grave.
Dr. Z: And you should, and you should because sometimes things are best left in confidence. But you know, just looking at your reaction I know it was amazing The student was right. You know, sometimes students are right. They’re very perceptive.
Dr. Prasad: Very perceptive.
Dr. Z: ‘Cause they know that patient. They spent hours sitting there trying to extract what little history they can pull out.
Dr. Prasad: Only so that the attending goes in and the patient volunteers information they didn’t tell the student–
Dr. Z: Every single time. Nurses complain about the same thing. Like, you know, they say one thing to the nurse, and then when the doctor’s there, it’s like, hey guys. It’s like, oh really? Come on, man. It’s all perception. It’s all a little hierarchical. And I mean, medicine is, it’s just emerging out of witchcraft, really. I mean, and to some of the stuff we do, you know this is your passion is witchcraft, it’s straight witchcraft.
Dr. Prasad: I think, and we don’t think of it as such which has been so ingrained and sterilized and formalized but may in fact be no better than witchcraft. A good chunk of what we do. But the other thing is we balance it out with somethings we do that are so of indisputable benefit. We get away with a little bit of it.
Dr. Z: That’s what it is. Yeah, that’s what it is, exactly. Dude, so I think we talked about a lot of things. Yeah, yeah, yeah, so guys like, I mean, I don’t even know, just share this thing, enjoy it. Cancel us, I don’t know. Yeah, I mean, this was fun. So every time, we’re just gonna keep doing this anytime you’re by.
Dr. Prasad: You have to stop ’cause I wanna record you a little bit for, yeah.
Dr. Z: Let’s do it right now. Guys, we out, we’re gonna do a Plenary Session podcast. Check out his podcast, Plenary Session, Vinay Prasad, it’s fantastic. All right, especially cause I’m on it. That’s probably the only reason that it’s fantastic. Those are the best episodes. All right, peace.