The Peter Attia Drive - #68 - Marty Makary, M.D.： The US healthcare system—why it's broken, steps to fix it, and how to protect yourself

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00:04:10.720 My guest this week is Dr. Marty McCary. Marty is who's a close personal friend from residency.

00:04:16.880 We overlapped when he was a fellow at Hopkins and I was a resident is currently a professor of

00:04:22.560 surgical oncology and the chief of the islet transplant center at Johns Hopkins. And while

00:04:26.880 so much of his work and professional accolades come from his surgical career and the work that he

00:04:33.000 does in pancreatic surgery, especially in minimally invasive pancreatic surgery, Marty is one of the

00:04:38.000 pioneering surgeons in doing one of the most complicated operations that's ever done, which

00:04:42.460 is removing the head of the pancreas minimally invasively, meaning laparoscopically something I

00:04:46.800 can't even fathom because at the time of my training, that wasn't even something that was

00:04:50.560 considered. We actually don't touch on that one bit because there's so many other things that we

00:04:55.580 really wanted to talk about. The other thing that Marty's really known for is being one of the

00:05:00.840 co-creators of the surgical checklist. And this is something that has made its way up to the WHO

00:05:07.020 safe surgery, save lives committee today. Many of you, if you're ever in the hospital,

00:05:11.840 if you're ever having a surgical procedure will encounter this checklist because it's the thing

00:05:16.620 that makes sure that people don't get operated on the wrong side, which is actually something that

00:05:20.720 happened to me when I was in medical school. And it actually is something Marty wrote about in his

00:05:25.500 first book, which was a New York times bestseller called unaccountable. And it's actually that book that

00:05:30.260 became the basis for a very, very popular television show called The Resident, which is based on Marty's

00:05:35.520 work. We touched on that briefly, but most of what we talk about is the material and the content that's

00:05:42.680 featured in his upcoming book, The Price We Pay, which will be available shortly. And this book really

00:05:48.200 takes on Marty's next challenge because if figuring out a way to do the most complicated pancreatic surgery

00:05:54.540 from a minimally invasive standpoint wasn't enough, and then going after medical errors and

00:06:00.240 trying to figure out a way to fix the system that makes it too easy to commit medical errors,

00:06:04.960 well, if that wasn't enough, you know, Marty's decided the next thing that he's interested in

00:06:08.280 trying to address is the broken healthcare system, which I think anybody listening to this knows in

00:06:13.460 the United States is pretty clear. What I like about Marty is he isn't one of these guys who's trying

00:06:18.400 to put the single silver bullet and blame it all on one thing. Oh, it's all drug prices, or it's all this,

00:06:23.020 or it's all that. What follows is a pretty nuanced discussion that it sometimes makes me really upset.

00:06:29.100 There were times during this interview when I just couldn't believe the stories he was telling.

00:06:33.860 And I think many of you will be equally upset by these things and find it totally unacceptable.

00:06:39.140 But at the same time, when it was all said and done, and as is often the case when these podcasts

00:06:43.760 finish and the mic is off, we keep talking. And I think to myself, oh, I wish we recorded that

00:06:47.680 because that was probably the most interesting part of the discussion we had. But I actually came away

00:06:51.720 before Marty left my apartment. I came away realizing there's actually hope here. And I've actually

00:06:57.180 never felt that there was hope for this problem. I truly thought that the US healthcare system is

00:07:02.580 something that will drive itself off a cliff until it bankrupts us. And that is the end of it.

00:07:06.740 And I came away from this discussion thinking, no, there are actual steps that could be taken to fix

00:07:13.100 the structural errors that have allowed people with, in some cases, very good intentions, in some

00:07:19.820 cases, reasonable intentions, and in rare cases, horrible intentions to basically create the most

00:07:26.280 financially irresponsible system that I think has ever existed in the free market. If you're listening

00:07:31.820 to this and wondering, why does this concern you? I believe it concerns almost anybody, because

00:07:37.360 anybody who's ever received an explanation of benefits that made no sense, anybody who's ever

00:07:41.720 received a medical bill that seemed ridiculous, anybody who's ever known anyone who's been chased down

00:07:47.360 by a collections agency, which sadly, the numbers of Americans who experienced this is staggering.

00:07:53.740 You'll want to listen to this because I thought I understood this system well enough that I could

00:07:58.240 coexist with it. I learned so much from Marty about what people can do to protect themselves from this

00:08:04.780 sort of predatory pricing that is, I mean, literally gouging the pocketbooks of people. I think if nothing

00:08:12.440 else, you will come away from this episode with a greater sense of empowerment and how you can

00:08:17.680 protect yourself in such situations and protect the people that you care about. I'll share with you

00:08:22.380 just one statistic that breaks my heart. I believe it's one in four, maybe one in five women who 0.98

00:08:28.780 undergo treatment for breast cancer about a year after their treatment is currently being pursued by a

00:08:34.940 collections agency for some sort of ridiculous predatory pricing scheme that resulted from the

00:08:41.820 treatment. To know that a patient now, based on some of the work that Marty has done, have steps that

00:08:48.080 they can take to put an end to that kind of stuff and fight for their rights is just one of the many

00:08:53.780 things in this episode that kind of gave me some comfort. So without further delay, please enjoy my

00:08:58.820 conversation with my good friend, Dr. Marty Macri.

00:09:04.360 Hey Marty, how are you, man?

00:09:05.680 Great to see you, Peter.

00:09:06.800 I love that I can see you twice in two days.

00:09:08.780 It's awesome. Awesome. Proud of you. Everything you're doing, helping a lot of people out there. So just really

00:09:14.360 great to see you.

00:09:15.140 Yeah, well, not as many as you. You know, it's funny. Whenever I'm doing a podcast, I'm sort of going over a

00:09:19.060 person's bio and I've had the luxury of interviewing a number of friends for this podcast. And so I'm thinking

00:09:26.160 to myself yesterday, I don't really need to review Marty's bio. I know Marty, but my team was kind enough to pull

00:09:31.880 the bio together and they sent it to me and I was reading it and I was like, God damn, what happened?

00:09:36.920 How did all of my friends leapfrog 27 steps ahead of me? And I say that without any envy, just complete admiration.

00:09:43.820 I was with Jorge Salazar a few months ago and it's just another one of those examples of like all these guys that we

00:09:49.220 trained with. Ted Schaefer is the head of urology at Northwestern. Jorge's building the pediatric cardiac surgery program in

00:09:56.500 Houston. I'm like, when did Marty even become a professor? How did you fully, I mean, dude, you are accomplished, man.

00:10:02.840 Yeah. Hopkins is a special place just as you've suggested. And I love it just as you loved it there.

00:10:09.800 But I've always had a special affinity for individuals that are highly creative, a little

00:10:14.580 too creative for the mold in medicine. And so you're one of those guys. That's why it's just so great to

00:10:19.700 see you here and be with you. That's a kind way of putting it. There are a lot of things I want to

00:10:23.860 talk about, but among them, of course, is you've got a new book that's coming out really soon.

00:10:27.780 And this is your third book, but really your second on the topic of medicine in a pretty

00:10:33.860 serious way. Let's start with your first book though, because that was, that's almost 10 years

00:10:39.060 old now, isn't it? Yeah. Unaccountable coming on eight years. Yeah. Eight years. What prompted

00:10:43.980 you to write that? And of course, what some people probably don't know is that a show that many people

00:10:48.920 love called The Resident is actually based on that. We'll talk about the show in a minute,

00:10:52.220 but let's talk about the book Unaccountable. Yeah. Unaccountable to me was an opportunity to talk

00:10:56.820 about what we all talk about, but engage the general public in a way that both brings honor

00:11:02.280 to medicine and at the same time warns people that it's important to get a second opinion. It's

00:11:07.440 important to ask certain questions. I've always been amazed, even from my days as a medical student,

00:11:13.200 where I was lucky enough to work with two of the leaders of the field of patient safety,

00:11:17.560 Lucian Leap and David Bates at Harvard. And at that time, they were sort of radicals. They were

00:11:22.540 talking about, hey, not only can you study infectious diseases or cancer, but you can study

00:11:28.340 the science of delivering healthcare, like medical mistakes and how that harms patients.

00:11:33.920 And then you go from that academic concept to surgical residency, where it's like, you can

00:11:40.300 debate on a policy level, should we ration care? But like on call in the trauma bay, you're rationing

00:11:46.500 care every minute. It's like, look on the ground, it's a different world. It's relentless.

00:11:50.380 And they seem completely detached, by the way.

00:11:53.000 Completely.

00:11:53.260 Like there's nothing in residency that, and maybe it's changed, but I'm guessing it hasn't

00:11:58.580 changed that much. There is nothing to prepare you for or teach you about those types of questions

00:12:05.120 and decisions.

00:12:05.860 Exactly. When I was at DC General City Hospital in Washington, DC as part of my residency at Georgetown,

00:12:12.520 and there was an open elevator door. And somebody walked into the elevator shaft thinking the elevator

00:12:22.080 was there, but it was just the shaft.

00:12:23.520 Oh my God.

00:12:24.340 And fell in and died. I don't mean to make light of it, but it was a tragedy and they had her picture

00:12:30.180 up everywhere. And the door remained in the open position with the open shaft for three more weeks.

00:12:37.720 Haven't we learned our lesson?

00:12:39.360 What do you mean? They didn't put a barrier?

00:12:41.240 There was no barrier. There was no cone. There's no do not cross tape or anything. And to me,

00:12:46.480 this was like the ultimate story of how hospitals were not learning from their own mistakes. And

00:12:51.620 three weeks later, another person walked into this opened elevator shaft and didn't die,

00:12:58.640 but fell down and hurt themselves. You just think, who is watching out for the whole ship? Who's in

00:13:03.820 charge here? And those sort of experiences, and we see them all the time as residents,

00:13:08.500 you'd see the elevator button wasn't working to the helipad or the person in the x-ray counter refused to give

00:13:15.480 you x-rays because they had their own little policy that they made up. And you're just like,

00:13:19.640 can't somebody just look at the whole picture? So it made me think about systems, hospital systems,

00:13:26.440 redesigning the delivery of care. And I think all of those questions naturally open up the question

00:13:32.820 of how can we do better? How do we harm people? And the lexicon is tricky, right? Because if you call

00:13:38.200 it a medical mistake, doctors get very, very defensive. And we work so hard to get to where

00:13:44.580 we are. By the way, John Cameron, who people may or may not know, maybe the most famous surgeon in the

00:13:49.740 United States. I spoke with him just before I came here and he told me, oh, you're going to see Peter

00:13:54.920 Tia. He was the best resident we've ever had at Johns Hopkins. And when you did your time at the

00:13:59.820 NIH in research, he said Steve Rosenberg, who's head of the NIH science surgery side, said Peter was

00:14:06.600 the best researcher we've ever had at the NIH doing his research. Anyway, we work our tails off in that

00:14:12.720 residency, right? And then to have someone say, oh, you screwed up. It's like, well, wait a minute. It

00:14:17.200 wasn't me. It was the system or I'm overloaded. And the reality is it is a systems issue. So the

00:14:24.300 lexicon is important. If you call something a medical mistake, then it assumes you're blaming

00:14:30.160 somebody. But if you say the patient experienced medical care gone wrong, it's a more patient term.

00:14:36.180 Now we have a lexicon in medicine that sterilizes everything. We call things a preventable adverse

00:14:41.360 event, right? Just kind of washes anybody clean of any responsibility. But it's medical care gone

00:14:49.160 wrong. And in the pricing world, it's the same thing. If you talk about healthcare costs, it's kind of

00:14:53.680 nebulous. But if I told you the price of healthcare has gotten out of control, it's like talking about

00:14:58.820 gas prices versus petroleum futures or something. It hits home. Medicine has a way of creating its own

00:15:05.840 lexicon. And it really has a value system behind it. So one of the things I've tried to do, at least

00:15:11.400 with the platform that I've been given from my surgical career at Hopkins is say, how can we change

00:15:16.180 the lexicon? How can we look at the systems and the delivery of care? How can we make sure somebody's in

00:15:21.420 charge of the overall ship? So the elevator door closes or somebody for the love of humanity, put a

00:15:26.560 cone in front of an empty elevator shaft. We laugh at that example, not as you said, because of the

00:15:31.460 tragedy of what took place, but because of the absurdity of it. But what's really scary is the far

00:15:38.260 less absurd errors that take place. And I knew we were going to be talking about this stuff. And I sort

00:15:43.700 of was trying to think of some of the non absurd mistakes that I made as a resident. And more

00:15:49.920 importantly, it's the lack of a system in which one could make the mistakes. I think we just didn't

00:15:56.140 know any better. It's only now I had the luxury of leaving medicine for many years before even

00:16:01.640 coming back to it in a sort of different capacity. So I don't think it was until I fully left that I

00:16:07.680 realized, holy cow, that was the Wild West, man. And we were doing our best. I mean, that was sort of,

00:16:14.500 to me, one of the real beauties of being at Hopkins in addition to, I mean, I chose Hopkins as the place

00:16:19.980 I wanted to go because of John Cameron, who was the chair of surgery, Charlie O, Keith Lillamo.

00:16:25.020 It was basically three people who I had never met before I interviewed there was the reason I wanted

00:16:31.120 to go. Great guys. So you had these three total legends. And then you had this idea of you were going

00:16:36.420 to go to the epicenter of the surgical residency program. William Stuart Halstead creates this program

00:16:41.460 in the late 1800s. And there was this sort of lineage of what was going on. You're in this place

00:16:46.500 that's in theory, the best place in the world. And yet on day one, I remember the responsibility I was

00:16:53.080 given. And I'm thinking, oh my God, am I good enough to do this? Am I? And the other thing that humbled me

00:16:59.200 was the absolute faith that the patients had in us. And it really humbled me, really made me think

00:17:06.020 they think I'm better than I am. They completely trust me. And how do I balance communicating my own

00:17:13.960 insecurity about even the most trivial thing? I'll give you a silly example. You're pre-opping a

00:17:19.760 patient and you're putting an IV in them. And you're thinking to yourself, I'm not even that good at this

00:17:24.160 yet. I mean, this patient is going to potentially get stuck three times while I fumble to put an IV in

00:17:32.280 them because the anesthesiologist couldn't be here right now to do it. And I'm sort of filling in.

00:17:36.380 And yet they're stoically sitting there thinking, well, I'm at Johns Hopkins. I think that's the

00:17:40.840 nature of a teaching hospital. So that's part of what we're supposed to be doing. But when it starts

00:17:44.520 to get to the really serious stuff, I think there were many times when certainly I felt like I was out

00:17:49.440 of my lane. You realize you walk into this incredible lineage historically of public trust in the

00:17:56.880 profession. And a patient you meet in the emergency room will trust you to put a knife to their skin

00:18:01.980 within two seconds of meeting you or to tell you secrets they've never told their spouse of 30

00:18:07.060 years just because you're the doc. And it's this incredible sort of awe-inspiring, wow, they trust

00:18:13.280 me more than I trust myself. I remember trying to put a central line into a difficult patient. You

00:18:18.560 know, at 3 a.m., the patient probably didn't even need the line. You know how we were putting central

00:18:22.960 lines in everybody? I was putting central lines between people in the parking lot practically when I was

00:18:27.500 an intern. I mean, you didn't want to have your chief resident walk in and say, why doesn't this

00:18:31.900 patient have a central line and lose it? So you just put a central line in everybody on this service

00:18:36.600 for fear of getting yelled at. It was just absurd, the things we used to do like that. And I remember

00:18:40.820 one night I tried to put a central line, couldn't get it, and I signed it out to the other resident.

00:18:46.180 And I said, I tried. I couldn't get it. I tried, I don't know, five, six times. And then he went to

00:18:51.240 do it. And he said, I was able to get it. By the way, I think you tried more than five or six times.

00:18:56.240 I said, what do you mean? He says, oh, there were 20 introducer holes in the neck area where you went

00:19:02.040 in. And I thought, gosh, the patient was ventilated. They were intubated. I just had no idea how difficult

00:19:07.280 it could be. And the mantra was, you just try again and again until you get something right.

00:19:13.100 That's the surgical mentality. That's sort of the idea is that you will perfect it. And if it takes a

00:19:19.540 million times, it takes a million times. Yeah. So what year did you start working on that book? I mean,

00:19:25.020 you and I had spoken about some stories that even ended up in the book years before. So obviously,

00:19:29.920 the idea had been with you for probably 10 years. But when did you actually like kind of put pen to

00:19:34.660 paper and start saying, I'm going to do this thing? I remember telling my dad, who's a hematologist or

00:19:40.520 leukemia lymphoma expert, I remember telling him that I was seeing things in the hospital as a student

00:19:46.200 and as a resident that were just mind boggling. And I couldn't really grasp with the collision of

00:19:51.880 sociological issues to see us spend a million dollars rescuing a patient only to go out and

00:19:58.700 have them repeat that behavior that brought them in or a new medication finally get invented

00:20:05.220 in the pharma world and brought to the bedside. But docs just didn't feel like giving it or weren't

00:20:12.120 aware of it. And you thought, wow, the implementation science of medicine is more challenging than the

00:20:18.680 discovery science. And if you can invent Kevlar, but people don't wear it, it's a failure of the

00:20:25.420 delivery or implementation. I thought this is where the opportunity is. And then I think, you know,

00:20:29.840 part of things in my career were right time, right place, right? That's when everyone started to say,

00:20:34.640 hey, wait a minute, we could deliver care better, safer, more reliably. But I told my dad these stories

00:20:39.800 about stuff I was seeing. And there's this one patient who basically didn't want anything done.

00:20:45.740 Sometimes as a resident, you connect with a patient at the bedside and you realize they really don't

00:20:52.100 want this surgery that they're going to have done. And you communicate that to your team. And you were

00:20:57.060 great about communicating. You had no hesitations to say, this is what the patient believes or I'm

00:21:01.720 concerned about this. And hyper communicators do great in surgery. They do great in medical school. 0.81

00:21:07.560 They do great in surgery. They're annoying in the real world. But in surgery, you want that

00:21:12.360 nonstop communication? Are you going to the emergency room? Should I come with you? Are

00:21:15.720 you going to get these lab tests? Where should I stand in the operating room? Those are the

00:21:19.200 communicators we love. It's always amusing. I have every now and then a parent who will call

00:21:23.220 and say, my son, who's in high school, wants to go to Hopkins Medical School. Can you help him or

00:21:29.080 talk to him? He has amazing hands. He was putting puzzles together at age two. It's like,

00:21:34.940 they're all learned techniques. Okay, there's no gifted hands. They're all learned techniques.

00:21:39.260 And by the way, we're not going to help any one kid give him preference and getting into

00:21:43.340 med school. But you realize there was this, when I was a resident, there was this patient

00:21:48.020 who just did not want surgery. And the doctors insisted that she have this invasive biopsy 1.00

00:21:54.060 in order to figure out what the cancer type was. But the CAT scan essentially said it was clear

00:22:00.060 what this cancer type was. And the biopsy was just to confirm it. And I remember the patient

00:22:06.280 just... But regardless of that, she didn't want the surgery to remove it, period.

00:22:10.560 Yeah. Presumably, she was old or... Yeah, she was old and she lived alone and she didn't want 1.00

00:22:15.760 the biopsy, the invasive biopsy. She wouldn't want a surgery to remove it if the biopsy confirmed.

00:22:21.000 So she was basically saying, I just want to go home and sort of live the last few weeks,

00:22:25.620 months of my life in peace.

00:22:26.820 Yes. Leave me alone. And I thought, well, maybe it's important to prognosticate, to tell her

00:22:32.440 you've got maybe two months or you've got six months. The reality is we never really know.

00:22:36.820 Like we have any clue.

00:22:37.880 Yeah, exactly. So I remember telling the team, she didn't want anything done. Well,

00:22:42.120 we have to do the biopsy because we don't know what it is. I'm like, well, she doesn't care what

00:22:47.060 it is. We have to get it. Well, why do we have to get it? To know. We have to know. And I'm just

00:22:52.520 looking at this train that just will not stop and listen to patients. And I'm thinking,

00:22:57.060 how did we get to this point where we just do stuff on people who don't want things done?

00:23:02.900 And you look on a broad scale now, as I've been researching the cost crisis for this new book,

00:23:08.000 The Price We Pay, healthcare is now the number one industry in the United States. It is the number

00:23:13.280 one business as of January, 2018. Entire cities have been transformed. I mean, look at Pittsburgh.

00:23:19.440 It used to be a big steel town in my home state of Pennsylvania. You look around, it's all healthcare.

00:23:23.460 All the tall buildings are healthcare, health insurance, health administration. And you

00:23:27.500 realize, how did we get to a point where we've created this train that sometimes doesn't listen

00:23:32.200 to patients? And my dad said, write these stories down, Marty, because you'll be amazed how you forget

00:23:38.620 when you go on. And someday you'll be teaching residents and students. And these are important

00:23:43.140 things to remember. And that's when I started writing things down for the book, Unaccountable.

00:23:47.160 The TV show, The Resident, by the way, did a beautiful, and it brought a tear to my eye. They did a

00:23:51.660 beautiful description of that case where that patient wanted nothing done. In the TV show,

00:23:58.040 the patient simply said, I want to go home and clean the garage. I don't want to leave my wife

00:24:02.300 with the mess I've accumulated over my lifetime. It was beautiful. To me, that was the most amazing

00:24:06.400 part of being a part of that show. Yeah. My mother-in-law is obsessed with that show, 1.00

00:24:10.900 and she didn't realize it was based on you and your book. And of course, for the listener, my mother-in-law,

00:24:17.320 it was kind of a funny story here because she used to work for Charlie Yeo, who was one of these

00:24:22.040 legends that drew me to Hopkins. And so she was actually one of the first people I ever met at

00:24:28.120 Hopkins because the day I showed up, I wanted to go and meet Charlie Yeo. So I went up to the office

00:24:33.900 like an eager, literal intern with my tail between my legs. But she just had like a soft spot in her

00:24:41.280 heart for me. And when she knew I was talking to you today, she just couldn't tell me as many times

00:24:45.760 as how many times I needed to tell you how much she misses you and how excited she was when I was

00:24:49.520 talking to you. But anyway, it's her favorite show. For me to be able to say, you know, that's about

00:24:52.980 Marty, right? She's like, what? Oh my God, no. And it went from being her favorite show to, I don't

00:24:59.760 know, like a deity of TV or something. By the way, your mother-in-law, Janet, was wonderful. And one of

00:25:05.880 the reasons why we all loved her so much as a resident was here's a normal, caring person in the

00:25:11.320 department of surgery. You can actually talk. They would listen. It wasn't like, suck it up and move

00:25:16.120 on. So it's here's like a normal, healthy, human ombudsman in the middle of Navy SEAL training. And

00:25:23.600 it's like, oh my gosh, she'll hug us. And she had this feelings and she was kind. So we all loved her.

00:25:28.320 But yeah, I try to lay low with the show because there's nothing really good that comes out of

00:25:32.880 associating your name with a show like that when you have no editorial control. And even the first

00:25:37.280 couple episodes, I learned in retrospect, there was a low budget. Now the show's crushing it and

00:25:42.000 they'd spend four or $5 million a show. But back then when it was a tight budget, they had, for

00:25:47.300 example, an episode in the early parts where a medical coder was rounding with the doctors in

00:25:52.920 the CT scan room and telling doctors they need to order this test. And it was like, come on, no coders 1.00

00:25:57.760 are rounding with us. And then over time and their budget and they got more people involved, they

00:26:02.920 really beefed it up. And now it's really, it's a drama about the business of medicine,

00:26:07.060 the TV show, The Resident, whereas previous medical dramas have been about sort of the medical

00:26:11.620 side and medical care. So this is an attempt to really look at the business of medicine.

00:26:16.240 When did you meet Peter Pronovost? Did you know Peter before you got to Hopkins?

00:26:19.920 No, I met him. I met him in the ICU. He's an ICU doctor, as you know. And so I met him in the ICU.

00:26:25.220 And then when you get on faculty at Johns Hopkins, they assign you an official mentor. So he was

00:26:31.620 assigned as my mentor and we had offices next to each other. And he started talking about,

00:26:37.640 gosh, we're using this checklist in the ICU when we round to make sure we're covering all these

00:26:43.700 points. Like what day of antibiotics is this patient on? Let's anticipate where they're going

00:26:49.200 to go after they leave here and how can we make preparations? So that's where I got to know him.

00:26:54.300 Yeah, he was incredible. I always think back to my time at Hopkins as unbelievable. Like I just

00:26:59.360 felt too lucky to be there and just couldn't believe like everywhere you went, there was

00:27:03.520 this person who was exceptional and arguably the best in the country, if not the world at what they

00:27:08.760 did. And certainly Peter was no exception. Interesting as an aside, when I decided to leave

00:27:13.800 medicine, a lot of people thought you were making the biggest mistake of your life. Peter was one of the

00:27:18.680 few people, and by the way, the people who said that and felt that way did it out of complete

00:27:23.020 compassion and concern. So nobody was nasty about it. But Peter, he gave me a book by Joseph Campbell

00:27:28.700 and said, read this. I think it will help. And he was the most understanding person about it. He was

00:27:33.980 like, no, Peter, you know, I think you'll be a decent doctor. But if you choose to leave the

00:27:37.920 practice of medicine, I completely support it and proud of you. And I've never forgotten that Peter

00:27:41.900 was sort of the first person who kind of accepted my decision to leave. We were so torn, by the way,

00:27:46.520 because we had these conversations when you were thinking about leaving. And I thought,

00:27:49.800 gosh, you're so creative. This place beats creativity out of you, this cookie cutter job.

00:27:55.960 So run with that creativity. But on the other hand, we loved working with you. It was like having a

00:28:01.040 reliable, solid doc to work with is the best part of the job. So that's anyway.

00:28:05.880 Well, the good news is there was so many of those at Hopkins. I mean, I felt like my absence certainly

00:28:10.400 didn't change anything because it was just, honestly, I felt like everybody there was, we joked about it.

00:28:15.240 It must have been like the play for the Yankees, right? Everywhere you look, there's like

00:28:18.240 the best person at whatever they were doing. But how much resistance did you get from the field?

00:28:24.000 Because I got to feel like writing that book ruffled some feathers. And again, you do a very

00:28:29.280 good job in Unaccountable of not turning this into a holier than thou crusade. You're self-deprecating.

00:28:36.660 I mean, but nevertheless, in some ways, it's one of the first times an insider said with vulnerability,

00:28:43.140 look, we're not perfect here. We're struggling and we don't have a system that's great. It wasn't

00:28:48.000 some sensational whistleblowing nonsense. It was almost a cry for help.

00:28:54.080 But we come from a culture, and this isn't just Hopkins. I think this is medicine of a very stiff

00:29:00.080 upper lip. You suck it up and you do it and you're doing the best you can because our intentions are

00:29:05.700 good. I mean, I can only recall two residents in the entire time I was at Hopkins that were just bad

00:29:11.940 people. And when you think about how many residents would come through that program,

00:29:15.120 that's less than 1%. So there's less than 1% of the residents I saw at Hopkins were just

00:29:20.420 horrible human beings. So we got all these people who are good, and they're trying to do the best

00:29:24.880 they can. And there is this veil of secrecy. And you come along and you say, we're not doing good

00:29:31.240 enough. Like we could be doing better. And I'm going to share with the outside world for the first

00:29:36.160 time what this means. So did someone like sit you down and say, Marty, shut the hell up?

00:29:41.120 I tried to make it very personal. And like you say, I tried to point out where I've made a mistake

00:29:46.500 in taking care of patients. I tried hard to basically say, look, I'm a human being. We're

00:29:51.780 all human beings. We're going to make human mistakes. Let's not blame the human being.

00:29:55.600 Let's talk about how we minimize those mistakes, how we create safety nets when they do occur,

00:30:00.340 and how we talk openly and honestly about them so that we don't go home with a little PTSD because

00:30:05.540 it is a horrible feeling when you're involved in those things. But I tried to tell my own story of

00:30:11.280 observing in residency at an affiliate hospital, a woman walk into a place that was a branded

00:30:18.080 breast cancer center. And it really wasn't. There was somebody there practicing outdated

00:30:23.300 breast care. They didn't offer all the surgical options. They didn't offer any trials. And I just

00:30:28.740 thought this is dishonest to the patients. Now, what do you do with that observation? Do you internalize

00:30:33.420 it? I remember telling my dad once about a surgeon who shouldn't have been operating. And we've all

00:30:39.260 seen them. They're everywhere. I mean, most surgeons do the right thing and always try to. And we don't

00:30:44.120 want to create hysteria. But you do see this 5, 10, sometimes 15% of surgeons that should not be

00:30:49.980 operating. And I told another doctor in the hospital about what I witnessed in the operating room and how

00:30:56.620 it was an entirely avoidable and it was a skill issue. And the doctor just kind of put his head down and

00:31:02.080 said, yeah, that's too bad. And I thought, is that how we help each other? Is that how we police

00:31:06.400 ourselves? There's got to be a better system. And at a certain point, you realize, okay, the state

00:31:11.680 medical boards, it's not really a feasible way to help outliers. The departments, they're not always

00:31:17.180 incentivized or driven. Generally, we respect everybody's autonomy. Hospitals are profiting from

00:31:23.540 the individuals, not that they want anything bad to happen, but they're just not financially aligned

00:31:28.500 to really intervene. Typically, I don't want to make a broad statement there, but no one is in nobody's

00:31:34.700 direct interest. And so I realized we've got to educate patients on second opinions. We've got to educate

00:31:40.220 patients on the questions to ask. And I try to be very honest about the issue. Now, the one problem with

00:31:47.160 the book Unaccountable was the title. The publishers slapped their own titles on it. And I, of course, had a

00:31:52.880 positive title on it. And they come back, no, we're going to call it Unaccountable, and this subtitle.

00:31:58.100 And of course, I'm thinking, that's not going to fly well with the medical profession. It might sell

00:32:02.180 more books. And they had title rights. And I've learned, I probably got burned on that title a

00:32:07.740 fair bit, because of the 10% of doctors that contacted me, most doctors said, thank you for

00:32:13.000 speaking up, or I've seen this, or this is going on here. But the 10% of doctors that gave me negative

00:32:19.420 feedback, I'd say nobody of those doctors read the book. They actually just reacted to the title

00:32:27.360 or the title of a book review. And the media sensationalizes the topic of patient safety.

00:32:34.540 And it's very difficult as a patient safety researcher to treat the subject in a way that

00:32:39.660 the media is fair and balanced, because what they want to do is just, they're all in the ratings

00:32:43.920 business. I remember Fox News wanted to do a one hour special on this topic and had me in it. And

00:32:50.600 yes, doctor, this is important. We want to help this effort in patient safety. And then they call

00:32:55.020 the show the night before it comes out, they call me and they say, the show's coming out tomorrow,

00:32:59.300 it's called Dr. Death or something like that. Or something. I'm like, come on, you know, I thought

00:33:04.020 you were going to treat this. And so that's the issue with patient safety researcher. To be very

00:33:08.920 honest, I'm thankful that I'm no longer a researcher in patient safety. And my entire research effort has

00:33:15.220 moved on to the cost crisis in healthcare. Because during that era, a 10 year era, when we were doing

00:33:21.560 a lot of research on patient safety, working on the surgical checklist, the media was sensationalizing

00:33:27.240 the subject a lot. And the profession, to be honest, if somebody had a medical mistake, a patient

00:33:31.920 was complaining, they were sort of relegated as crazies. They were just kind of put out there,

00:33:37.080 or any malpractice claim that was resolved, had a gag rule that I wrote about in unaccountable.

00:33:42.860 So you could not speak to anyone for the rest of your life about your medical mistake.

00:33:47.160 Well, mistakes happen. And gagging somebody is tragic, because talking about the mistake is part

00:33:53.860 of the therapy, not just for the patient, but for us docs.

00:33:57.000 Well, I'm glad you said that, because there are several things that I still feel upset about

00:34:01.900 from residency. Again, they're not specifically directed towards any individual or even the

00:34:07.040 program itself, but more the overall culture. And this is one of them. As you probably recall,

00:34:12.040 there was a very clear rule. Now, it obviously wasn't a written rule. It was an unwritten rule.

00:34:16.620 But whenever there was an outcome that was not desirable, so that meant a patient died,

00:34:22.560 even if there was no mistake involved or obvious mistake, but patients die.

00:34:25.820 At Hopkins, doing the most complicated surgery that can be done on this planet,

00:34:30.460 and because it's a huge tertiary center, you're getting people from all over the world who are coming

00:34:34.680 with the biggest problems, invariably, people are dying. Well, the rule was, the unwritten rule,

00:34:40.700 was if there was even a chance there was going to be a lawsuit involved, you weren't permitted to

00:34:46.480 speak with the family. And so, and I remember this very clear one night when I was an intern,

00:34:51.680 and I was in the WICU, so one of the ICUs at Hopkins. This patient had been on our service for,

00:34:57.060 patient had been in a hospital for probably three months. I was just coming off the end of being on one

00:35:02.840 of the, so actually, I wasn't the WICU resident. I was on one of the surgical teams, but you're

00:35:06.780 taking care of the patient in the ICU. And one night I'm on call, and this is kind of the end.

00:35:11.860 I think the family withdrew support, and this patient died. And so I'm filling out the death

00:35:16.340 certificate, and his wife comes up to me, and it's two in the morning. And she just wants to talk.

00:35:24.480 I mean, she just wants, their kids aren't there yet. They're probably not going to be there till the

00:35:28.660 morning or whatever. So I just talk with her. And again, there's no blaming. This is just a,

00:35:35.420 she's questioning, oh my God, should we have even done this surgery? The gravity of this is starting

00:35:40.360 to weigh in. It's a typical situation of a patient who was probably in his late 70s, who had an

00:35:45.760 aggressive surgery for a cancer. And yeah, maybe in retrospect, it wasn't the right thing to do.

00:35:51.140 Did anybody make a mistake there? No.

00:35:53.520 Even if somebody made a mistake, it's remarkable how patients are forgiving.

00:35:57.760 They just want honesty. They just want honesty. They're hungry for honesty.

00:36:00.200 Absolutely. And so I remember kind of the next morning getting spanked a little bit by the chief

00:36:05.000 resident when he found out, you were talking to Mrs. Smith for an hour last night?

00:36:10.100 Like, how dare you? How dare you? Right? Our job at this point is to make sure that if their lawyers

00:36:16.420 call and want the medical records, we get them to them in a timely fashion. We cooperate. And I'm like,

00:36:21.160 what the hell are you talking about? Why is that what we're thinking about at this point?

00:36:25.860 And as myself being a victim of a medical mistake, which you wrote about actually in the book,

00:36:31.060 I was amazed at how well you knew that story. I don't even, like, it's funny. I remember when

00:36:35.300 you sent me the galley of that, I was like, I can't believe Marty remembers all this stuff because I

00:36:39.780 have total hippocampal wipeout from residency. I remember huge blind spots I have, but I never wanted

00:36:48.160 to sue the surgeon who did this stuff to me. But I was definitely upset about the fact that

00:36:53.920 he wouldn't talk to me. It was surgery gone bad, if you will.

00:36:57.500 I feel like I may have told the story before, but I had a wrong side surgery. When the surgeon

00:37:01.440 operated on the wrong side of my spine, something went wrong. I woke up from the surgery in worse

00:37:06.700 shape than when I went in. And for three weeks, he refused to acknowledge anything was wrong. I was

00:37:11.400 seeing him in clinic. He actually called me a pussy and told me to suck it up. He was a horrible

00:37:16.640 human being. There's no question about that. Not because of this. It's just, this guy was a

00:37:20.540 horrible human being who happened to do this. But what amazed me was the complete and utter lack

00:37:25.220 of honesty. I mean, just, and to this day, people say to me, how did you not sue him, sue the hospital?

00:37:34.040 And I said, look, maybe it's because I'm Canadian and we're just not litigious people, but it was never 0.97

00:37:38.700 about that. This wasn't something a dollar was going to solve for me. I just wanted a guy to be able to say,

00:37:44.780 oh my God, Peter, I can't believe in all. And I understand how the mistake happened. It was VIP

00:37:51.260 treatment. That's the problem. So I'm a medical student at Stanford. I've got this huge finding

00:37:55.480 on the MRI. They want to get me right to the OR. It's a Sunday night. We're going to pre-op you first

00:38:00.360 thing in the morning. You're going straight away. Didn't even meet the surgeon, no physical exam.

00:38:04.840 It was a perfect and colossal mistake that was the result of a whole bunch of people trying to do the

00:38:11.940 right thing as quickly as possible. And in all of the hoopla, they got the side wrong.

00:38:16.100 Yeah. It's always the case with VIP care, isn't it? If you're a VIP, do not tell anybody.

00:38:21.060 Yeah, exactly. Do not get VIP care.

00:38:22.860 Do not say you're on the board or have a buddy who's a doctor, just your average Joe walking in

00:38:28.140 and ask all the right questions.

00:38:30.560 Yeah.

00:38:30.780 But you went through, I mean, that was a lot, but people are just hungry for honesty. And you know,

00:38:34.700 unfortunately now the risk managers of hospitals have dominated the practice of medicine.

00:38:41.220 When things go wrong, they basically create this deny and defend mentality.

00:38:47.040 So you're saying that's gotten even worse?

00:38:48.560 It's got, well, I personally think that hospitals are making too many decisions based on what the

00:38:53.960 risk managers are telling them to do. Because from a risk management standpoint, legally,

00:38:59.940 and this is with any corporation, it's not just medical, you want to basically shut off communication,

00:39:04.760 deny and defend, hold your party line and fight it in court and in the settlement process and

00:39:10.300 deposition. But in medicine, people want honesty. They're forgiving and they want to understand

00:39:16.380 what happened. And it's remarkable. I had a patient once who said that surgeon wasn't able

00:39:21.220 to do this in the surgery and they sent the patient here to Hopkins. And I said, well, yeah,

00:39:26.480 I'm sorry you went through that. Yeah, us too. But you know what? Our surgeon did his best and he

00:39:30.980 offered for us to come here initially to Hopkins. And we said, no, we'd really want to stay here in

00:39:36.720 North Carolina. We'd like you to go ahead if you feel comfortable. And there was so much honesty.

00:39:41.620 You realized people don't really sue because things go bad. They sue because things go bad and there's

00:39:47.300 no honesty and transparency. Well, and I think there are data to support that because I remember

00:39:52.000 in residency getting kind of annoyed by this situation of when bad things happen, you're not

00:39:57.540 allowed to talk to the family. And I remember pulling out some, this was soft research, but the

00:40:02.920 takeaway seemed very clear to me, which was lawsuits happen when communication breaks down

00:40:09.340 independent of the severity of the outcome. So you can have lawsuits over bad communication when

00:40:16.220 the outcome was not really that bad. You order the wrong diagnostic test on a patient, for example,

00:40:21.500 they're not hurt from it. They were exposed to maybe more radiation than they should have been.

00:40:24.900 And that's bad, but that's different than you operate on the wrong carotid artery. But it seemed

00:40:30.080 that the lawsuits, the severity of any sort of litigious behavior was much more proportionate

00:40:35.040 to everything that happened after the breach. Absolutely. I mean, again, that was my very

00:40:40.460 kludgy takeaway 15, 20 years ago. Is that still, did the data bear that out? Yeah. Well, the studies

00:40:46.120 show that satisfaction of the patient is the bigger driver rather than the actual events. So if the

00:40:52.040 patient is extremely satisfied, the risk of a lawsuit is low. And that's why I tell docs when something

00:40:57.540 goes wrong, reach out to the patient immediately and disclose. I had a patient where I ordered a CAT

00:41:03.480 scan and they shouldn't have had a CAT scan. I remember you told the story once and this patient

00:41:06.820 didn't like you in the first place. The patient was already pissed at me. The patient had a pancreatic

00:41:10.920 leak, which is 20, 30% of all pancreatic surgery. They struggle with a leak that keeps them in the

00:41:16.840 hospital longer. They feel sick afterwards. And I basically went to this patient thinking, gosh,

00:41:22.440 this guy's going to sue me. He had a similar name to another patient. And when I talked to the resident

00:41:27.920 who then talked to the clerk at the nurse's station, something broke down. I might've not been

00:41:34.540 clear. I might've said the wrong name. I don't remember. I was busy. The resident might've passed

00:41:38.760 the wrong name. The clerk may have entered the wrong name. Who knows? We're not going to have an

00:41:43.280 investigation. But I went to the patient and I said, look, I made a mistake here. Something went wrong.

00:41:48.580 I take responsibility. You shouldn't have had that CAT scan. It was not intended for you.

00:41:53.540 It was intended for another patient on this floor. I mean, this is the stuff risk managers just vomit

00:41:58.600 when they're hearing this. They're like, shut up. Come up with an excuse. Because it's plausible that

00:42:03.800 you would do a CT scan on a patient with a pancreatic leak. You could have easily gone in

00:42:07.320 there and said, Mr. Smith, I just wanted to be doubly sure that the leak was contained. Yeah.

00:42:13.400 So the guy looked at me and I said, I'm happy to get the results right now. As soon as I found out

00:42:18.540 about it, I came up here to tell you. I'm happy to go down and get the results right now. I haven't

00:42:22.440 seen the results yet and share them with you. And we can just see what the CAT scan showed.

00:42:26.500 This guy already had sort of an angry look on his face. He was already upset. I think idealistic

00:42:31.380 expectations of how his recovery should have gone. And he looked at me and this guy put a big smile on

00:42:37.520 his face. And he said, doc, thank you for coming up here and explaining this to me. I really appreciate

00:42:43.420 your honesty about it. That guy never sued me. Okay. We are Facebook friends today because he just

00:42:51.200 hit me. People are hungry for honesty in medicine. Now, honestly, when you make a mistake and someone

00:42:57.020 dies, you need to talk about it. I mean, I hear every now and then about a tragic, horrible,

00:43:01.800 avoidable case. And my first reaction is I want to talk to that cardiology fellow or whoever was

00:43:08.140 involved and let them know this happens to all of us. We're human beings. Things are going to happen.

00:43:13.380 Let's talk about how to prevent it. How do you feel about this? We've got to talk through because

00:43:17.800 I'll tell you, when we internalize, it's bad for our bedside skills. We turn into robots. I don't know

00:43:23.360 if you saw the movie Hurt Locker where this guy's diffusing bombs in the Middle East. Then he comes home

00:43:30.020 and his wife is telling him like, go pick up some cereal in the supermarket. And he's just looking at

00:43:35.580 these cereals like, what's this matter? I'm in a war overseas and who cares what cereal? He can't

00:43:42.240 do the activities of normal living. American sniper, the same thing. He's a hero in war. And then he

00:43:48.940 comes home and he's watching his kid and daycare's wife's trying to engage with him. And he's just a

00:43:54.660 robot. And that is exactly what we doctors go through when you're in the ICU, you're in the trauma

00:44:02.220 bay and somebody has a tragic illness and you're yelling and screaming to get a chest tube in and

00:44:07.040 you go home. Unless we address it head on, unless we talk about it, unless we can't cope. And the way

00:44:13.940 we tend to cope is we just internalize it. I'm always laughing when one of my friends says, I went

00:44:18.800 on a date with a doctor and he didn't have any emotions. And he just started talking about different

00:44:24.500 incisions he would use on the scalp to approach a brain tumor. And I'm like, we internalize too much

00:44:30.460 at the hospital. And it's important to have these honest conversations. By the way, this is what I

00:44:35.000 love about the students. The students have like very little tolerance for BS. I guess it's just

00:44:39.440 part of this millennial generation. So when they see stuff in the hospital, they call it out. Wait,

00:44:44.680 this lady didn't want a biopsy. Why are we doing the biopsy? Ho, ho, wait a minute. And they don't 1.00

00:44:49.440 care about how it's very different from us. As students, we were head down. When someone says jump,

00:44:57.040 we say, oh, hi. You fall in line. I mean, do you remember the twist, which was this pastry on the

00:45:02.540 tray, on the catering tray at M&M conference at Hopkins for many years? Yeah. Yeah. That was the

00:45:08.080 NAFLDT2D special. Right. Exactly. But the word was John Cameron, the chief of surgery, loved the

00:45:15.440 twist. And there's only one twist on the tray. If any resident or med student took it, it was like

00:45:20.600 the biggest faux pas. You do not touch the twist. And they would literally orient you like, here's

00:45:26.060 how you call the blood bank. Here's where you send the labs in. And don't touch the twist at M&M

00:45:31.800 conference. Like part of the four things they tell you when they start to orient the students.

00:45:36.760 And I heard one day, I wasn't there, but I heard one day they found a student who showed up early

00:45:42.220 for conference and he was halfway through the twist. And they were like, what are you doing? No.

00:45:48.060 Oh. We've got to get another twist sent up here immediately. 0.96

00:45:51.100 A twist emergent stat. They're trying to do like the Heimlich on them and preserve the remaining

00:45:56.040 piece of the twist and make a clean cut and prepare their apologies. I mean, that, like you're saying,

00:46:01.720 we just fell in line. It was the military. And gosh, I remember a patient struggling in the ICU. Their

00:46:07.220 oxygen saturations were low, but it was 627. And it took me three minutes to walk to the M&M conference.

00:46:14.620 And you were never late for that conference. And I'm literally like, nurse, can you just manage?

00:46:19.400 I have to go. I have to. This is absurd. This patient's struggling in the ICU with this incredible,

00:46:25.600 I've never seen anyone show up late to that conference in my 16 years of conference at

00:46:31.100 Hopkins. And it's just amazing, this militaristic. And the reality is we should be at the bed,

00:46:35.920 whatever the patients need, we should be there for them. But there's this culture and it's changing.

00:46:40.180 So I love the students. The students are the most exciting part of the job. They are,

00:46:45.520 with the pricing failures that we're writing about now in our research, they are going after these

00:46:50.500 predatory billing practices. And they're saying, excuse me, what the hell? You billed a patient $10,000

00:46:56.360 for a CAT scan. And they've started this movement called Restoring Medicine. They've got a Facebook

00:47:01.960 group. They've got a website.

00:47:03.420 These are medical students at Hopkins?

00:47:04.460 Yeah, medical students at Hopkins and around the country. They're just trying to get a grassroots

00:47:08.320 thing going. They did this on their own. They approached me and they said, look, we love the

00:47:11.780 book, The Price We Pay. We want to work on this. These are our patients that are getting harassed

00:47:19.180 for their medical bills. The patients did not come to the hospital administration or billing department

00:47:26.040 for medical care. They came to us, the doc, and now they're getting shaken down with these egregious,

00:47:31.840 overpriced, surprise bills. It may be that this is going to be the number one issue in the next

00:47:37.680 election. There's some early polling from the LA Times that are showing it's not just health care

00:47:42.100 that's the number one issue in America at the voting polls. It's medical bills. In the midterm

00:47:47.260 elections, Trump's first term. In the midterms, health care surprised everybody. It was the number

00:47:52.000 one issue. They didn't think it was going to be that high. That was not the Obamacare debate. That

00:47:56.040 was people getting hammered with medical bills. And the students right now are saying enough is

00:48:00.960 enough. That generation demands transparency in every aspect of life.

00:48:04.280 There's so much I want to talk about on this front because that's the subject of your book

00:48:07.820 and the stories that you tell in that book just they really resonate with me. But I want to tell

00:48:14.020 a funny story just because you brought up John Cameron and he is such a god to me. As you pointed

00:48:19.480 out, the Hopkins medical students are probably the best medical students in the country. And so that

00:48:23.540 was sort of one of the privileges of being a resident there was for the listener, there's a real

00:48:27.640 hierarchy in medicine. So you have the attending, that's the faculty member. You have the fellow,

00:48:32.600 so they finished their residency, but they're now doing some additional training. You have the chief

00:48:36.840 resident, who's the most senior resident, so they're still in training. You have sort of mid-level

00:48:41.720 resident, junior resident, intern, sub-intern, which is still a medical student, but in their final year

00:48:47.600 and then the third year medical student. I mean, that's basically the entire hierarchy. So one of the

00:48:51.800 real privileges of being at Hopkins was even as an intern, you got to scrub in with Dr. Cameron when

00:48:58.520 he was doing a Whipple procedure. You got to retract and you got to remove the gallbladder.

00:49:02.940 You have the privilege of being yelled at if you're really lucky.

00:49:06.460 Well, I mean, it's funny because if you were in the general surgery categorical program,

00:49:10.380 you couldn't wait to get in there and do that. Now, of course, if you were one of the neurosurgery

00:49:14.180 residents, that might not be as appealing because you're like, oh my God, you know,

00:49:17.140 I just got to get through this thing. But I loved it. So anytime I got to be in the OR with Dr.

00:49:21.900 Yo, Dr. Cameron, it was like the greatest day of my life. And I didn't care if I got yelled at

00:49:25.500 a hundred thousand times and I didn't care if my fingers went numb trying to retract that liver.

00:49:29.780 It was the best. And there was generally a medical student in there as well. And again,

00:49:34.380 if the medical student wants to go into surgery, it's just going to be a fun afternoon if they're

00:49:38.980 competent because they're going to get pimped. So I don't know if the word pimping is still,

00:49:42.660 is that still legal? Oh yeah. Pimping is alive and well.

00:49:45.360 Okay. Okay. Can you explain what pimping is?

00:49:47.460 It's the Socratic method of teaching. It's really posing a question. And so it's just a method of

00:49:53.380 explaining things, but the students perceive they've been taking tests their entire life.

00:49:58.180 On average, every four days of a human being's existence before they come into medical school,

00:50:02.640 they've been taking a test. So they perceive it as, oh my gosh, the great John Cameron or whoever

00:50:09.100 the surgeon is, yo, Lilimo, is asking me a test question. And I'm cataloging through the billions

00:50:15.980 of things I've memorized to see if I know the answer. And if I do, I will make it. And if I don't,

00:50:21.580 I'm dead, we're more interested in someone's communication skills, honesty, affability than

00:50:26.460 we are. They know every fact. And some of this stuff is not knowable. Anyway, pimping is alive

00:50:31.260 and well.

00:50:31.640 So the term still exists because it was a very important part of what was happening. And you

00:50:34.860 thought a lot about this. You knew any day you went into the OR, okay, what are they going to

00:50:38.760 pimp me on? Is it going to be the anatomy? Is it going to be the history of this surgery? Is it going

00:50:43.280 to be what the next step is? That kind of thing.

00:50:45.440 I personally don't do it after somebody passed out when I asked them a question once. Normally

00:50:50.420 they're shaking as you're asking them a question and you need their hands to be steady. So

00:50:55.200 I've basically asked myself the question. If I were to ask myself so-and-so, I would think

00:51:00.580 it's, so anyway.

00:51:01.960 Well, I'll tell you, I thought there were some attendings who pimped purely from the standpoint

00:51:06.120 of just trying to torture. Cameron was not one of them.

00:51:10.280 No.

00:51:10.360 And Cameron, I actually talked about this with Ted Schaefer on my interview with him. Cameron

00:51:14.900 did this thing called Sunday school with us interns every morning. It's like seven o'clock

00:51:18.900 every Sunday morning. We did Sunday school with Cameron where we would have these discussions

00:51:22.280 about the history of surgery. And for those of us who came to Hopkins with that sort of

00:51:26.160 love, this was a gift from God. Like you couldn't imagine you were getting to sit down

00:51:29.940 with the most famous surgeon in the country and one of the greatest historians of surgery and

00:51:35.240 get this lesson. So to be in the OR with him was usually a history lesson.

00:51:38.900 Okay. So fast forward, I'm an intern on GI gold, which was the flagship service at Hopkins.

00:51:44.700 And we had a medical student. You always have two medical students. And as I said, usually

00:51:48.980 the medical students at Hopkins, cause it's, they're just so good that it's just, it's

00:51:52.460 fun to have them around. Even if they don't want to go into surgery, they're just good students

00:51:55.540 and you get to know them and stuff. So I became friends with many of the students. And

00:51:59.000 in this particular month, one of the students wanted to go into neurosurgery. Well, she's at

00:52:03.040 the right place. We're at Hopkins, but you knew deep down that it wasn't going to

00:52:06.400 happen. She just was a space cadet. Like there's just no other way to describe it. She was out

00:52:12.520 to lunch. Actually. The problem is she didn't know it. She had this incredible confidence

00:52:18.220 about her that did not match her ability. That's the most dangerous subtype. It really

00:52:22.280 is. So we're in the OR one day and Dr. Cameron is always talking to the medical student. He's

00:52:28.560 always being friendly. And he says, I do remember her name, but I won't use it. So let's pretend

00:52:32.780 her name is Susie. He's like, Susie, what are you interested in? And again, this is where

00:52:38.020 any medical student will say, Oh, I'm interested in pediatrics. Great. And he will march down

00:52:42.620 the path of, do you know who the first pediatrician was? Blah, blah, blah, blah, blah. And he's

00:52:48.400 just walking you down the path. And so Susie says, I'm interested in neurosurgery. And he's

00:52:54.140 like, great. Do you know who the first neurosurgeon was at Johns Hopkins? And she's like, no. Now

00:53:03.140 the listener, if someone's listening to this, they're thinking, Oh my God, how would you know

00:53:06.720 that? But here's the deal. If you're at Hopkins, you know, this stuff, just as you know, William

00:53:10.960 Osler and William Stewart Halstead, who they were like, everybody knows who created neurosurgery.

00:53:16.560 It was a guy named Harvey Cushing. And he trained under Halstead in the late 1800s before moving to

00:53:21.180 Boston and basically creating the field of modern neurosurgery, the Cushing reflex, right? If you're

00:53:25.980 listening to this and you're not in medicine, you'd be like, why should she have known this? But

00:53:29.220 if you're in medicine, you realize you can't be at Hopkins and not know this. Okay. So she doesn't

00:53:36.540 know the answer. So he keeps trying to give her a hint. He's like, well, he trained at Hopkins under

00:53:41.920 Halstead in the 1880s. No, I don't know. He then went up to Boston and created

00:53:51.060 this pro. No, I don't know. And by the way, at the time, Dr. Cameron is holding the Bovee,

00:53:57.160 which is, this is called the electrocautery, but everyone just calls it a Bovee. And this

00:54:00.520 is a device that revolutionized surgery. It's hard to imagine you could do surgery without

00:54:04.660 electrocautery. So this is a device that cuts and simultaneously cauterizes. So almost everything

00:54:10.860 we're doing in surgery is using this device. And it was invented by, of course, Cushing. And

00:54:15.580 so as he's holding the Bovee, and he's starting to get a little irked now that she doesn't

00:54:19.380 even have a clue. And he says, he invented the device I'm holding in. And he rattles off

00:54:27.280 whatever year it was, 1907. No idea. No idea. He must have rattled off 10 other hints. She

00:54:34.580 finally blurts out her best answer. Ben Carson, who at the time was a pediatric neurosurgeon

00:54:40.580 at Hopkins, who of course has since gone on to become involved in politics. And he loses

00:54:45.020 it. He's like, I suggest you learn your history of neurosurgery. And I couldn't wait to get

00:54:53.100 out of the OR that day to tell my other co-intern this story. And this is how deprived you are

00:54:59.240 of any sense of whatever. We thought this was so funny that we spent the next few months

00:55:04.680 referring to Ben Carson as Benjamin Beauvoyer du Carçon. Because we came up with this idea that

00:55:12.160 Ben Carson had actually invented the Bovee. And that's why it took his name. But we had to come up

00:55:16.640 with this whole French twist to make Beauvoyer. So 20 of the residents at Hopkins heard this story.

00:55:22.380 And we were all going on about how Benjamin Beauvoyer du Carçon created the Bovee. And it wasn't

00:55:28.740 Cushing and all of this other stuff. And to me, that's just an example. Like, I don't even know

00:55:32.740 why I told that story. Other than it's just, you're so sleep deprived. You're so giddy. You're

00:55:38.920 under so much stress that you have to latch on to the dumbest thing as something that's funny.

00:55:44.260 Yeah, absolutely. And it's like whatever it takes to appease the higher ups. The sort of deep sarcasm,

00:55:50.420 I've been the subject of it many times with Dr. Cameron. I have a very good, strong, complicated

00:55:57.200 relationship with the man. He's my senior partner. We've shared a secretary in our practice now for my

00:56:02.540 entire career since I was a fellow under him. And he's both my best friend. I play golf with him

00:56:09.880 maybe every other week. We're great friends. We've done vacations together. The man's 82 years old

00:56:15.500 and a legend in the field. And at the same time, he's my greatest adversary in some of the innovation

00:56:21.660 I've been trying to do at Hopkins, mainly introduce minimally invasive pancreatic surgery. Now he's been

00:56:28.200 very supportive at times. At other times, he'll look at me with the suspicion of, are you using

00:56:33.400 those toys again? Heaven forbid we have a single complication. Even though the baseline complication

00:56:39.620 rate from pancreas surgery is 20%, it's unavoidable if you do a fair amount. If I have one complication

00:56:46.720 and we had, did you use those sticks and toys and cameras? Yes, Dr. Cameron, we use the minimally

00:56:53.220 invasive to have less surgical stress on the patient's physiology and nearly eliminate the

00:56:59.380 risk of a wound infection and other complications. And he will say, well, next time you might as well

00:57:05.300 just take that patient and roll them into an empty elevator shaft, you know, or he'll call you an

00:57:12.340 assassin or what was the other one he used to say? Marty Eminem conference. Sometimes I wonder

00:57:17.860 whose team are you on, the patients or the cancers? We'd be like, no, Dr. Cameron, the gas does not

00:57:26.880 spread the cancer, inflating the CO2 gas. And that was an old criticism that I've answered thousands

00:57:32.300 of questions about. I heard the gas spreads the cancer. No, that's not true. It's like lunar eclipse

00:57:37.960 can spread the cancer. I do want to go back to something else you've said. We sort of glossed over

00:57:42.680 it. But before we get onto this sort of price stuff, which is, it's so frustrating to me. Two things.

00:57:47.700 One is you're absolutely correct. And I've never really thought of it as explicitly as you've

00:57:52.340 described it. But the idea that the doctors, nurses, and healthcare providers who are involved

00:57:59.180 in seeing bad outcomes, it's a form of PTSD. Now it's absolutely not as severe as a person whose

00:58:07.660 job it is to defuse roadside bombs. And I don't think that anything we would ever see in the hospital

00:58:13.100 on our worst day comes close to what you're going to see in the battlefield. But it is still PTSD.

00:58:19.600 Yeah. And you bring it home.

00:58:20.840 And I think of all of the weird rituals I used to have. And I don't think, I mean, I maybe told

00:58:25.920 this story once, but we saw a lot of gunshot wounds. And sometimes the patients die in the field,

00:58:31.020 so you never see them. And then sometimes they come in and you'd get to do these heroic things and

00:58:34.620 you save them. But there's a subset who die in the trauma bay. There's quite a few of them.

00:58:38.500 And I don't know why, but I couldn't sort of let that go. And I remember distinctly one case of

00:58:44.440 this guy who looked like he was about 25, single gunshot wound to the head, but he must have had

00:58:49.320 some vital signs in the field. So he was still brought in the trauma bay. And I might've actually

00:58:54.120 been the intern at this point. I don't think I was the Halstead chief. So we're doing the few things

00:58:58.780 that we can do to basically try to at least see if he has some vital signs so we can do something.

00:59:03.900 But very quickly, it's clear that nothing's going to happen. So we don't even bother to call

00:59:07.480 neurosurgery. I think at this point he's just declared dead. And at this point, everybody just

00:59:10.880 has to sort of leave the trauma bay quickly so that the cleaning staff can come in, body can be put

00:59:16.340 into a bag, get all the blood off the floor, open the trauma bay up for the next one. And his wallet

00:59:22.820 is on the floor and nobody else is in there except one of the nurses. And I pick up the wallet

00:59:28.420 and I open it up and there's his driver's license. And I look at the picture and you can see what he

00:59:35.160 looks like when he doesn't have a gunshot wound in his head. It looks good. I bet.

00:59:38.800 Yeah. And there's a picture of a girl in his wallet and she looks like she's about three years old.

00:59:44.300 And I'm guessing it's his daughter. And I'm thinking to myself, I realize this guy is involved

00:59:50.320 in something to do with drugs because 95% of the trauma we saw was drug related. And it's so easy

00:59:56.800 to just dismiss that as well. Now that's what's going to happen. If you're going to sell and buy drugs

01:00:01.020 in the streets of Baltimore, you're going to get shot once in a while. And I have no attachment to

01:00:04.420 this. But I looked at that. I look over at him and his brain is coming out of the side of his head.

01:00:08.580 That's unfortunately just the reality of what a gunshot wound to the head looks like. And I'm

01:00:12.360 looking at this picture and I'm just torn up by it because I'm thinking, this is one more kid that

01:00:17.380 doesn't have a dad. Whatever this guy did, he didn't deserve this. Whether he stole something or

01:00:22.680 didn't pay somebody or whatever he did, this was too extreme a punishment. But then I also realized

01:00:27.780 whoever did this to him is also in the same situation. This is just one horrible situation.

01:00:32.740 And it just killed me. It's hard to explain how upset I was about this. But I also realized

01:00:39.000 you have about 10 seconds to get your stuff together and get on to the next one because

01:00:44.300 you're going to get paged again and again and again. And oh, by the way, you've got seven other

01:00:49.240 things you didn't do yet on your list today that you have to go and do. And you've got to go track

01:00:53.340 down those blood culture results. There just wasn't a moment to stop and do this. And I thought to

01:00:57.620 myself, we saw so much trauma. And I don't mean just trauma literally as in trauma, but I mean

01:01:05.280 things that are traumatic to a human. And yet I don't once remember there being a discussion about

01:01:11.900 that and how one should deal with that. And I do think that so much of the burnout that we see,

01:01:19.420 and my friend ZDogg, who I know you've met briefly, but...

01:01:22.560 Yeah. You guys should spend a lot of time together. He's spoken about this so eloquently,

01:01:27.420 but this idea of physician burnout, he calls it sort of mortal wounding. And I think he's right.

01:01:33.320 This isn't, I'm tired of my job. It's, I don't know how to internalize what I'm seeing. And we're

01:01:41.200 just, I don't think as a society, whether it be in the military or in medicine or in any field,

01:01:47.080 we're just not, I don't know, we're not coached. We're not encouraged. We're not taught how to

01:01:52.300 share that. I mean, it would never make sense to me to talk to that, to talk with anybody else about

01:01:58.240 that, including my peers, because why would I bother you with that story? Because you got 10 of

01:02:03.620 the same story and you never think that, well, maybe there's value in talking about that. And by

01:02:08.280 the way, acknowledging how much it tears you up.

01:02:10.180 Yeah. And it's exhausting to allow your emotions to go there and think about that patient's daughter.

01:02:16.620 And what's happening with the family? And should I reach out to a family member? You know, there's

01:02:22.780 a nurse saying at the nurse's station, we have the family on the line. And you're thinking, I don't

01:02:28.500 want to take that call because it's emotionally exhausting and you're already exhausted. You haven't

01:02:34.520 slept for the love of humanity in 36 hours. You got to prepare for the next one. So as a coping

01:02:40.760 mechanism by default, without any outside instruction, a human being in that situation

01:02:46.720 will naturally turn into a robot. You just become androgynous. You do not express any emotions. You

01:02:52.920 basically say, this is part of the job and I've got to move on. But what happens is it changes who we

01:02:58.680 are. And you see these incredibly bright, young people interview for med school. The sort of kid in

01:03:06.440 college that says, when everyone's talking about their careers, I'm kind of thinking about med school.

01:03:11.220 They're different from their peers, right? There's this intense sense of compassion, a desire to apply

01:03:15.920 science to help people. It's a compassion-driven profession. The sort of person in high school

01:03:21.540 says, you know, I'm thinking about nursing. They're different from their peers. We're all driven to

01:03:25.560 medicine because of a sense of compassion. And then you take these students when they interview for

01:03:30.660 medical school at Johns Hopkins and we ask them the standard question everybody gets asked in every

01:03:36.220 medical school interview. Why do you want to be a doctor? Because I really want to help people.

01:03:40.700 And 90% of people will say they want to go into medicine to become a missionary doctor or to help

01:03:46.000 the poor or underserved in some capacity, if not full-time, as part of their job, as a part-time

01:03:52.460 co-career. I didn't realize it was that high. 90% of people starting out have some desire to serve

01:03:59.320 underserved, underprivileged people in some capacity. Exactly. They're not coming in saying,

01:04:03.860 I want to be an orthopedic knee surgeon and we need good orthopedic knee surgeons, but they come

01:04:08.060 in. Which you can still do in an underserved capacity. It was basically less than 10% of

01:04:12.220 people have a very clear sense in their mind that they want to do the most elite or whatever thing.

01:04:17.280 Yeah, they're coming in open-minded. They want to do some good. I mean, especially nowadays,

01:04:21.360 the millennials are coming in with this social justice mentality. I mean, when you interviewed for

01:04:26.540 med school, I said it. Let me ask you, how did you answer that question? Did you have?

01:04:30.320 I don't know that I was asked that explicitly. When I went to medical school, I wanted to be a

01:04:33.080 pediatric oncologist. And I had been sort of very moved by an experience that I had seen of a child

01:04:39.240 dying of leukemia, whose name I still remember when I was in college. It's funny. It's a funny

01:04:44.640 story, actually. I interviewed with a surgeon at Stanford, an ENT surgeon. And you sort of get this

01:04:50.100 random draw. Like you get a medical student that's going to interview you in three faculty. And I don't

01:04:54.200 remember who the other two faculty were, but this one guy interviewed me. He was sort of a big shot

01:04:59.040 ENT surgeon. And when he went down this path of, what do you want to do? And I said,

01:05:02.940 pediatric oncology. He spent the entire interview trying to talk me out of it.

01:05:07.080 Classic. Classic.

01:05:08.260 He's like, what? What are you talking about? Do you have any idea how hard that is? I mean,

01:05:12.340 are you crazy? Like, are you a glutton for punishment? You want to watch kids die of cancer?

01:05:17.500 Let me tell you something, kid. You do not want to do that. All right. You want to be a surgeon.

01:05:21.740 You want to, and he just rattled off all these other things you would do,

01:05:24.500 but you do not under any circumstance want to go into pediatric oncology. And I was like, okay,

01:05:28.760 all right. It's impressive. I mean, first of all, that is probably the most admirable area of

01:05:37.060 medicine people can go into. I think pediatrics and psychiatry are probably the most impressive

01:05:42.300 and honorable subfields of medicine people go into. And of that, say cancer care in children,

01:05:48.020 it's just, I really admire those folks.

01:05:50.300 But there is something to be said for what he pointed out that I couldn't appreciate at the time.

01:05:54.300 And so as much as I can mock that story, when you don't have kids, there's something you're

01:05:59.680 missing in that equation. I couldn't do pediatric oncology today if my life depended on it because

01:06:05.060 I think as a doctor, you're sort of always putting yourself a little bit in that person's shoes

01:06:11.080 that's sitting across from you. That's what empathy means. And if we're doing our job correctly,

01:06:15.700 we have to have empathy. So you have to be able to look at the world through their lens.

01:06:19.960 The problem is once you have children, you look at the parent of someone whose child you're taking

01:06:26.540 care of who has cancer. And I don't think I could do, I mean, I, now that I have kids, there are a lot

01:06:31.000 of things I could take in life, but losing a child, I don't think I could take. And so maybe he probably

01:06:35.860 had kids and maybe he understood without being able to articulate why, maybe he understood, are you

01:06:41.320 crazy? It takes a superhuman to do anything in that space. And I remember my time in this sort of

01:06:47.640 pediatric oncology world, as you said, it's a very special nurse, respiratory therapist, physical

01:06:52.440 therapist, physician, everyone who was involved in that care. That's a different cloth those people

01:06:58.680 are cut from. Yeah, it's very impressive. We take people when they come in with these very altruistic

01:07:05.180 goals in life. And you look at them fast forward, eight or 10 years later, and they're like different

01:07:13.520 people. They are, all of a sudden, we beat them down, we make them memorize and regurgitate the urea

01:07:20.000 cycle and the Krebs cycle 18 times, even though no one's ever needed to know the intermediary of the

01:07:25.760 Krebs cycle on the fly in the hospital, right? It's just this absurd, this entire medical education is just

01:07:31.860 so absurd. And I loved in the Price We Pay book, highlighting what's happening now with some of the

01:07:38.840 innovative education, Jefferson, for example, the dean there saying, we're going to hire based on empathy

01:07:44.380 and compassion and self awareness. And yeah, we'll teach you what you need to know, you'll know the

01:07:49.120 vocabulary, we're going to teach you the life skills that you need to know, we're going to teach you how

01:07:53.320 to communicate, how to find knowledge when you don't know it, how to be honest and say, I don't know, and

01:07:58.740 you need to say that. So I love learning about this new approach to education. But there's, there's this

01:08:04.240 thing that we've been doing where we take these highly creative and talented, altruistic people,

01:08:08.860 I mean, they look beautiful when they're in the lobby of the Ross building, waiting for their

01:08:13.940 interview, their hair is combed perfectly, they're wearing these suits or dresses that are just dressed

01:08:18.960 to the nine. And they say all the things that show that they are 100% in to help people. They're

01:08:25.940 mega athletes, they've run immunization programs in Nicaragua, right? They're the most creative,

01:08:31.120 beautiful, awesome souls in the world. And they come in. And then we beat them down with this urea

01:08:37.960 cycle, Krebs cycle, regurgitation treadmill. And in residency, don't ask questions and internalize all

01:08:44.380 this crap that you're going to see. That's stuff that isn't right. Is this still happening, though?

01:08:48.580 Oh, it's happening. I mean, I was just talking to one of our medical students about it. And they were

01:08:52.000 talking about how a lot of it's the accreditation boards and the examiners. These are not your

01:08:57.000 millennials writing the boards. These are folks saying you have to know how to refract somebody

01:09:01.760 for glasses, even though you're becoming a urologist. It's important information for you to know

01:09:06.540 ophthalmology. It's just territorial. So they come out and eight to 10 years later, look at them. Their

01:09:12.640 hair is all messed up. They're wearing pajamas. They don't have a business card. If you ask them,

01:09:16.560 where's your office? They say, I don't know. They feel humiliated, belittled, subjected to all this

01:09:22.020 beating. And we wonder why they feel entitled. And we wonder why they feel while they're doing

01:09:27.580 stuff they know they shouldn't be doing. We wonder why a doctor in a primary care clinic is giving out

01:09:33.060 antibiotics too frequently. Or 10 years ago, we prescribed as physicians in the United States,

01:09:39.220 2.4 billion prescriptions. Last year, it had hit 5.4 billion. Did disease double in the last 10 years?

01:09:46.080 No. We have a crisis of appropriateness. To memorize everything in medicine, it's pairs. Diagnosis,

01:09:50.780 treatment. Diagnosis, treatment. That's the only way you can memorize the thousands of things we have

01:09:54.800 to regurgitate. So you develop these reflexes. Gout is a condition where the big toe has pain at the

01:10:01.760 joint from crystals. You treat it with colchicine. And you memorize these pairs. And what you lose is

01:10:07.840 the sense of the threshold of treatment or the appropriateness of care. What comes out are these

01:10:13.300 doctors that are entitled sometimes, burnout. We beat them down. They're speaking a different language 0.99

01:10:18.460 that has its own value system. Now, this is not everybody. I mean, this is the sort of risk or

01:10:23.400 the hazard along the path. To me, I think of the exceptions. I think of Chris Sonnende. He's,

01:10:28.800 to me, the most special, one of the most special residents I ever knew. I don't know. I always

01:10:32.800 looked at Chris and thought, and Chris, by the way, is he's now running the transplant program at the

01:10:36.680 University of Michigan. But there was just something about that guy. Yeah. Emotionally vulnerable.

01:10:40.340 Yeah. And maintained his humanity under any circumstance. And always, I guess I've never

01:10:46.320 met a human in the context of medicine. And I've met some amazing people. But it's hard to say,

01:10:51.320 like, you've met one person who took everything that you would want to be able to do to the highest

01:10:55.940 level. Yeah. So I always wonder, why couldn't everybody, myself included, that is, be like Chris?

01:11:01.820 I mean, it's hard. I mean, you're one of the most disciplined people I've ever known in my life.

01:11:05.780 But it's hard not to get beaten down. Oh, man, I was so jaded. That's the beauty of someone like

01:11:10.960 Chris. And you never really got jaded either. I mean, you were also in this group of people who

01:11:15.760 just never, because you pointed this out yesterday when we were having dinner, it came up. It's like

01:11:20.020 most of us, when we become jaded, become sarcastic. That became our coping tool of,

01:11:26.840 we just became sort of snarky, sarcastic bastards. Coping tool. Yeah. Coping tool.

01:11:32.120 I mean, I remember my first day in the clinics in medical school, I was assigned a primary care

01:11:39.100 office. And I was working with a doc who's an internal medicine doc. I show up a little early,

01:11:44.860 and he says, the charts are in the door. Here's the schedule. Feel free to just go in and see the

01:11:50.440 patient. And I go in to see the first patient at eight o'clock. And there's a 15 minute slot. And

01:11:56.180 they're getting into all these deep issues. And they're asking me about medication interactions.

01:12:00.100 And I'm thinking, I think there's an interaction there. I got to look it up. And basically,

01:12:03.300 I leave the patient with, I'm going to get back to you. There's a lot of stuff here to unpack.

01:12:07.940 And then I go to the next patient at 8.15. And then the next patient at 8.30. And four patients

01:12:12.980 in the hour. And each one, I feel like I gave kind of a half bait. And it's like, this is insane.

01:12:18.080 And I stopped at nine o'clock. And I looked at the head doctor. And I said, I know I'm giving you

01:12:23.120 brief presentations here for a minute. You're going in for a minute. And then we're

01:12:26.620 treatment plan and a minute of documenting. And I get 10 minutes with the patient. By the way,

01:12:30.820 are we going like this till five o'clock? Because like, I'm dead. We're an hour into this. And this

01:12:37.220 is crazy. He's like, oh, yeah, yeah. And you do this every day? He's like, well, I do it four days

01:12:43.400 a week. And I have an administrative day. Like, how are you not going bananas? How would you possibly

01:12:49.800 manage this? He's like, well, you know, you get comfortable with certain diagnoses. The reality is,

01:12:55.020 show me somebody in America today who's practicing office-based high volume medicine who's not

01:13:01.240 burnout. I mean, it's probably, I don't know, 20, 30%. But you talk to folks, I was talking to an

01:13:06.760 editor of the New England Journal of Medicine at the Brigham when I was visiting. And we met and she

01:13:11.780 said, I just came back from clinic, endocrinology clinic. And I said, oh, how was it? And she's like,

01:13:17.420 I only do it one day every two weeks or something because I'm work for the New England Journal of

01:13:21.780 Medicine. But it's clear to me, everybody there is burnout. I'm like, how could you not be

01:13:26.360 burnout with office-based medicine?

01:13:28.180 I mean, what's the solution to this? We have a population that seems to be getting sicker,

01:13:31.840 and that's not medicine's fault. There's lots of blame you could point at maybe why we're getting

01:13:36.440 sicker. But there's no doubt about it. I mean, people are getting more and more sick with chronic

01:13:43.220 diseases. And they're going to come to the healthcare system to get cared for. Again, I don't have the

01:13:51.160 insight you do into what those volumes look like and to how many of those patients are being treated

01:13:55.880 as outpatients and things like that. But how do we take care of people? How is there enough time in

01:14:01.820 the day to have enough doctors to take care of these folks? Because what you described sounds

01:14:06.780 horrible. I can't imagine if I only had 15 minutes to see a patient. I get angry at my office staff if

01:14:13.200 they give me less than two-hour blocks between patients. Once in a while, they'll stack them one hour

01:14:19.220 apart and I'll get upset. I'll be like, guys, are you joking? We have to spend the first 30 minutes

01:14:24.240 just catching up before we even talk about the lab. So what you're describing seems so foreign to me.

01:14:29.900 But at the same time, I'm empathetic because I realize that's the nature of patient volume. So

01:14:35.200 how does one fix this? By the way, it's horrible on both ends. Patients don't like it either.

01:14:39.820 What I've discovered is doctors were able... So first of all, I personally believe that doctors are not

01:14:45.980 lazy people. We just don't want to spend our time on things that don't matter. And there's an

01:14:51.160 incredible amount of shit that's just been thrown at doctors in the last several years that has

01:14:56.240 nothing to do with patient care. And I know you've talked about some of that in some of your other

01:15:00.120 episodes. But the most exciting thing, and I'll tell you, in writing about these issues,

01:15:05.060 be it medical education or pricing failures or overtreatment or primary care, in the book,

01:15:09.800 The Price We Pay, one thing I wanted to do is balance every problem with a solution or exciting

01:15:15.860 disruptor. Because right now, I am so optimistic and up on the future of healthcare. So many cool

01:15:20.580 things are happening. They're mostly the young folks, mostly people that have very little tolerance

01:15:24.580 for BS. The globally capitated primary care clinics are freaking awesome. 0.99

01:15:30.140 Okay. So let's explain to people what all of those words mean and start with what does capitated mean?

01:15:34.540 So basically, there's no billing going on because globally capitated means that the clinic

01:15:39.580 as a whole, the organization is getting paid a lump sum amount of money. So they don't have to

01:15:45.160 worry about billing for every little thing. And they can spend as much time as they want with

01:15:49.640 patients because they are evaluated by the outcomes of those patients long term, what percent of their

01:15:55.820 patients use an emergency room multiple times or get readmitted to a hospital after discharge or

01:16:01.680 the rates of certain health complications in a population long term. There's an exciting one in

01:16:08.300 Florida called Chen Med. And the Chen family is an incredible group of doctors, a father and two

01:16:13.600 sons, both of whom are primary care physicians. And they have made a deal with insurance and employers

01:16:20.220 where they've said, look, pay us a lump sum for the entire journey of care of your beneficiaries,

01:16:26.980 your population, your employees, and we will assume the downstream risk. And if you do enough,

01:16:32.600 if you have enough patients, you can assume that risk.

01:16:34.720 So if your patient goes on to surgery, it's sort of counted, that money is sort of counted against the

01:16:40.200 amount that you've been allocated for that patient. So what it's done is it's created this incredible

01:16:46.280 incentive because the primary care physician assumes and takes the downstream financial burden of the

01:16:53.480 care. It creates this incredible alignment of incentives long term to do what's in the best

01:16:59.440 interest of the patient. And docs know what's in the best interest of the patient. It's exactly what

01:17:03.520 you're doing. It's spending time. It's being able to go to the home or send somebody to the home.

01:17:09.000 And they hire these patient navigators. At least IORAC does this. And the navigators will visit the

01:17:16.080 home to figure out why aren't they taking their medications or what's in their refrigerator or what

01:17:21.660 do they want to talk about or what's their activity challenge here.

01:17:25.420 But this is different. The only example that people would think of today on a massive scale of

01:17:29.360 capitation would be Kaiser Permanente if you're on the West Coast. Is there any other large capitated

01:17:33.760 system in the country?

01:17:34.940 I'm a big fan of Oak Street, Iora, ChenMed. There's the Magento Clinics.

01:17:40.240 These are smaller. They're probably doing much more than what one of these huge cap systems are

01:17:45.940 doing, right?

01:17:46.560 Exactly.

01:17:46.900 Is there a critical mass at which, from an actuarial standpoint, to manage risk, you have to have a

01:17:52.820 certain number of patients in a pool to justify what, for example, the Chen family are doing? Because

01:17:57.440 if I'm putting my sort of risk mitigation hat on, that's a dangerous proposition for the physician.

01:18:03.900 They could get wiped out. If you have a small enough pool, one bad outcome, which can be entirely

01:18:09.760 out of your hands, patients walking down the street, they get hit by a car, or patient gets cancer.

01:18:14.900 This is going to happen despite all of your best efforts in prevention. If that counts against

01:18:18.940 your cap, you're done. Do you need 1,000 patients at a minimum to be able to-

01:18:23.200 500 has been the number that's been floated out there in the actuarial science for when it's

01:18:28.880 worthwhile to self-fund a population. In other words, if you're Apple and you've got giant cash

01:18:34.960 reserves, why do you need insurance? You can just process the bills yourself. With a 3% overhead,

01:18:41.220 you hire like a bill claims processing company.

01:18:44.980 So right now, Apple, I don't know who their ASO is, but Apple goes to Blue Shield and says,

01:18:51.020 we're going to pay you X dollars to administratively manage, but we manage the risk.

01:18:55.700 Yes.

01:18:56.040 We hold the risk. We are paying for the cost. And what does that work out to? Maybe you don't

01:19:02.780 know Apple's numbers, but if you'd pick a company that for whom you know the data, what is the

01:19:06.640 cost per life that is typically paid for by a large employer in the United States today?

01:19:12.320 Average, it might be $7,000. And with there being a financial benefit to self-funding or what we call

01:19:19.460 self-insuring, it's usually just below that once you self-fund. So at the point of 500 employees or

01:19:25.500 more, the vast majority of businesses in the United States have recently moved to self-funding.

01:19:32.240 This seems crazy. Obviously, my company is very small, so we're not self-insured. We pay

01:19:40.840 an insurance company to take the risk. We pay way more than $7,000 per person per year.

01:19:47.620 Yeah. Traditional insurance usually is more expensive. Now it's regional and it's based

01:19:52.120 on the age of the employees and whether or not families are covered. But per person,

01:19:57.200 that's generally the average expenditure in a self-funded plan. Now there's many variations.

01:20:02.840 So a lot of businesses, let's say a business of your size might say, we're going to take out stop

01:20:07.000 loss coverage. So if anybody gets one of these giant bills over $100,000, that stop loss plan will kick

01:20:13.420 in. There's 21 stop loss insurance companies in the US. They sell across state lines. It's very

01:20:18.580 competitive. It works beautifully. And businesses are saying, look, we'll assume the first $100,000 of risk.

01:20:24.580 A lot of businesses can afford that risk, especially if they're saving money on the front end.

01:20:29.480 And if they have a large enough patient population that they can spread that risk out.

01:20:32.480 Yeah, exactly. This is the future of healthcare and what's happening pretty soon. And the reason

01:20:37.540 I'm so excited about healthcare is that doctors, primary care doctors are saying, let me help you.

01:20:42.580 Let me move in. I want to be the doc for your company. I want to go over the occupational hazards

01:20:47.580 on the factory assembly line. I want to talk about prevention and doing stuff immediately so that

01:20:53.440 patients don't need to go to the emergency room. They can come to me for urgent care,

01:20:57.240 then I'll sort of figure out. And the utilization is down, the costs are down. Because if there's

01:21:01.080 one story of a modern American medicine, it's that price gouging has become an accepted way

01:21:05.680 of doing business in certain pockets of healthcare. And as a business, you're very vulnerable.

01:21:10.840 Okay. So now I want to dive into this quickly, but to do it, we have to set the stage for

01:21:15.340 the listener. So I want to tell a story and then I want to talk some numbers. Here's the story.

01:21:19.800 When I left medicine, the first thing I went and did is worked at a consulting firm. And what I got

01:21:23.860 involved in just based on my background was on credit risk. When I left medicine, I really left

01:21:28.100 medicine. So I'm now a model spreadsheet jockey, and we're working on something called the Basel II

01:21:33.840 Accord, which then turned into two years leading up to the mortgage meltdown. I was part of a team that

01:21:41.120 was basically now in the business of predicting how bad that was going to be. And then once it became

01:21:48.040 clear, it was going to be a catastrophe, figuring out how would you stem that tide. By the end of

01:21:54.340 two years of that stuff, I actually understood pretty much everything one could understand about

01:21:59.560 mortgage backed securities and all of the ridiculous financial tools that were very eloquently

01:22:07.380 described in the movie, the big short. Yeah. Now, look, you can watch the big short and in two hours,

01:22:11.440 I think understand frankly, 70% of it, but I spent two years knee deep in it. And I understand 95%

01:22:17.900 of it by the end of it. If you gave me another three years and said, Peter, I want you to devote

01:22:22.780 yourself to this study of the U S healthcare system. And at the end of that three years,

01:22:27.800 I want you to explain it to me as clearly as you could today, explain to me how mortgages work,

01:22:32.880 how they're securitized, packaged credit default swaps, all of these things, and how it led to a

01:22:38.020 calamity. I wouldn't be able to do it. And I can tell you this because over the past 10 years,

01:22:43.140 I have tried to understand it over the past 13 years, actually. And I can't even fully give you

01:22:50.620 the profit and loss statement of the U S healthcare system. Now, I don't think I'm the smartest guy in

01:22:55.500 the world, but I'm also not the dumbest guy in the world. And that drives me bananas that all I see is

01:23:01.760 a black box for which over $3 trillion goes in and $3 trillion gets pulled out. I don't understand

01:23:11.780 how we can fix something when most people can't even wrap their heads around what's happening.

01:23:19.040 It's incredibly frustrating, especially when you master a certain domain of medicine to be able to

01:23:25.220 have no understanding about this gigantic industry that you're in the midst of people came up to

01:23:32.380 doctors all the time during the health reform debates and said, what do you think? And the

01:23:36.720 reality is, have we ever really talked about how we finance health insurance or whether or not Dr.

01:23:42.680 Pay gets pulled out of nursing home payment allocations. We've basically been focused on two issues

01:23:49.120 in terms of our doctors groups, Dr. Pay and malpractice reform, which is a whole nother

01:23:55.680 subject. The big short beautifully explained that no, it's not a credit default swap. It's so

01:24:03.420 complicated that nobody can understand. Leave it to us experts. It's actually pretty simple. It's just a

01:24:08.580 way around insurance to do that. It's spending money you don't have. And so what I wanted to do is in

01:24:15.620 the book, The Price We Pay, create the big short for healthcare to explain things in a way that are

01:24:22.680 understandable, relatable, and that touch on every area of healthcare. And basically, because there is

01:24:28.980 no silver bullet in healthcare, as you're alluding to, it requires a brief moment understanding

01:24:36.480 pricing failures, a moment understanding the overtreatment crisis that we've created,

01:24:42.580 and a moment understanding middlemen and administrative waste. And if we can tackle each

01:24:48.640 of those subjects in one book in a way that people can walk away and say, oh, now I understand

01:24:53.520 how a PBM or a pharmacy benefit manager works. I try to give an example explaining it like somebody

01:25:00.800 selling Girl Scout cookies and how the money flows.

01:25:03.480 All right. So use that example because PBMs, I think, I mean, it took me two years to understand

01:25:07.760 what a PBM did. Again, I might not be the sharpest tool in the shed. 0.68

01:25:12.680 No.

01:25:12.900 It annoys me that it took me two years to actually understand how PBMs worked. So explain it using

01:25:17.080 this Girl Scout example.

01:25:18.440 So let's say that a mom comes to your business and says, I'd like to be the exclusive seller and

01:25:25.740 provider of Girl Scout cookies to your employees. You say, okay, that sounds good. I don't really know

01:25:31.660 what Girl Scout cookies cost. But yeah, I'd like the idea of all my employees having Girl Scout cookies.

01:25:36.960 So this mom then brings in a bunch of kids who sell Girl Scout cookies to the employees and the 0.99

01:25:43.760 employees walk up and say, oh, how much is a box? Well, which company do you work for? I work for

01:25:49.040 this company. Okay. Then you just have to pay $3.

01:25:52.720 Oh, because this mom sells Girl Scout cookies to many companies. She's the exclusive provider of 0.78

01:25:57.520 Girl Scout cookies to more than one company.

01:25:59.420 Yeah, but that's not why it costs $3. It costs $3 because that's just the co-pay of what the

01:26:05.360 employee's paying for the box. The mom then charges the employer $50 per box as the benefit. The 0.85

01:26:13.600 employer is saying, oh, great. Thank you for providing Girl Scout cookies to my employees.

01:26:17.980 You have $50 a box. I don't really know what they go for. Well, they go for $5. Sometimes in the real

01:26:25.320 pharmacy benefit world, the employer is paying $6 a box of Girl Scout cookies, which covers the entire

01:26:32.400 cost and some profit. And then they're still billing the employer $40. Now you would think

01:26:37.660 the employers would say, this is complete bullshit. I know what you're up to. I know those boxes are $5

01:26:43.140 a box. You're gouging me. Screw this. I'm going to get another pharmacy benefit manager. I believe in

01:26:50.140 competition. I want to put it out for bid. The problem is employers cannot understand the names of

01:26:57.080 the drugs and the generic substitutes and the biosimilars and the bioequivalents and the

01:27:02.500 different dosing schedules and the different frequencies. So they literally get a report at

01:27:08.780 the end of a year with, say, let's say you have 1,000 employees of 4,000 medications that you paid

01:27:15.900 for as a self-funded or self-insured business. Right. Which is different from saying there's chocolate

01:27:21.260 chip, there's Oreo cream, there's vanilla mint, or, you know, I'm making up with cookies. It's easier

01:27:27.300 because there's only like 10 flavors. Right. You can understand that market value. When you're doing

01:27:32.300 it with medications, there are so many games. It's so hard to understand. I've talked to employers

01:27:37.120 when doing the research for the price we pay that they get these reports and they're like, I don't know

01:27:41.480 what the hell I'm spending money on. I can't understand this. And the brokers or the PBMs say, look,

01:27:48.420 you're getting bulk discounts. OK, you're getting a 15 percent discount. And the employers, they look

01:27:55.880 at these shiny objects and think, OK, well, I guess. And then there are all sorts of money games

01:28:00.400 that they added on. Now, providing pharmacy benefits is a valuable service. I believe

01:28:06.340 businesses should make a profit. So they should make a profit for the service. But what they've done

01:28:10.780 is played a massive shell game with things that nobody can understand. Sometimes the pharmacists

01:28:15.080 themselves can't understand. Why when you pay out of pocket, when you go to GoodRx, which is one of

01:28:20.420 the apps I recommend people use when they need a prescription, go to GoodRx and they'll tell you

01:28:25.180 what the price of that drug is in all the places near you. Why is it that that price is often below

01:28:30.720 what your employer is being charged? And it's sometimes even below what your copay would be.

01:28:35.540 Yeah, I did this actually recently. I had to pick something up. And so I'm a big fan of GoodRx

01:28:41.120 as well. We should make sure everybody knows to use that. I'm actually friends with the guy who

01:28:44.580 built the app. So I looked up what 30 day supply of this drug would cost if I went to buy it in cash

01:28:50.120 because I've been I'm so annoyed with how high my insurance premiums are. I keep saying to myself,

01:28:55.120 why do I have health insurance? Like, I'm not even sure I know anymore because the copays we get stuck

01:29:00.380 with. I was telling you last night, I mean, I got an ambulance bill for $15,000 or something. It's

01:29:05.540 just ridiculous. So I noticed that the cash price of 30 days of this drug was $227. It was fine. So I

01:29:14.980 went to the pharmacy and I'd already paid for it with my insurance. So my copay was $30. But when I

01:29:21.040 looked at the slip, I saw that my insurance company was charged almost $1,000. So there's a bit of a

01:29:27.440 disconnect here. My insurance company, who's charging me a premium to take care of my family that is,

01:29:33.380 I think, beyond absurd, is getting gouged. They just paid $970 for something that if I didn't

01:29:42.840 have insurance, I would have paid $200 for. How does that happen? So one thing that has come up

01:29:49.020 in the recent case of the insurance executive who got charged $70,000 for a hip replacement,

01:29:56.980 even though Medicare would pay $20,000 and the benchmark blue book price is $28,000 or $29,000,

01:30:05.080 how did he get charged $70,000? Now, he didn't get charged directly. He was responsible for

01:30:10.240 something like 20%, a 20% of that amount. He's an insurance executive or leader in the field of

01:30:16.920 insurance actuarial science. And he basically said, who the heck negotiated this rate? It wasn't a

01:30:23.320 sticker price. It was the negotiated price between his insurance company and one of the big hospitals

01:30:28.960 in New York. Why wouldn't they negotiate a better rate? And the article basically suggested that it's

01:30:35.640 not necessarily in the financial interests of all insurance companies in all areas to really

01:30:40.480 negotiate the best rate. Why? Well, for a couple of reasons. One, there's something called the medical

01:30:44.960 loss ratio or the MLR that was instated with the Affordable Care Act that said that insurance companies

01:30:49.760 can basically only have a profit, if you will, of 20%. That is, 80% of all the money they take in for

01:30:57.040 insurance premiums has to be paid out as claims payouts. I mean, I understand that and I applaud the

01:31:04.260 idea behind that. But to say that, well, let's just be completely wasteful with the resources to make sure

01:31:11.420 we hit our MLR is crazy. Why not instead say, if you blow through your MLR, let's say your profit margin

01:31:17.600 is 40% instead of 20%, just apply the extra 20% to next year's premium reduction? Well, if you can

01:31:24.700 only make 20% of the premiums as profit, how do you make more profit the next year? Organizations

01:31:30.920 like to make profit. You build in, you almost want more payouts and then build it into your premiums for

01:31:38.100 next year. So the more they pay out, the more they can say, well, premiums are going up 12% next year.

01:31:43.140 That gives them more money. I see. So you're saying they want to drive revenue as high as

01:31:48.180 possible because they're only allowed to keep 20% of gross. Exactly. The higher the gross,

01:31:54.300 the higher the profit. Yeah. Now I don't think I know a lot of insurance executives. I don't think

01:31:58.620 they're diabolical people. I have really asked how intentional is this or passive is it? And I've

01:32:04.660 heard it's mixed. Some insurance markets are very competitive, but this was in New York City,

01:32:09.140 one of the big hospitals charging 70 grand. So the insurance companies may not be your fiduciary,

01:32:15.560 your independent. And if I can just take an aside for one second, one of my biggest frustrations is

01:32:21.360 the lexicon or the language that we all use. Oh, not to criticize you, but I do this also. You've

01:32:27.200 referred to my insurance company paid that amount. Well, actually you paid that amount in your insurance

01:32:34.520 premiums. Oh, my employer paid the rest. Well, guess what? That's from the same pool of money of

01:32:39.300 wages and benefits that you would otherwise get a raise from. So this lexicon of, oh, my,

01:32:45.160 the government paid. Well, we're paying what? A 7.5% Medicare excise tax on your end. And then if

01:32:51.840 you're self-employed, double that, you're paying 15% Medicare excise tax because otherwise the employer

01:32:57.720 is paying. Well, you're paying. It's the same pool. Oh, the government paid. Oh, Medicare paid. Oh,

01:33:02.120 the insurance company paid. Oh, my employer paid. No, no. You pay. The joke is on us, right? You've

01:33:07.220 paid in so many different ways. People say that healthcare is now 18% of the GDP and it may be as

01:33:14.700 high as 16% of our federal expenditure, all of our tax dollars. In Massachusetts, guess what percent of

01:33:22.820 all the state dollars go towards healthcare? 43%. I was going to guess 25. 43%. I just met with one of

01:33:30.580 the recent legislators in Florida who's now in D.C. working with us on price transparency advocacy,

01:33:36.740 43%. So people think, okay, 16% of the federal expenditure. Well, guess what? Guess where people

01:33:42.240 are spending their social security checks? They're increasingly spending on those co-pays and

01:33:47.160 deductibles. Is our health-related costs still the leading cause of personal bankruptcy? Yeah,

01:33:52.780 it's the number one cause of personal bankruptcy. And FICA score is getting ruined. And now,

01:33:58.700 tragically, one in five Americans has medical debt in collections. What?

01:34:05.120 One in five Americans has medical debt in collections. And that seems, I mean, not saying

01:34:10.620 I don't believe you, that just seems hard to imagine. FICA scores are getting ruined. People

01:34:16.560 are paying more for their mortgages because they had a surprise bill that was unpaid. People are getting

01:34:21.760 hammered out there. And when we hear that healthcare was the number one issue in the midterm elections,

01:34:27.120 it's really medical bills. People are angry. They feel they have no recourse. In some cases,

01:34:33.240 I discovered in the book, the hospitals take the patients to court and garnish their minimum wage

01:34:38.600 or paycheck. There's a court in Virginia, an hour south of my house, where if you don't pay your bill

01:34:44.560 to that community hospital, they will take you to court within months, garnish your wages. And if you

01:34:49.940 don't have a job where you prefer not to have your wages garnished, the court will ask for your ABA

01:34:54.560 number and your routing number and your bank account number. And the money will just get pulled

01:34:59.740 right out of your savings from the hospital. Now these are- Is this hospital a for-profit or

01:35:04.420 not-for-profit? It's a not-for-profit. It's a not-for-profit. And the for-profit, HCA has a

01:35:10.340 hospital in town and they behave. They stay true to the mission of medicine. They don't shake people

01:35:16.240 down that are poor. I mean, you can shake down, look, a rich person who had plastic surgery and

01:35:22.140 didn't pay their bill. I got no problem with you suing the socks off of that person.

01:35:25.740 But that doesn't even happen because you pay up front for all of that stuff anyway, don't you?

01:35:29.240 Yeah.

01:35:29.360 That's sort of a non-issue.

01:35:30.600 That's a non-issue. But these are low-income, these are poor people who work and have health

01:35:36.200 insurance. They've done nothing wrong. They've showed up to work. They work hard. I've met several

01:35:41.760 of them who are single moms. I was in New Mexico visiting a hospital for the book I profile in,

01:35:50.860 for the hospital I profile in the book We Price We Pay, where the hospital has sued half the town

01:35:56.220 in New Mexico. The town only has like 28,000 people in it. They've sued half the town. The

01:36:00.680 courthouse, when I walk in there, the clerk says, that's all we're dealing with here is hospital

01:36:05.160 lawsuits. I said, what percent of your civil cases in this courthouse, in this town, is the hospital

01:36:10.620 suing patients to garnish their wages. So very low-income, blue-collar towns, an oil town,

01:36:15.780 mostly oil workers. And they said, oh, it's 95% of what we deal with. I said, how many in a day

01:36:21.280 will you get? Oh, we could get 10 or 20 lawsuits in a day from the hospital. It's almost become like

01:36:27.140 the court is now their collections department. And one woman, her car was in the shop for repairs.

01:36:34.500 It cost 800 bucks. She didn't have the 800 bucks to get it out of the shop. And then she gets hammered 0.97

01:36:39.060 with a $4,000 bill for taking her kid in for an asthma treatment that took 45 minutes.

01:36:44.260 People are getting hammered out there. And what we're saying, and what I'm trying to use this

01:36:49.140 incredible platform that God's given me as a surgeon at Johns Hopkins is to say,

01:36:54.660 this is not our heritage. This is not our profession. We have this incredible public trust.

01:37:01.640 We need to stand up for our patients.

01:37:03.720 I mean, just to take a step back from this, I don't think anybody listening to this right now

01:37:08.020 thinks what you're describing is cool. I mean, this is totally unacceptable. The doctors think

01:37:13.380 it's unacceptable. The patients think it's unacceptable, but the doctors and the patients

01:37:18.320 aren't the ones that are making it happen. So you've got now two groups who are finding this

01:37:23.380 unacceptable. One, because they're the ones actually getting gouged. That's the patient. And of

01:37:27.040 course, and the physician who's saying, wait a minute, this just doesn't even seem right on first

01:37:31.220 principles. But how do we do anything about it? I mean, it's very frustrating because I grew up in

01:37:37.460 Canada. I think it's totally overblown when people in the United States romanticize Canada. Let me

01:37:41.880 tell you something. Canada does not have a perfect healthcare system. So any of you listening to this

01:37:45.240 who think, oh, we should just be like Canada, be careful what you wish for. Because I could tell you

01:37:49.240 57 horror stories of what it's like to be a patient in Canada who tears their ACL and has to wait

01:37:56.540 seven freaking months to get an MRI to confirm a diagnosis. And if you want to do anything else

01:38:02.740 about it, good. Drive to Buffalo and pay out a pocket for your MRI and join the price gouging

01:38:07.380 south of the border. So Canada is not a panacea either, but there is something in Canada and the UK

01:38:13.980 and in other single payer systems that just makes sense. And it is the following. It is a budget,

01:38:21.160 not a demand driven system. And a single payer always owns the risk for life. Those are, in my

01:38:28.940 humble opinion, two things that are sorely lacking here. I'll explain what those mean. I know you

01:38:33.720 understand what that means. In the UK, the NHS has a budget. The budget determines how much they're

01:38:39.420 going to spend on healthcare that year. In the United States, we have a demand driven system. You can

01:38:44.920 predict what we're going to spend next year on healthcare, but the reality of it is demand

01:38:49.780 determines how much we'll get spent. The demand is set by the patient and the provider. A lot of the

01:38:57.300 stuff you talk about, the over-treatment, the unnecessary treatment. I want to dive into that,

01:39:02.240 by the way, because there's so many interesting ideas there. The second thing is, I think I'm

01:39:06.380 blue shield right now as my insurance company, but tomorrow, next time there's an open enrollment,

01:39:10.200 I could switch and join Aetna. And then I could decide a year later, no, I want to go back and do

01:39:14.740 United. I think there are probably stats on this that would suggest that the average

01:39:19.440 tenure of an individual with a given payer is probably less than four years. So you have

01:39:26.980 this portability of risk. So if I'm in charge of Marty's risk, but I know that I've only got

01:39:34.660 Marty's life for three years, what incentive do I have? Let's say you were just diagnosed with type

01:39:40.640 two diabetes today. I know that in 40 years, I know that in 20 years, you are going to be a nightmare

01:39:48.160 for me to manage from a cost perspective, your amputations, your cost of insulin, because even

01:39:54.280 though you're not on insulin today, you're going to be on insulin then. And the cost of insulin is

01:39:58.020 another, one of the greatest scams in the history of civilization. But in the next three years,

01:40:02.960 are you really going to cost me that much? Nah. So I don't have any incentive to do what you

01:40:07.520 described in the capitated system. I don't own your risk for long enough. Whereas in a single

01:40:12.500 payer system, guess what? I own your risk forever. So I actually have an incentive to do something

01:40:16.320 about it. So I think it's that coupled with this demand driven system that has created

01:40:20.660 something broken. And then notwithstanding what you just said, which is we don't have universal

01:40:25.860 coverage. And I know that's such a politically charged topic. And I realized that in saying that

01:40:30.800 you just take 50% of the population and you piss them off for saying we should have some 0.94

01:40:35.500 universal coverage. But what do the polls actually say? I mean, I know this is such a political

01:40:41.520 topic, which I don't understand why this is a political topic. Like to me, save the political

01:40:47.900 topics for things that are political. Like, but what is the public's opposition to some form of

01:40:53.100 universal care, at least to cover sort of primary care or some sort of basic expense? Like why is

01:40:57.940 someone who makes $28,000 a year and has health insurance ever getting a bill for $4,000? What's the

01:41:07.240 morality behind that? And when people understand that fact, how many of them still oppose a net that

01:41:14.440 would prevent it?

01:41:15.300 You're absolutely right that there's has not been a traditional financial incentive to reduce long term

01:41:21.900 health complications and utilization because I even had don't laugh, but I had one insurance

01:41:28.300 executive actually tell me, actually, if we do some things that reduce long term complications,

01:41:33.500 we're actually saving money for our competitors. Now, he didn't because he's basically acknowledging

01:41:38.900 that whatever we do today, our competitors will reap the benefit of because four years from now,

01:41:44.600 this life will be my competitor's life.

01:41:46.500 Yeah, this patient is going to be with a different carrier for sure. In five years, with rare exceptions,

01:41:51.380 people just switch jobs, they switch plans. He was being very honest with me. And I have this

01:41:56.260 great relationship with insurance executives and hospital executives where they're saying,

01:42:00.280 Marty, you're right about these issues, but I want to do something about it. So he's being honest,

01:42:04.880 and he's not saying I deliberately do not want to invest in long term health because I could save

01:42:10.860 my competitors money. It's just there's no real reward financially to accompany the goodwill that we

01:42:17.180 all have that we want what's best for patients. So that's what I love about these,

01:42:20.740 what I call globally capitated primary care that have lives for the long haul. And they're doing

01:42:25.320 incredible things. And if you're a business, sign up with Iora Chen Med Oak Street, one of these

01:42:30.020 globally capitated primary care, or get some of these local primary care practices are pooling together

01:42:35.180 and saying, we want to go to the local business and we want to work with them. GM just signed a big

01:42:40.100 contract with Henry Ford Health System direct employer contract. I've helped some businesses do these

01:42:45.480 deals just sort of free service to I love it. It's the most exciting thing going on right now.

01:42:51.020 But I think the reason why the outrage has been suppressed is just like we saw with the mortgage

01:42:58.100 crisis and the financial collapse of 2008. People just don't understand what's happening. And the money

01:43:04.460 games have sort of been flipped around. So for example, if a business gets a higher insurance premium

01:43:10.300 rate for next year, they'll tell their broker, this is crazy, 11% increase in one year, they'll say,

01:43:17.400 well, the cost of drugs and the cost of the reality is, it's more the intermediaries, it's the money

01:43:22.860 games. I have met a couple independent brokers, these brokers in the business routinely and almost always

01:43:31.900 get paid a giant kickback from the insurance company or the pharmacy benefit manager for sticking

01:43:38.940 an employer with one of their plants. And it's hard to watch, you realize why people are paying too

01:43:44.600 much. Sometimes they're not given the best options. I profile it in the price we pay businesses that

01:43:49.400 said, no, no, I want another broker, I want an independent broker. And they just immediately save

01:43:54.880 half a million dollars or a million dollars. And businesses all over America are getting ripped

01:43:59.380 off right now on their health insurance and on their pharmacy benefit manager.

01:44:02.780 So these brokers are not legally required to be fiduciaries?

01:44:06.380 No, they are routinely accepting...

01:44:09.440 So it's worse than real estate. In real estate, you know your agent's not a fiduciary, but at least

01:44:13.300 you know, at least you have transparency into what their commission is.

01:44:17.080 It is worse. And it's, at least in real estate, you know there's a 6% commission. In this world of

01:44:22.760 selling health insurance, which by the way, I've not met a doctor in America who knows how

01:44:27.000 healthcare is sold in America to businesses. This is sort of, when we were memorizing the

01:44:32.320 Krebs cycle 12 times, how about substitute one of those 12 times for a quick lesson on how

01:44:38.440 healthcare services are bought and sold on a grid like energy. These brokers get a, say in New York,

01:44:44.500 it's a standard 4% commission of every premium dollar the business will spend on healthcare. It goes to

01:44:50.260 that broker who cut the initial one-time deal. They placed you... So imagine you're a real estate

01:44:55.440 agent getting 5% for life. You're paying every year. It's a one-time cost, so it's not really a good

01:45:01.100 example. But every year a business pays a million dollars, 4% goes to the broker who cut the deal.

01:45:06.960 It'd be like a rental agent. Wait, wait, wait. You mean if you cut the deal in 2019 and the employer

01:45:12.760 keeps going with that same deal, you continue to get your commission on the tail?

01:45:16.900 Yeah, 4%. In New York, it's regulated. Some places it's a little competitive, but generally,

01:45:22.200 like in New York, it's 4% for life.

01:45:24.220 So let me ask a question. What is the... If you use the word single payer, half the country loses

01:45:29.480 their mind, you might as well say, we want to resurrect Stalin and put him in the White House. 0.85

01:45:35.500 Like it is such anathema to our existence. I don't know that a single payer fixes a lot of problems,

01:45:41.360 but it fixes this problem. Yeah, it fixes this problem.

01:45:44.280 So question one, why are we so morally opposed to a single payer system? And I'm not sure I would

01:45:50.300 like it, by the way, because when I see the single payer system in Canada, I can point out all of the

01:45:54.840 flaws. And two, is there a hybrid where you can get some benefits of single payer? Because almost

01:46:01.500 everything I've heard you say so far is a cost center because of the complexity of negotiation.

01:46:09.880 And so if you took out that complexity, you would eliminate the need for a broker. Why do you need

01:46:14.860 a broker? I don't need a broker when I buy underwear. Why? Because underwear are freaking

01:46:19.560 easy to buy. And I can price shop myself. I mean, most things in my life I don't need a broker for

01:46:25.460 because they're easy to buy. I mean, the issue here is you need brokers for things that are really

01:46:31.120 complicated to buy. And I don't think there's anything... I don't think this is an exaggeration.

01:46:37.020 I don't think there's anything more complicated to buy than health insurance.

01:46:40.500 I want to answer your question about the Medicare for all issue that's coming up. But real quickly,

01:46:44.780 by the way, the brokers don't like this either. Okay, they went into this thinking,

01:46:48.380 oh, I'm going to do something good in society. I'm going to work in healthcare. I'm going to help

01:46:52.540 businesses and guide them. Then they find themselves in these traps where they're getting

01:46:57.300 these cash flow streams, these retention bonuses, these threats from insurance companies.

01:47:02.320 I profile in the book a guy who basically got fired as a broker, if you will. They closed all books of

01:47:08.400 business with him because he suggested to an employer they could get a better deal somewhere else.

01:47:13.560 And it was one of the big Blue Cross Blue Shield plans. They said, screw you.

01:47:17.180 They wrote him this nasty letter. They trash talked to him. They closed all his books of

01:47:20.880 business. So all of his lines of revenue, all his steady commissions and the bonuses on top of that

01:47:25.900 all got shut down. That's catastrophic if you're a broker. They don't like living like that. They

01:47:30.780 know. I went to a broker conference and I started talking to them and they just start saying, look,

01:47:36.420 this shouldn't be. This is a dirty secret in the business. We don't even like it. Write about this.

01:47:41.880 They gave me these stories and these spreads. But the Medicare for all thing, real quick, right now

01:47:47.080 it's polling very high. The American public is very, very much liking the idea of Medicare for all.

01:47:54.240 The Democrats are running with it. As you know, I work with both Democrats and Republicans in the

01:47:58.240 government. I brief, I advise, I try to be as independent as possible. Medicare for all is very

01:48:03.360 appealing because all of these money games in this mirage and shell game all disappear with a direct

01:48:10.620 Medicare for all system. Has anyone done, is there an independent think tank that's done the actual

01:48:15.580 analysis and said, look, right off the top, you're going to save 8% of $3 trillion if you do that. Is

01:48:23.160 there a sense of what the benefit is of making that type of a change?

01:48:26.520 My research team's estimated that you save 15% right off the top.

01:48:30.300 15.

01:48:31.160 Immediately. Immediately. Not even over time. And no journal's interested in publishing that.

01:48:36.980 It's not a randomized controlled trial, but it's the biggest issue facing America, right?

01:48:40.800 Now, here's the issue I have with switching over to this single payer Medicare for all system,

01:48:47.160 is that over time, historically, governments have shown 100% of the time,

01:48:53.520 they cannot resist the temptation to make across the board cutbacks on healthcare. We've done it in

01:49:00.940 Medicare as a country. And so you go 10 or 20 years, sure, you've cut all this waste initially,

01:49:06.720 but politicians, governments, political will, they cannot resist the urge to just dial down,

01:49:12.680 dial down their spending on healthcare. And then you're left with these dilapidated systems in parts

01:49:17.480 of the UK or other countries where their spending on healthcare is just so weak that when they're

01:49:23.500 doctors, like in England, went on strike, the government's kind of like, well, you guys are

01:49:27.860 civil servants, suck it up. And that's what I worry. And if we can accomplish these incredible

01:49:33.580 efficiencies in the market to cut the waste, I mean, I've seen estimates that as much as 50%

01:49:39.480 of our healthcare spending is wasted. And if you look at the amount we spend per beneficiary,

01:49:44.480 we're more than double what some countries are. The average person in the United States

01:49:48.940 might have a total health spend of $12,000 per year on average. That's not self-funded. It's

01:49:54.800 not your part. It's the overall expenditure. We are way, way over the curve. And we didn't spend

01:50:00.920 this money growing up. When we showed up to the emergency room with a cut, you might've seen a

01:50:04.900 bill for a hundred bucks, but insurance always took care of it. Now there's a woman who was charged for 1.00

01:50:10.160 just checking into the ER. She left before she went back into the emergency room and she got this big

01:50:16.180 bill for like 1200 bucks. I mean, the pricing failures have really hurt. So I'd like the idea

01:50:21.820 of cutting out the waste, but I think if we can do it through free market competition,

01:50:27.140 then it's much better for the longterm. So, so Marty, the flip side of there's

01:50:31.780 advantage to a single payer system because you could cut out all of the machinery that's necessary

01:50:38.440 to make a market understandable. The flip side is, but a free market works better. And I think

01:50:46.100 that's generally true. I mean, it's hard to argue that capitalism works. It's hard to argue that

01:50:52.000 it's the least bad option, maybe to put it mildly. It's hard to argue that competition is not a good

01:50:57.840 thing. So what's the argument that says, no, no, no, no, no, no, no. A single payer system is a

01:51:02.740 disaster. We want to stay with this sort of system that has multiple different competitors across

01:51:09.800 every spectrum from hospital systems to that are each competing to do the best to payers to PBMs to

01:51:18.120 brokers and all of these things. So what's the argument that says, don't leave that, but let's

01:51:23.180 just re channel it. Yeah. Well, I mean, one of the big tasks I've been trying to do is educate the

01:51:28.460 American people. I described the book, the price we pay as the big short for healthcare. If we can

01:51:33.200 educate employers, everyday Americans, how to buy drugs, how to buy health insurance, how to ask the

01:51:41.000 questions, get second opinions, challenge their bills, recognize that when you get one of these

01:51:46.260 massive bills, you're not legally obligated to pay it. And we're making these legal cases to judges

01:51:52.680 across America. I've got a group of pro bono lawyers as a part of this restoring medicine movement

01:51:58.740 that we're assigning to individuals and we're swimming in cases. I mean, there's just unlimited

01:52:02.920 cases out there. One in five Americans have medical debt collections. Well, some of those go to court

01:52:07.520 where basically telling the judges, there's no legal contract. How can I mow your lawn and then send you

01:52:14.640 a bill for $5,000 and say, well, that's what I charge. I mean, you'd say we have no legal contract.

01:52:21.660 How could I cut your hair for 30 bucks? And then one year you come in and I say it's $900. There's no

01:52:27.580 legal contract. So this is a very important point, Marty, because I didn't know this. Yesterday we had

01:52:32.360 dinner and one of the people we had dinner with, who's just amazing. We could go off on stories on

01:52:37.960 how amazing that guy is in his work. Yeah. African doctor. Yeah. But he told a story of his son

01:52:43.820 needed an endoscopy and they're back in the U S for this. And so to get an endoscopy, which is a

01:52:49.420 tube that goes into your esophagus and your stomach and takes a look around and comes back out and makes

01:52:54.080 sure everything is okay. You have a lot of fees in there. You've got the fee for the gastroenterologist

01:52:57.880 who's doing it. There's a hospital fee for that. There's an anesthesia fee because you need an

01:53:02.660 anesthesiologist to give you some sedating medication. So you're not under complete

01:53:06.660 anesthesia, but you're comfortable so that you're not gagging at this thing happening. And it turned

01:53:10.800 out that the hospital was inside the network. The professional fee for the gastroenterologist was

01:53:15.280 quote unquote inside the network, but the fee for the anesthesiologist was not inside the network

01:53:19.880 because for no reasons that this patient could ever understand the anesthesia bill came from a group

01:53:26.020 that was outside of the network. So he got a bill for $10,000 for the anesthesia portion of this,

01:53:33.240 which let's just call a spade a spade, Marty. That's putting an IV in somebody and for 30 minutes

01:53:38.980 taking care of them after you've administered some propofol. I mean, let's just be completely

01:53:43.600 honest about what actually happened there. So a few dollars worth of propofol and some IV equipment

01:53:48.160 and an EKG and a pulse oximeter, and you're watching someone for 30 minutes. So I might be in the

01:53:53.380 wrong business, by the way, if that's 10,000 bucks, that is insulting to what money means.

01:53:58.900 So there's two issues I'd like to understand there. One, what in God's name does it have to do

01:54:04.420 with the fact that that was in or out of network, that such an egregious charge could be levied on

01:54:08.660 that patient? And two, what is the legal obligation of that patient and how can that patient fight and

01:54:15.800 say, this is totally bullshit. We're not doing this. Well, right now the judges have been sympathetic

01:54:20.980 to the hospitals. And we're trying to show the legal argument that there's no contract.

01:54:26.820 When you walk into the emergency room today with a cut, chances are they're going to give you some

01:54:31.200 form and say, you have to sign this. And the person giving it to you doesn't know squat about what's in

01:54:35.840 it. You could be in excruciating abdominal pain and need to go have your appendix removed. You're

01:54:40.880 signing it at a vulnerable time. Well, and in fact, let's take a step further. If you have a

01:54:45.660 prenuptial agreement and you want to get that held up and there's any evidence that that was signed

01:54:50.520 under duress, guess what? It doesn't matter. And I don't know about you, but an acute abdomen sounds

01:54:56.140 like duress. Yeah. I mean, if you're in a criminal trial and somebody says, gives the key evidence

01:55:02.740 that somebody murdered somebody, the other lawyers could argue entrapment. He felt a little pressured

01:55:08.380 to offer that confession and then it's negated. And yet in the hospital, not only is there no contract

01:55:13.600 sometimes, but there's this document that is fooling you into thinking it's a consent to be

01:55:20.380 treated. But there's a law in the United States called EMTALA that requires any hospital to take

01:55:25.700 care of any urgent or emergent patient that walks into their door. It's not dependent on giving your

01:55:30.360 credit card when you check in. It's not dependent on giving your social security number and your mom's

01:55:35.300 address and all these other things that they try to collect. You don't have to do that. Hospitals are

01:55:40.820 required by law. It's called EMTALA to take care of anyone with an urgent or emergent condition. If

01:55:46.120 you feel that there's a legal document that you have to sign your home and your financial life away

01:55:51.060 in order to get stitches and you're concerned about predatory billing, you sign in that little

01:55:56.220 signature box in the iPad, you sign did not read because no one's going to read what you sign in

01:56:02.120 there. Okay. And then when the collectors call and the judge says you have to provide your routing

01:56:07.780 number and your account number or we're going to garnish your wages, you say there's no legal

01:56:12.220 contract. We're trying to empower people in the United States to say we need a competent and fair

01:56:17.740 pricing system. The surprise bill issues, by the way, people are getting hammered with surprise bills

01:56:23.060 right now. Hammered. And why are they so hard to understand? I'm taking you off that question,

01:56:27.280 but I get about three EOBs, Explanation of Benefits, per month, maybe four of them. I feel like

01:56:32.660 there's a never ending stream of them. You take your kid to the pediatrician because he's got a

01:56:38.380 fever and you think he might have an ear infection. The pediatrician looks in the ear, confirms that he

01:56:42.360 does. You get some amoxicillin, you go home, everybody's happy. I get six EOBs for that encounter.

01:56:48.540 Each one saying something I can't understand. This is what we build. This is what your insurance

01:56:54.120 company paid. This is what you're responsible for. And then they attach a check to it. And I'm like,

01:56:59.360 what? I don't get it. And again, if I don't get it, at least one other person listening to this

01:57:06.520 doesn't get it. Right, right. Well, look, I took one of those bills to a hospital CEO. Like I said,

01:57:13.260 I've got great relationships with a lot of these hospital CEOs. Quite honestly, sometimes they're

01:57:16.860 just disconnected from what's happening with their revenue cycle department. Don't you love that word,

01:57:21.340 revenue cycle? Collections. Revenue cycle. One woman handed me her card and it literally said on it,

01:57:28.140 Director of Revenue Enhancement. Like, what the hell is this?

01:57:35.600 Oh, gosh. Hippocrates, man, would just be rolling over in his grave.

01:57:39.860 It's funny. I hope that the guys in the mafia are listening to this and upping their game a little

01:57:44.680 bit. Because if you're running collections in the mafia, you should at least have a revenue

01:57:48.280 enhancement card. Well, in Florida, drug dealers have given up drugs and turned to doing medical

01:57:55.460 fraud because it's more profitable and they can make more money. I don't know if you know,

01:57:59.540 but the Medicare anti-fraud offices, I know the head of the division, they've essentially closed down

01:58:05.220 most of the regional offices and moved them all to Florida because Florida is just the rampant

01:58:10.680 center of a lot of abuse. So you show an EOB to a hospital CEO.

01:58:14.200 Yeah, they can't even interpret the bill. I mean, there is a buddy of mine who had a friend get a

01:58:20.440 $5,000 bill for an hour in the emergency room or something like that. Did a couple simple things

01:58:25.580 and the bill was over $5,000. Took it to my friend who's a consultant, knows the healthcare

01:58:30.660 executives. Went to the CEO and knew the CEO. He said, by the way, my friend went to your emergency

01:58:35.120 room. She was in the ER. She got the little oxygen nasal cannula and an IV and was sent home about

01:58:40.480 45 minutes later. Guess how much the bill was? And of course, he's cringing, embarrassed. And he

01:58:45.620 says, I don't know, $1,500? No, it was $5,000. Oh my God. You know, he's like, let me take care of

01:58:51.720 that for you. And there's this embarrassment when it comes up that, yes, we've allowed this game of

01:58:56.760 dialing up bills and then offering these bigger discounts as shiny objects to employers and

01:59:02.180 insurance companies has gotten so out of control that the victims, because hospital CEOs will often tell

01:59:06.740 me, Marty, you're so right, but nobody pays those bills. Those are sticker prices. We give discounts

01:59:11.960 liberally. Well, not to the people I'm meeting in Fredericksburg, Virginia, in Carlsbad, New Mexico,

01:59:17.260 who are fighting their bills and they can't even get a call center representative and they're being

01:59:21.360 harassed and the collectors are calling saying now it's in the hand of collectors so you can't talk to

01:59:25.860 the hospital. And let's explain what that CEO is trying to explain to you, which is, look, we want to

01:59:30.180 make this look really good. So something like coming into the ER, having a nasal cannula, an IV and an EKG

01:59:36.280 and sending you out, we're going to put a sticker price on that of $5,000. And we don't really think

01:59:41.800 anybody's going to pay it, but what we're going to do is we're going to tell the insurance company

01:59:46.600 or the employer, we normally charge $5,000 for this. But for you, my friend today, one time only,

01:59:54.300 if you sign up now, this will only cost $500. And you're thinking it's a great discount. We're all

02:00:01.080 over it. And if a different company shows up, they might get a different rate. They might get a

02:00:05.160 different discount. So different people can get different discounts on the same egregious price

02:00:09.260 that serves no purpose other than to make you feel like you're offering a great discount. I mean,

02:00:13.800 can you imagine if the rest of the world ran on this principle? Like the grocery store. Yeah,

02:00:18.440 yeah, exactly. The restaurant. I'll have the tikka masala, please. Well, here's the deal.

02:00:21.660 Who's your employer? It's $1,000. Who do you work for? I work for Walgreens.

02:00:27.600 Oh, take this menu. The tikka masala is not $1,000 for you. It's only $100 for you.

02:00:34.240 And the guy sitting across from you works somewhere else. And well, it's $50 for him.

02:00:38.460 Right. But he gets a 2% discount. On the 50. On the 50. Yeah, yeah. So he's only paying $49.

02:00:45.360 Employers are telling me all the time, our insurance company, we get a 40% discount. Well,

02:00:49.300 I'll give you a 99% discount if I'm selling you a car. As long as I get to set the price,

02:00:53.680 you can have a 99% discount. Is there another example in our economy that works this way?

02:00:59.120 Well, there is bulk purchasing and retail. But here's what I would add to your example that you

02:01:03.660 very well described. In addition to these secret discounts, both parties are sworn to secrecy that

02:01:10.440 this discount cannot be made public. And that kills the competition. And that's what we're

02:01:15.800 working on with legislation. And that's legal. It is legal to put a gag on the chicanery. 1.00

02:01:23.600 Yeah.

02:01:23.800 Okay. So going back to our friend from yesterday, the reason he gets a $10,000 bill for someone putting

02:01:30.580 in an IV and some propofol is because the anesthesia group set a price that was ridiculous,

02:01:36.760 not necessarily expecting people were going to pay this out of pocket. Again, they didn't go into this

02:01:41.460 trying to kill people. For whatever reason, the anesthesiologist who was probably supposed to do

02:01:45.800 that case was maybe not. So someone else comes in, they're out of network. And now that ridiculous

02:01:51.360 price actually sticks to this patient. Now, what is his legal recourse in that situation?

02:01:58.640 He got overcharged?

02:01:59.700 Yeah.

02:01:59.980 I mean, what we're telling them is you argue as strong as you can argue to the collectors,

02:02:05.460 to the courts, if they take it to court, to whoever, that they need to provide the legal contract.

02:02:11.280 Sure. Oh, they're charged. They want $10,000. Just send me the agreement. I understand it's part of my

02:02:16.640 consumer rights that when a collections agency calls that I'm entitled to see the contract or

02:02:22.920 agreement that obligates me to pay.

02:02:24.540 What type of contracts are being produced at that request?

02:02:28.020 Well, I've never seen a collections agency produce a contract because it's that little iPad form that

02:02:32.900 you sign in the lobby or something that doesn't exist or it's combined with a consent to treat.

02:02:37.840 So it doesn't exist at the beginning. So let's say open enrollments every January. I mean,

02:02:42.420 I'm sure we signed something in January when we enroll. Is that the contract? Is there something

02:02:46.880 in there that the collections agency can come back and say, well, Marty, I'm not going to show

02:02:50.980 you a contract from when you were in the ER in May. I'm going to show you a contract from January when

02:02:55.820 you signed up through open enrollment.

02:02:57.520 No, because that's a contract between you and the insurance company. It's not a contract between you and

02:03:01.500 the medical center. Oh, good point.

02:03:02.920 And they're the party that's going after you.

02:03:05.120 So this is a great point. So the only time you're being technically presented with a contract for

02:03:12.040 price is at the provider's level. And we're basically saying it's very easy to render that

02:03:18.180 contract null and void.

02:03:19.320 Yeah. And sometimes it doesn't exist or logistically, honestly, they just can't produce it. They send the

02:03:23.720 what they call bad debt to the collectors and the collectors go after you, but they're not sending.

02:03:27.760 I love the idea of signing did not read.

02:03:29.680 Did not read. Exactly. Right. Oh no, I never entered a legal agreement obligating me to pay. If I did,

02:03:35.760 show me the thing. The other thing we're telling people to do, if it's really egregious,

02:03:39.760 is contact your state's attorney and contact your local news network. Now, unfortunately,

02:03:44.760 some of the local news networks, their number one client is the local hospital that's running ads.

02:03:50.820 This complex is gigantic. It's incredible. But contact them and tell them. My friend,

02:03:55.100 Sarah Cliff at Vox, Elizabeth Rosenthal at Kaiser Health News, they each have sections where you can

02:04:00.220 send in your bills. I'm swimming. I'm underwater. I've got, I don't know, 54,000 emails I haven't read,

02:04:05.280 probably half the number of emails you have and have not read. I'm going to try to clean it out.

02:04:09.760 this weekend. But so many people are getting hammered out there. It's like an unlimited

02:04:14.960 drinking from a fire hydrant. But those are things people should do. Ask for the contract,

02:04:19.380 sign if you feel like it's not a fair agreement, if you're not disclosed prices. No.

02:04:23.300 I wish I knew this two years ago when we got stiffed with some $15,000 bill for an ambulance ride.

02:04:29.600 Well, you know, one of our friends from residency that had a sort of a catastrophic medical illness

02:04:34.280 in Australia. Yes. And he was flown back. We all paid money to chip in for this. There was a whole

02:04:40.220 Facebook page where we were all kicking in thousands of dollars for his care. I mean,

02:04:44.540 yeah. So what happened? Oh, I don't want to upset you, but some of that money.

02:04:48.860 Do I get a refund on that? Was that all given back to him?

02:04:51.660 I mean, this guy's one of my best friends and it was awesome to see everyone come together. But the

02:04:56.160 flight back, they charged him like a quarter million dollars. Okay. For that flight,

02:05:00.660 you could get a private G7 and fly to Beijing and back five times for that money. That was just pure

02:05:08.120 price gouging. And actually, I had got him some legal help to knock that bill down.

02:05:12.740 Because this came outside of his insurance? Like his insurance decided they didn't cover that kind

02:05:16.380 of stuff? Bingo. You just nailed the number one story of the modern American healthcare system.

02:05:21.340 Entities, organizations, doctors, hospitals, ambulances, helicopters have figured out

02:05:27.020 if you bill outside of insurance, you can just gouge. And some people will pay it. And if you

02:05:33.320 just send it to collections and harass and send them 50 bills, some people will just pay it. And

02:05:38.240 the reality is God's been good to you and I. If we got a $5,000 bill, we'd find a way just to pay.

02:05:43.600 It might be annoying, but we'll find it. But half of America has less than $300 in savings.

02:05:47.920 People are getting hammered.

02:05:49.720 Oh, God. That's so upsetting.

02:05:51.240 Now, can I talk about something positive on this subject?

02:05:53.980 Yeah, please. Please, for the love of humanity.

02:05:58.720 Talk about one good thing here. Keith Smith in Oklahoma City has basically said,

02:06:05.520 this is total BS. I don't understand how a doctor can take an oath, treat a patient,

02:06:11.100 and ruin their life financially. It's against everything I've ever considered sacred about this

02:06:16.040 heritage of medicine. He has offered one bundled price for every service at his medical center.

02:06:22.760 If you come in and you need a shoulder surgery, you don't get a bill for the epidural separate and

02:06:27.720 for the anesthesiologist pro fee separate. They got their act together. And hospitals need to get

02:06:34.320 their act together instead of sort of the finger pointing of, oh, well, that's the lab. The lab's

02:06:38.960 billing you separately.

02:06:39.840 We laugh at this because it's so true.

02:06:45.580 It's pure gouging. And we're all paying for it. It's not, oh, my insurance paid or my Medicare paid

02:06:50.580 $4,000 to test for one gene allele. You can genome your whole 23andMe cost, what, 150 bucks?

02:06:59.000 And that's like all these gene tests. So we've seen that. Genes that are in the 23andMe panel

02:07:03.960 billed separately for thousands of dollars. So people need to ask when we all started,

02:07:09.660 and I have you to thank a little bit for this, started asking about healthy foods. You remember

02:07:14.140 that conversation early on when you were learning about this subject and you're like, Marty, this is

02:07:18.240 incredible what I'm learning. I started asking in restaurants, what kind of food is this? And does

02:07:22.280 this have this? And how is it prepared? And it's putting pressure on the restaurants. It's driving the

02:07:27.820 market, the food label world. The food industry is now trying to say, hey, this has these healthy

02:07:33.200 ingredients that are good. This has no added sugar. And so the inquiries are moving the market. And in

02:07:40.500 addition to Keith Smith disrupting healthcare in Oklahoma, and it's awesome. The insurance companies

02:07:45.800 hate him. The hospitals hate him. All these people want him to fail. It's like Elon Musk. Everybody's

02:07:51.440 shorting him. Everyone wants him to fail. But he's actually growing like crazy. People are flying in from

02:07:57.440 Japan to Oklahoma City. Why? Because they have a fair and honest bundled price.

02:08:03.200 He had 200 Canadians, I think, last year. We did a study at Hopkins of all the price transparency

02:08:09.040 medical centers in the United States before and after they decided to go full, honest pricing,

02:08:14.680 not charge master pricing, but the real price. Not, oh, here's a price and we're going to give you a

02:08:19.180 discount of 2%, right? The real price. And they all do incredibly well. Their business goes up. Their

02:08:25.220 satisfaction goes up. We published the study. This is the future. It's exciting. It's disruptive.

02:08:29.940 It's why I'm so up on medicine right now. And you think that this is potentially a better solution,

02:08:35.920 which is basically still private healthcare, but with market demanded transparency. I do.

02:08:43.420 I do. Look, it's very appealing to wipe out all the money games overnight with a single payer

02:08:48.960 system. It's very, very attempted. And you know what? People are advocates for it are absolutely

02:08:53.340 correct. It will slash the money games overnight. It'll just put it to a screeching halt. But over time,

02:08:59.200 historically, if you look academically at every government that's done it, they cannot resist

02:09:03.380 the temptation to just skim cut, skim cut year after year, 10 or 20 years.

02:09:08.760 Yeah. And I don't want to live in Canada. I mean, I don't want to live in a Canadian healthcare system

02:09:12.160 either because I see what my parents experience. I see what my whole family is still in Canada.

02:09:16.440 Every single person in my family is still in Canada. And I wouldn't trade places with a single

02:09:21.720 one of them for their healthcare, even though average, it's infinitely better than American healthcare

02:09:27.100 in terms of accessibility and cost.

02:09:29.720 My dean of Harvard School of Public Health, when I was a student said,

02:09:33.280 Canadian is essentially an unarmed American with health insurance.

02:09:40.060 No, I agree with you. We have an incredible healthcare system. The problem is it works for

02:09:44.300 the wealthy and it works most of the time and the reliability is not there.

02:09:47.620 But the only reason it works for the wealthy is something you said a moment ago. It's that

02:09:50.720 the cost of the care for the wealthy falls below the hurdle rate of hassle. I mean,

02:09:57.060 is there any place in the country that someone of means would rather get their healthcare? No,

02:10:01.180 I don't know the last time an American of means left the U.S. to get their healthcare. It's the

02:10:06.820 exact opposite. Hopkins, I feel like half the people we took care of were outside of the United

02:10:11.680 States. So there's no question that we have the best healthcare when it's applied correctly,

02:10:18.220 which is to say the quality of care we have the potential to deliver is exceptional under the

02:10:24.440 right circumstances. That's a lot of caveating. We have a cost crisis and we have an access crisis.

02:10:31.000 And the two people, the two subsets of people who are therefore going to be crushed in the U.S.

02:10:36.240 healthcare system are people who cannot afford access at all and people who can't afford egregious

02:10:42.560 costs when levied upon them. If you're not in those two camps, you're going to be okay.

02:10:47.100 It's annoying as hell, but you're going to be okay. And I think that's what's allowed this system

02:10:51.800 to sort of limp its way along. And I guess what I'm hearing you say is we might, and I hate to use

02:10:59.580 the term tipping point, but we might be at a tipping point where it's become so egregious

02:11:03.960 that even the people now who, A, there might be enough people that are moving into the latter

02:11:09.680 categories of, okay, this is now, if one in five people are getting collections through healthcare,

02:11:15.120 I mean, we have a fundamental problem. Half of women with stage four breast cancer in the United

02:11:20.040 States today, recent study just came out at ASCO, half of women with stage four breast cancer in the

02:11:25.080 United States are being harassed by medical debt collectors. Did you talk to the medical debt

02:11:29.560 collectors? Well, that study was published by another group. Oh no, but in general. Oh yeah.

02:11:33.460 And are they feeling, I mean, how are they feeling? Let's try to do something we talked about early.

02:11:37.720 Let's try to have empathy for them. You need a job. Everybody needs a job. So I got a job. I'm

02:11:41.660 a medical debt collector. Do I feel good about myself? I mean, I'm calling a woman with stage 0.99

02:11:45.620 four breast cancer every day and threatening her. That's a good person that's on the phone. I don't

02:11:50.360 believe that that medical debt collector is some like evil incarnate. No. So how do they feel about

02:11:55.060 what they have to do? Well, some of them hate their life. I would say for the most part,

02:11:58.640 they are glad to be in a position where for the most part, if you object, fight your bill,

02:12:05.400 they're going to just knock off 20, 50% right off the top. And this is another tip for people out

02:12:12.380 there. Bills are negotiable. When you get your bill, they are negotiable. I wish I knew this when

02:12:16.900 I got that goddamn ambulance bill a few years ago. Yeah. I mean, imagine they're kind of hoping that

02:12:22.580 you, I don't want to say hoping, like you say, we have all good people working in a bad system,

02:12:27.200 but the business model relies on some people just saying, ah, screw it. I'll pay. And entire

02:12:32.740 careers and industries. That could be a slogan, right? The business model is, quote, ah, screw it.

02:12:39.780 I'll just pay. I'll just pay, right? And these folks in the so-called revenue cycle world.

02:12:45.540 They're in revenue enhancement. It's revenue enhancement.

02:12:48.840 Revenue enhancement. I mean, how did I discover these people? I get invited to speak at a lot of

02:12:54.080 conferences as you do. And I never actually get invited to speak at conferences, by the way.

02:12:58.640 Oh, well, consider yourself invited to everyone I've done. No, no, I'm happy to not. So they say,

02:13:03.600 I got invited to this conference of revenue cycle managers. And I just, sure, I'm happy to speak to

02:13:09.280 them. That's a nice. That's awesome. I mean, that's a great opportunity for you to learn.

02:13:12.960 Yeah. And that's basically this book, The Price We Pay is a two-year tour around America,

02:13:17.780 talking to patients and revenue cycle people and businesses and brokers and everybody. I wanted to

02:13:24.280 talk to everybody and get their point of view. And I don't believe there's any one bad villain.

02:13:28.460 I think it's the system. But the revenue cycle people, I show up and I'm like, I'm sorry,

02:13:32.920 I just got out of the operating room and flew into town. Who are you people? What is revenue cycle?

02:13:38.300 What do you do? And is this in healthcare or are you outside of health? What is it? Are you tax

02:13:43.300 accountants? And they explain to me how it works. And I look out, there's a conference of like 4,000

02:13:48.700 people. And I'm like, does every hospital have one of the, you know, this, oh yeah, every hospital

02:13:53.840 has a department. At Duke at one point, there were more people working on billing and revenue cycle

02:13:58.840 than there were beds in the hospital. Come on, that can't be true.

02:14:01.860 No, but this is a true fact. I think they had 900 beds and they had it just over that in terms of

02:14:06.520 billing, coding, and revenue cycle and managing these discount.

02:14:11.320 Okay. So let me give you another contrarian argument. If you fix the healthcare system,

02:14:15.420 how many people are going to lose a job? A lot.

02:14:17.620 Healthcare is an enormous industry. It employs tens of millions of people.

02:14:22.720 Yeah. Look, what are those people going to do now?

02:14:24.800 Well, you can make the same argument about the financial mortgage crisis. You had all these

02:14:28.820 people selling subprime mortgages and getting rich and employing other people in these giant

02:14:33.120 companies. Healthcare is a gigantic bubble right now. And the parallels to the financial crisis

02:14:38.520 are striking. And at some point, if you think about it, we are spending money we don't have

02:14:44.440 on products that we don't even need sometimes. The PBM world, medical services that are unnecessary,

02:14:50.860 the enormous middle layers. And doctors, quite honestly, are very suspicious of what's happening.

02:14:56.800 They don't understand. I mean, I didn't understand until I started touring and going to these conferences

02:15:02.340 and saying, I'm sick of this. I'm a professor of health policy. I don't feel like I have a handle

02:15:08.400 on the entire healthcare system. And I decided, enough is enough. I want to learn, educate myself

02:15:14.060 on every tiny detail of this ginormous system. I want to know every law, Medicaid, rule, insurance,

02:15:21.600 contract, negotiation, talk to the negotiators. What goes on at that meeting? Well, they say,

02:15:26.400 our prices are going to go up by 10% next year, but we're going to give you a 12% discount.

02:15:30.860 And then they turn around and dial up the prices 15%. And then the hospital says, oh, good job,

02:15:36.520 Bob. I'm just making it up. You generated another $4 million for us. You're now promoted to whatever

02:15:43.000 title. This gigantic industry. And they're coming up to me at the conferences and other places and

02:15:47.580 telling me, I do this and this, but quite honestly, my job doesn't need to exist. If we had honest and

02:15:52.800 fair pricing in America, we wouldn't need this gigantic negotiating of discounts and markups,

02:15:59.540 the markup discount game, I call it. And one important thing, and one thing I'd ask you and all

02:16:04.160 your listeners to do is use the honest lexicon, just like we talked about medical care gone wrong

02:16:09.980 versus a preventable adverse event. Let's use the patient-centered terms. Let's talk about prices

02:16:15.960 and not costs. Let's remember that we're paying, not our insurance company or our employer or other

02:16:22.220 folks. Let's talk about bills you shouldn't be getting. Refer to them as predatory billing practices

02:16:28.860 or predatory medicine, screenings you don't need.

02:16:32.980 So let's talk a little bit about that. You talked about how studies have looked at what percentage

02:16:39.040 of tests that physicians order do they deem unnecessary. So in other words, you go and you

02:16:46.020 pull a thousand doctors and you say secretly and confidentially, so no one's going to come and

02:16:52.840 spank you for this. How often are you ordering a test that is unnecessary? And the answer turned out

02:16:58.500 to be 21%. 21% was the average. Now actually, the question said, excluding your own practice

02:17:06.340 in your observations. Got it. Okay. Okay. As we develop practice pattern measures of waste,

02:17:12.920 which is a big project we're doing at Johns Hopkins and with some other groups, we've asked

02:17:16.880 doctors, tell us about an egregious area of overuse in your specialty, something that's done

02:17:22.700 too much in a certain clinical situation. And sometimes they'll be like, I can't really think

02:17:27.300 of anything. And then we'll say, well, think about your competitor groups. Are they doing other stuff?

02:17:32.740 Oh my God. Yeah. They're doing endoscopies every six months after an initial screening.

02:17:36.880 They're doing 50 biopsies and all this stuff.

02:17:39.660 So it's easier to get an answer when you don't force the lens inward.

02:17:43.240 Right. And I think it's back to our opening conversation. We work our tails off in residency.

02:17:48.920 How dare we start saying that you've crossed over to an area of entitlement and burnout where you do

02:17:54.760 too much unnecessary. Let's talk about the system. It's not a threatening, we talk about low value care

02:17:59.280 in the medical literature, and that's how we're talking about this subject.

02:18:02.400 Now you could take a couple of those into, I've always thought of this as an area that doesn't get

02:18:06.560 enough attention. Because I sort of divide it into two categories. So let's take one of the most

02:18:11.880 egregious examples, which I'm sure will upset a few people, which is interventional cardiology.

02:18:16.760 There's a lot of people already upset from the podcast.

02:18:19.580 Yeah, I think we've upset a lot of people. Okay. So the medical literature on stenting is like all

02:18:26.040 things in the medical literature, there's some room for interpretation, but there are some things

02:18:29.780 that we kind of know. So if somebody is having an ST elevated wave MI and they're hemodynamically

02:18:36.180 unstable in the emergency room, those are patients that do a lot better when you put a stent in them.

02:18:41.320 This can be life-saving.

02:18:42.200 Yep. You're going to save that person's life. So we're here to say stents are not bad. Okay.

02:18:46.500 But then there's a whole body of literature that makes it also pretty clear that there are a whole

02:18:50.080 bunch of people that don't seem to get any better with stents, meaning there's no evidence you're

02:18:54.160 going to save their life. And that's not the only reason to put a stent in, because if you save a

02:18:59.780 that might be a reason, anyone who's had a heart attack would say, I don't care if it reduces my

02:19:04.560 risk of dying, but just not having a heart attack would be a benefit or if it reduces chest pain.

02:19:08.640 So you have this whole other group of people who actually have no benefit of a stent,

02:19:13.540 doesn't reduce chest pain, doesn't reduce subsequent heart attack, and it doesn't save a

02:19:16.780 life. And then you get into the business of, well, how many stents should you put in?

02:19:20.900 You know where I'm going with this, right? There are interventional cardiologists out there

02:19:24.680 that are putting stents in people and violating every aspect of what is known, meaning they're

02:19:30.460 putting them into the wrong patients and they're putting in far too many and they're getting paid

02:19:35.020 by the stent. Okay. You've actually talked publicly about this in the dermatology world about people

02:19:40.280 doing Mohs surgery. That's one type of bad actor in the system. And you could argue some of that is 0.84

02:19:47.280 conscious, some of that is subconscious. So it might be the case that that doctor who is putting

02:19:52.220 five stents in the person with stable angina, who's never shown even evidence of MI or EKG change

02:20:00.640 deep down as a good person and thinks that they know something that none of the studies have ever

02:20:06.000 shown. And I get that. Okay. And then within that, there's going to be some nefarious actors who are

02:20:11.840 simply used car salesmen gone wrong. I just realized I insulted a bunch of used car salesmen, but

02:20:17.580 they're people who are literally just shaking down the system and they know that they're going to get

02:20:21.160 a thousand bucks for every stent they put in. So I'm going to put five in this guy today, even though

02:20:25.460 he probably needs zero. My impression, which could be entirely incorrect, is that the majority of

02:20:30.560 unnecessary care is not in that category. It's in a different category, which has two ends to it.

02:20:37.680 One is the, I don't have the time to deal with figuring out exactly what the right thing to do is.

02:20:45.020 And the cost of me giving in and giving someone an antibiotic when I'm pretty sure they have a viral

02:20:51.560 infection that's going to go away in three days, the cost of me trying to educate the patient on

02:20:56.760 that and explain antibiotic resistance, it's just too high. I've only got 15 minutes. I'll just give

02:21:02.100 them the goddamn Z-Pak, right? That's one. And then the second subset of that, which by the way, 1.00

02:21:06.920 I think is the worst one, is the, I'm not going to be the guy that gets sued because I didn't order

02:21:12.140 the head CT on the person with a headache, even though I know that this person stopped drinking

02:21:18.080 coffee two days ago and they went from three cups of coffee a day to nothing. And they're coming in

02:21:23.140 here with the worst headache of their life. And I'm pretty 99.999% sure it's caffeine withdrawal,

02:21:29.680 but I'm not going to let this person walk out of this ER without a head CT because if God forbid,

02:21:34.260 it's a tumor or an aneurysm, I'm going to get sued. So everyone gets a head CT. I mean,

02:21:39.840 I told a funny story last night at dinner that I won't repeat, but of a patient coming in with

02:21:44.560 complaining that their hair was vibrating and they get a head CT because the ER docs like as an

02:21:51.320 individual, I know that's bad for the system, but as an individual, it's in my best interest to do

02:21:56.220 that. Or one time I saw a patient with hair vibrating and I got a CT and it showed a cancer.

02:22:00.780 Yeah. I'm like Osler reincarnated. I'm so good. I suspected that that vibrating hair was

02:22:09.260 actually a meningioma beneath the surface. This to me is a very dirty problem in America,

02:22:16.080 which is we are a very litigious culture. And it is that. So when people talk about medical

02:22:21.460 malpractice, which I want to come back to, cause you alluded to it, people tend to be dismissive

02:22:25.880 of it and say, it's not actually that big a part of medicine because they're looking at the actual

02:22:29.360 cost of medical malpractice. What I think they're missing is the threat of medical malpractice

02:22:34.780 has created a culture of completely unnecessary testing as part of the CYA fellowship that everyone

02:22:44.700 gets taught in medicine. So somewhere down the line, each of us in residency was taught

02:22:49.660 cover your ass, which means you are doing stuff that is not good, but it is going to look good

02:22:56.760 in a deposition in the worst case outcome here. Now, how do you fix that problem?

02:23:03.260 Good medical care. So for every five docs in the ER that will say, if somebody has a headache,

02:23:09.700 you just for liability reasons need to get a CAT scan or an MRI. I bet you there's a senior doc who

02:23:15.460 says, no, you don't look, people are more likely to sue you because they're just angry at you or

02:23:20.360 they're incredibly dissatisfied than because you failed to order a test and do the right thing.

02:23:25.720 And you can defend it if you need to defend it, that the patient had a moderate headache. And so

02:23:31.000 really good sound judgment. I mean, I love these very senior wise doctors that say, do the right

02:23:36.340 thing. Don't just react to some fear of a potential risk. The unnecessary testing and unnecessary doing

02:23:43.100 things because of malpractice concerns is definitely a problem in certain pockets of medicine, the emergency

02:23:49.420 room and OB, they're getting hammered in OB, but it's not the driver. You know, people, it's so vivid

02:23:56.700 to us doctors and it seems so wrong and so unnecessary. And you want to blame these lawyers that have these

02:24:02.600 contingency games. The reality is it is such an inconsequential small fraction of the medical spend,

02:24:08.840 even though most doctors think it's one of the primary drivers of our higher healthcare costs.

02:24:14.300 When you say it's insignificant, you mean the actual cost of malpractice insurance, litigation and

02:24:18.860 things like that. Well, not just that, but studies have shown it's not just doing stuff that costs

02:24:23.220 money, but you are avoiding things because of malpractice concerns. People may avoid surgery.

02:24:29.220 I don't want to touch this guy because if something goes wrong, I don't want to have that liability.

02:24:35.460 So you also have avoiding care because of malpractice concerns.

02:24:39.160 I remember once in clinic, a discussion coming up with a patient that was an attorney and the

02:24:46.120 attending said, complex case and an attorney don't do it. I mean, like, you know, you asking to be

02:24:52.300 sued if something goes wrong. Yeah. So how many unnecessary head scans the Medicare pays 300 bucks

02:24:58.720 for did that one of operation avoidance balance out? So if you talk to the real scholars of healthcare

02:25:05.780 costs, they'll tell you it's not malpractice. I know it's an emotional issue.

02:25:09.420 So yeah. And it's not the malpractice, but you're saying even the over treatment to minimize the risk

02:25:15.280 of it. So, so what about another thing, which is, do we have a culture of just expecting that? Like,

02:25:23.460 so how many times has you get that patient who comes in, who said, I stopped drinking coffee three

02:25:28.640 days ago. I've got a really bad headache, but I'm really worried. And is there ever room for the

02:25:33.700 discussion that says, look, in my judgment, and I've already talked to three of my colleagues here

02:25:38.520 today, we all think that your headache is from caffeine withdrawal. And we think you should

02:25:43.980 take Tylenol and maybe have a coffee and maybe taper off as opposed to just going from three

02:25:49.080 coffees to zero coffees. But if you really, really want a CT scan, we'll do it. It's going to cost this

02:25:53.760 much. Now your insurance company is going to cover this much, but you're going to cover this much.

02:25:59.600 I mean, that seems like a reasonable discussion. I mean, again, it's artificial in that I

02:26:03.520 can't imagine an ER doc having the luxury of time to sit down and have that, let alone the

02:26:07.660 transparency into pricing. But to me, that's the way the world works in everything else. I mean,

02:26:15.100 Marty, if you want to buy a Ferrari, you can, you know how much it costs and you would presumably

02:26:22.040 decide that car is worth more than a house. You would make that decision if you felt that way.

02:26:27.740 So in theory, you should be able to say to people, look, I'm your advocate here as the doctor. I don't

02:26:34.180 think you need a head CT. If I was in your situation, I would not want the radiation.

02:26:38.720 I think people don't understand the radiation they're getting in CT scans.

02:26:41.620 A hundred times more than an X-ray.

02:26:43.200 I don't think you should be allowed into a CT scanner without someone telling you how many

02:26:46.760 millisieverts you're getting and showing you the NRC guidelines for how many millisieverts of

02:26:50.980 radiation you should be exposed to. And look, I order CT scans on patients all the time,

02:26:54.720 but I have this discussion. It's like, okay, you're allowed 50 millisieverts of radiation a year.

02:26:59.260 We're going to do a CTNG gram in you. But in this facility, it's 2.2 millisieverts. And you're

02:27:05.260 going to pay this amount for it. If you go and do it over there, it's 18 millisieverts and you're

02:27:09.680 going to pay less. Your choice. Great. To me, that makes sense. So I guess I didn't realize that. I

02:27:14.760 guess I thought it was a bigger problem, but you're saying the data say that's not an issue. It's a small

02:27:18.220 issue. It's less than three-tenths of 1% of the overall healthcare cost crisis. And that's been

02:27:24.440 studied many times, but yet it's vivid and we're proximate to it as doctors. And to be honest with

02:27:29.200 you, like you say, healthcare has a lot of things that we don't understand. And here's one thing we

02:27:33.320 see and we understand, and it just seems wrong. And that's why it's disproportionately dominating

02:27:38.780 the discussion of healthcare costs. The reality is my malpractice insurance, it's about 40 some

02:27:44.820 thousand dollars a year as a surgeon at Johns Hopkins. It's been about that for 25 years,

02:27:50.560 but yet premiums go up seven to 11% a year.

02:27:54.960 For health insurance.

02:27:55.640 For health insurance, for what we're spending.

02:27:57.220 Yeah, yeah.

02:27:57.660 So I mean-

02:27:58.440 So if you're going to rank order the things, I mean, you've pointed out an enormous one. If

02:28:03.560 simply, if bogus discounts in middlemen is 15% of it, that has to be the single largest item then,

02:28:10.920 isn't it?

02:28:11.300 Well, that's just the pricing failure piece of it. And that's just an estimation. So then you add

02:28:15.640 to that 21% of healthcare services are unnecessary, according to this survey of 2,000 doctors that

02:28:23.100 we did at Hopkins around the country. If they're saying that 21% of everything we're doing is

02:28:27.980 unnecessary, there is a huge cost reduction opportunity if we can focus on appropriateness.

02:28:33.620 What about drug pricing, generic versus non-generic? I mean, that seems to be another

02:28:37.360 place where the United States pays disproportionately more than anyone else in the world.

02:28:42.720 Yeah, absolutely. Another piece of it. I mean, that's where people are coming up with the stats

02:28:46.700 that roughly half of our healthcare spend can be chopped off and we can still deliver high

02:28:52.420 quality healthcare that has better patient outcomes.

02:28:54.440 So what about the counter argument? Counter argument would say, look,

02:28:57.320 pick your favorite drug. Americans are going to pay two times more than anybody else. In some

02:29:01.480 cases, much more. I mean, we sometimes use a Canadian pharmacy for our patients for really

02:29:06.040 expensive drugs, just on principle. It's not that the patient necessarily can't afford it,

02:29:09.960 but I just say to them, look, I'm morally opposed to the fact that you're going to pay $30 a pill

02:29:14.500 for something that I know in Canada is $1.97 a pill. And that example is actually true.

02:29:20.240 And if I'm going to give you 300 of these for a year, I'd much rather you pay $2 a pill than $30

02:29:24.620 a pill because your insurance won't cover this, by the way. The counter argument is, yeah, yeah,

02:29:28.500 yeah, yeah, yeah. We have to pay more for drugs as Americans because we're reaping the benefit

02:29:33.740 of drug discovery. All the best drug discoveries taking place here. These are our companies,

02:29:39.600 which by the way, is not entirely true. And therefore we subsidize the rest of the world's

02:29:43.880 drug costs because that's the price we pay for being the innovator. Is that kind of a bogus

02:29:48.440 argument? You're absolutely right. Pharma companies, when they develop drugs, are factoring in,

02:29:52.940 they're sort of budgeting the profit down the road into the drug development price. So if there's

02:29:58.640 bigger profits in the US, that's all part of the investment that they make in the research.

02:30:02.400 Problem is with drug pricing is there are so many moving parts. And what I've seen is,

02:30:08.380 first of all, as a cancer surgeon, some of these drugs do miracles and save lives. It's just

02:30:13.300 incredible what we're seeing. Biologic agents now are working wonders in part because it's a whole

02:30:18.180 different generation. These are not small molecules. These are expensive drugs to develop.

02:30:23.040 They're immune-based medications. Yeah. Keytruda is just unbelievable.

02:30:27.360 Unbelievable. And it's getting more awesome and we're seeing lives saved. What we're seeing is a

02:30:31.680 couple bad actors engage in the business of price gouging. We're seeing a couple bad actors

02:30:36.560 transition from brand to generic by not giving the information to the generic companies. They're

02:30:43.380 not disclosing it like they should. Normally, you have to disclose when your brand is done all the

02:30:48.480 manufacturing stuff. You're supposed to disclose it. So whether, well, they just delay it and they

02:30:52.920 drag. And Scott Gottlieb, the head of the FDA, has basically said, enough is enough. When your patents

02:30:57.160 are over, you've got to turn all this stuff over. We've got to get the generics going right away.

02:31:00.920 If you drag your feet for a couple of years, it's like having a patent for a few more years.

02:31:04.860 Wow. I didn't even think of that opportunity to screw people harder.

02:31:08.340 And then you get the PBM middle games, which the smoke bomb in the PBM world is the rebates.

02:31:13.700 Rebates are when the PBMs or middlemen, you name it, any of the middle layers say,

02:31:17.920 to the pharma companies. And this is where I have a little sympathy for pharma. If it's okay

02:31:23.080 to say that in America today, the PBMs say, oh, or group purchasing organizations. If you want to

02:31:28.440 be in our catalog, our formularies that we make available to our employees and on the benefits

02:31:33.380 programs we manage, or the hospitals that we supply, if we're a group purchasing organization

02:31:38.000 or GPO, pay us a million bucks to be in the catalog. Well, what does the pharma company do?

02:31:43.100 They pay the million bucks and they build it into the price of the drug. And then the middleman says,

02:31:47.680 hey, this is a good game. How about 2 million? Sure. Build it into the price of the drug.

02:31:51.480 How about 50 million? And we'll give you exclusive placement in the formulary or exclusive

02:31:57.100 placement in our group purchasing catalogs. Numbers directionally. I mean, are you making

02:32:01.600 these numbers up or is that literally what some of the dollar numbers are?

02:32:04.340 It's literally what they are. And not only are they forcing the pharma companies, device companies

02:32:12.160 also are being held hostage to these middlemen to say, look, you pay us these fees or you're not

02:32:16.360 going to be in our catalog. How do you think we had a shortage of saline? I mean, ask Jill, 0.77

02:32:20.980 who's one of the best nurses I've ever worked with at Hopkins. Ask her, how do we have a shortage 1.00

02:32:25.200 of saline? It's salt water, salt. The two most common elements in the world, salt and water.

02:32:32.200 How do we have a critical shortage in the price spikes? Why? Because these middlemen played these

02:32:37.320 play to pay fee games called so-called rebates or really kickbacks. Let's call it what it is.

02:32:42.260 Let's change the lexicon. Pay us these kickbacks to be in our catalog or pay us a lot of money. 0.87

02:32:47.900 You can be the exclusive saline company in our, and then all of a sudden their supply chain gets

02:32:54.180 so thin. I love the notion of there needing to be exclusive saline provider. Like there's something

02:32:58.260 so proprietary about putting sodium in water. The shiny object they're floating to the hospitals

02:33:04.000 and the employers is to say. You're going to get the biggest discount. Oh, we get bulk discounting.

02:33:08.500 Well, you don't even know what the bench reference price is anymore. There's only one company

02:33:12.200 making it. And so they figured out this game. Now the game is very profitable for the,

02:33:17.860 I call it a rich man's game. It's very profitable for everybody.

02:33:21.860 Except the last guy holding the bag.

02:33:23.940 The patient. I mean, the hospitals are even getting a share back sometimes. These rebates are

02:33:28.520 basically kickbacks. And I've argued to every single politician I get in front of, which is a

02:33:33.420 lot of them. And I can tell you, I've met with a lot of people in the Trump administration even last

02:33:37.120 week. And I have told them we need to eliminate all kickbacks in healthcare. It's time we ban

02:33:43.080 all kickbacks. Is that a policy issue? Is that a legal issue or is that a market issue?

02:33:48.340 It's two issues. It's one, it's a policy issue. In 1987, law was passed to give PBMs and GPOs,

02:33:56.100 or it gave PBMs and GPOs exclusivity. So the Sherman Antitrust Act does not apply to this supply chain.

02:34:03.760 I'm glad you bring that up because I was just about to say that sounds like antitrust. Like

02:34:07.460 we certainly wouldn't allow that in any other industry.

02:34:11.780 How bad is it that those middlemen, PBMs, GPOs, have benefited from a law that was passed,

02:34:17.740 which gave them so-called exclusivity to the Sherman Antitrust Act? It's called the safe harbor. And

02:34:24.160 you'll see a lot of us writing about it. You'll see a lot of it in the policy discussions. Let's get

02:34:27.800 rid of the safe harbor. Let's get rid of kickbacks in healthcare.

02:34:30.140 Okay. So to fix any problem, you have to immediately understand who's going to be hurt

02:34:34.940 by this situation, leaving its status quo. Surely there must be an army of lobbyists that have no

02:34:42.840 interest in anything you're talking about. They don't want any safe harbors being revoked. They

02:34:47.560 don't want any middlemen going away. And despite the fact that at the individual level, I believe

02:34:52.320 many of these people are disgusted by the profession. In the end, as a group, you stand up for what you

02:34:58.880 have and you stand up for your livelihood. So it seems to me one of the biggest challenges is,

02:35:04.500 okay, Marty is a voice of opposition to this, but the people who are being hurt the most,

02:35:10.900 which are every human out there, every person in this country, that is, they're not collective.

02:35:16.900 They're sort of like, I'm one guy and I got my bill and I'm getting screwed. And you're one guy and

02:35:21.860 you're fighting with the collections agency and you're one woman and you got breast cancer and you got

02:35:25.540 these guys riding shotgun up your butt and blah, blah, blah, blah, blah. But there's no one that

02:35:29.800 brings them together. So it's sort of like you have an industry complex, a machine that is very

02:35:35.120 easily able to diffuse a bunch of one-off attacks. That strikes me as to me, the biggest single

02:35:40.800 problem here. It's not the structural problem within the system. There are relatively straightforward

02:35:45.920 ideas that can be tested and iterated on. The problem is how do you create the inertia for change

02:35:51.460 when the people who have to force change at the individual level have less to gain than the

02:35:57.700 collective entity does to lose? That's, I mean, not to be depressing, but that strikes me as the

02:36:03.120 problem here. But the exciting thing is that young people, millennials, doctors, senior physicians that

02:36:11.420 have been in practice who see propofol and sudden shortage, people who understand there's money games

02:36:17.140 and there's stuff that's going on that shouldn't be happening. They're standing up. They're organizing.

02:36:22.140 I mean, look how- So this has got to be grassroots. I mean, it's grassroots. And you know what's

02:36:25.760 awesome is this is our heritage. This is the medical profession. This is who we are as doctors. We're

02:36:31.340 advocates for our patients. That's who we are. It's in our blood. I mean, when Dr. Sabin invented the

02:36:37.580 polio vaccine, they told him, all his colleagues told him, and these business guys, you need to get a

02:36:43.740 patent on this because this could be the biggest moneymaker in the world. He said, no, this is the

02:36:48.160 property of humanity. I want as many people to get this as possible. There are estimates of what

02:36:53.540 Salk forfeited by not- $8 billion. Forbes estimated $8 billion of that day. That was 1954, a year when

02:37:00.980 20,000 people were living in an iron lung machine. You talk about a horrible disease. And he said, this is

02:37:08.260 a gift to mankind. This will be disseminated as broadly as possible. And it's probably one of the

02:37:13.220 greatest and most inspiring stories. That guy's a hero. That is medicine. That's who we are.

02:37:18.540 I mean, when Benjamin Rush, one of the five physician signers of the Declaration of Independence,

02:37:23.900 had his practice his entire life, he took care of patients with schizophrenia. And he de-stigmatized

02:37:29.800 mental illness. So it wasn't seen as demon possession. His patients were chained to buildings. They had no

02:37:36.020 money. Mental illness meant you were impoverished. He took care of those patients. He was a role model. He was

02:37:41.180 one of our greatest leaders in society. President Adams says, you know, Benjamin Franklin and Dr.

02:37:46.700 Benjamin Rush both had great contributions to mankind, but Benjamin Rush had more and they were

02:37:53.620 greater. And that's our heritage. I mean, that is who we are. That's who my dad was as he took care of

02:37:59.960 cancer patients. He's now retired. He would never treat a patient and then destroy their FICA score

02:38:05.680 with surprise bills. We have this incredible heritage of being patient advocates. And if we

02:38:10.960 can channel 1% of the energy we spend on lobbying for higher doctor pay in Washington, D.C. into being

02:38:18.940 the champions of fair and honest, transparent pricing, we're going to see this incredible public

02:38:24.020 trust come back. Because I worry, and I'd love your thoughts on this, but I really worry we are seeing

02:38:29.740 the public trust eroded by this medical money game, billing, predatory game that's going on.

02:38:37.520 I'm from central Pennsylvania, a town called Danville. The Amish people are very close to that

02:38:42.420 area. We have more Mennonite closer to our region. The Amish people, when someone gets a serious illness,

02:38:48.820 half the time they take an Amtrak train for five days to Mexico because the medical care there has

02:38:56.500 honest and fair, transparent pricing. They're worried about getting price gouged in the hospitals

02:39:02.060 locally. What's that say about our country? I mean, you get on the Amtrak train in Pittsburgh,

02:39:06.100 where the Amtrak from Lancaster connects with the train that goes cross country. It is mostly Amish 0.98

02:39:11.340 people going to Mexico for breast cancer surgery, for a chronic disease therapy, for a medication.

02:39:18.620 What's that say? It says people are hungry for honest and transparent pricing like Keith Smith has

02:39:23.940 in Oklahoma City. That's what I'm hearing you say is, look, physicians aren't the reason that this

02:39:28.220 system is broken, but now the onus is on them to play a role in catalyzing reform because by

02:39:34.620 association, whether we like it or not, we're now a part of the problem. And it's so proximate to us.

02:39:39.660 We interact all the time. I mean, when I show the egregious bills or stories of individuals harmed by

02:39:46.840 these bills, or they're paying more on their mortgage because their FICA score was destroyed from a

02:39:51.060 balance bill from an epidural, the hospital executives are very understanding. I mean,

02:39:56.340 they, I think sometimes just don't know how far the revenue cycle or billing outsourced departments,

02:40:02.560 how aggressive they've gotten. And if you appeal to everyday human instinct, they will say, yeah,

02:40:08.120 this does not seem right. We are very close to our hospital leaders in medicine. We need to say,

02:40:14.420 okay, here's a couple of things, a hospital code of conduct. We can get our act together and provide

02:40:19.420 one honest, transparent bill. That's not jacked up for discounts. We can agree. We will never sue

02:40:24.540 a patient that's low income and came in for basic medical care. We can agree that if we're going to

02:40:30.060 bill a patient directly, we'll use the Medicare allowable amounts. We're not angry when Medicare

02:40:34.440 pays us. We shouldn't be angry if somebody pays us the Medicare allowable amount.

02:40:39.320 That's a great idea, Marty. Is there such a code of conduct that's being generated and signed off on?

02:40:43.560 This to me sounds like a great first step. There's no order to these steps that can be done in

02:40:47.920 parallel. But I think you could rattle off 10 things that 90% of physicians and hospital

02:40:55.340 administrators would look at and go, yeah, I believe in. Like everything you just said,

02:40:59.120 who wouldn't agree to those principles and potentially seven more? Is that in the works?

02:41:03.660 Yeah. My students have put it up at restoringmedicine.org, a basic code of conduct for

02:41:08.700 medical centers. But it's not just docs. It's not just medical professionals. I have people all the

02:41:14.500 time. Everyday folks, if I speak to a conference of, say, real estate agents and we get into all

02:41:19.500 these issues, they'll often say, and I want to do something. What can I do? And I tell them, get

02:41:25.000 involved in your local hospital. It is a community organization. It's a nonprofit with a public mission.

02:41:30.800 And ask these questions. How do you manage patients who can't pay? If their deductible is high and they get

02:41:37.600 a bill or they're uninsured, how do you bill? What's your average markup? Is it 1.5? Is it 2.5?

02:41:45.020 Is it 23? Like we found in some of our research, what is your average markup defined as how much do

02:41:51.240 you charge above the Medicare allowable amount? We did get the Trump administration. I was very

02:41:55.740 impressed. Seema Verma, Alex Azar, Kelly, I mean, incredible folks that basically said, yeah, we get it

02:42:01.060 when it comes to deferred pricing. We want every hospital to submit their prices. And they did that

02:42:05.580 January 1. It's a first step. It's a first step. These are jacked up prices. We got to get the real

02:42:09.760 prices. But everyday folks want to know what to do. I tell them, find out what's your hospital's

02:42:15.680 average markup. How do they handle bills that are not paid among low-income insured and uninsured

02:42:20.140 people? Reach out to your local courthouse. Find out if they're suing the socks off of the town,

02:42:25.740 like we've seen in 20% of hospitals in the state of Virginia. And then reach out to your board members

02:42:31.020 and ask them, engage them on the subject. And the hospital board members, it's always the

02:42:36.420 president of the local bank. It's always a couple of business leaders. They're always reasonable

02:42:40.520 people. They come in. I'm on a hospital board. I got a meeting later today, Anne Arundel Medical

02:42:45.480 Center. It's at the big hospital in Annapolis, Maryland. These are good people. Appeal to those

02:42:50.080 people and say, look, we want to take this code of conduct seriously. We want a hospital that provides

02:42:56.080 roughly 6% of our services as charity care disclosed up front to the patient. Not, we shake you down

02:43:04.020 and whatever we can't get out of you. Whatever we can't get, we deem charity. We deem charity, which is

02:43:08.240 the standard way of doing business. 6%, charity, honest pricing, honest billing practices. Those are

02:43:14.940 things we can engage our community board members on. That's the purpose of writing this book, The Price

02:43:21.140 We Pay. You know, when you write a book, especially as a doctor, maybe especially even as a surgeon,

02:43:26.140 some people who don't like this message will ascribe to you, and I know you're working on

02:43:30.720 a book. People will ascribe, oh, they're self-promoting. They're just doing this for

02:43:35.080 self-promotion. What's known among authors is the books don't make money. You don't make them for

02:43:39.940 the time you spend. I mean, I make a lot more money just doing surgery, but this is a way of getting

02:43:44.940 the message out there and to engage people and to say, hey, this is what's happening and this is what

02:43:50.020 we can do about it. Well, Marty, I know you do have to get down to Annapolis today, so I guess

02:43:54.160 we'll bring this to a close. I think there are a lot of things here. It's sort of overwhelming. As

02:43:57.940 I said, I can't really think of a machine that I find more confusing than the U.S. healthcare

02:44:03.280 system, and that in general probably isn't a good thing. I hope that you're right. I mean,

02:44:08.380 I got to be honest with you. I'm concerned that the force necessary to overcome the inertia is so

02:44:13.660 great that we need a bigger crisis because in the end, we'll do things until we can't do them

02:44:20.820 anymore. We always talk about, well, this isn't sustainable. Well, technically it is because we're

02:44:24.880 still doing it, right? What does it take for this to not become sustainable? I don't know, but I love

02:44:31.340 your message that doctors need to sort of get involved in this a little bit because by proxy,

02:44:37.600 we are involved in it, whether we want to be or not. So you take that example of a woman, 1.00

02:44:41.460 if you provide care to this woman with breast cancer and you're doing the best you can,

02:44:45.920 and you don't realize that a year later she's getting shaken down for medical bills, well, 0.92

02:44:51.640 you can say, well, I didn't have anything to do with that. And it's true you didn't,

02:44:55.360 but do you also have an obligation to her? And if the answer to that question is yes,

02:44:59.380 then I think that doctors and patients alike can probably overcome what you're describing.

02:45:04.540 I hope that turns out to be the case. I'm seeing some exciting things. I mean, right now,

02:45:08.400 I think the American people are prioritizing this problem as the number one problem in America.

02:45:14.200 When the LA Times reporter Noam Levy tells me that more Americans are making different choices at

02:45:21.320 the supermarket, they're cutting their vacations, and they no longer have money to save for their

02:45:26.820 kids. And sometimes their FICA scores are getting destroyed, all because of surprise medical bills

02:45:31.840 or inflated bills. This is saying, and he's saying, this is going to be the number one issue

02:45:37.460 in the election. This is the number one issue for the American public. And my goal is how can we

02:45:42.520 educate people? I'm never going to run for office. I mean, I've thought about running for president

02:45:46.560 simply on one issue of banning all plastic surgery. Because I go to Florida a lot, you know,

02:45:53.260 it's the evolutionary reflex of a human being identifying another species and being frightened,

02:45:59.440 you know, like a kid, you know, if a kid sees someone ugly, they don't jump, but if they see someone

02:46:03.460 with all this plastic, they're startled. And it's sort of the natural selection of identifying

02:46:08.140 foreign species. But this is something that is imminently fixable. We're seeing employers now 1.00

02:46:13.220 saying, I want independent brokers and consultants renegotiating my PBMs that don't take kickbacks.

02:46:18.220 There's a group of them. There's not a lot. We put them on the website, Restoring Medicine.

02:46:21.560 Give me all the resources. So where can someone go if they want to know how to find an independent

02:46:25.420 versus a kickback broker? So Health Rosetta is started by Dave Chase. And what he's done is try to

02:46:31.120 create a brand of sort of the free trade brokers, if you will. That is those people that have agreed to a

02:46:37.400 code of conduct. And it's all transparent and you feel it's worth getting a second opinion.

02:46:41.760 So that's healthrosetta.com?

02:46:43.460 Health Rosetta. If you Google Health Rosetta, it comes up. We're putting a link to it on our

02:46:47.380 resource, which is- And what's your resource?

02:46:49.520 Restoringmedicine.org. And we're trying to generate some interest. The students created the

02:46:53.920 website. I put a post on there that showed the prices of everything in America and prices of hospital

02:47:00.020 services, which was crazy off the charts compared to everything else in society. And this thing,

02:47:06.120 I just posted it. God, I don't know, 70 likes in a day or 70 shares in a day. I don't know if I have

02:47:13.020 70 friends. I realized like people are connecting with this issue that we can do better. So that's

02:47:18.620 Restoring Medicine.

02:47:20.260 Restoringmedicine.org basically can point people in the direction of all of the things you're

02:47:24.760 talking about here.

02:47:25.620 Yeah. And also I've got a website, martymd.com, where I try to provide some resources for folks

02:47:31.040 that are interested in learning more about this.

02:47:32.820 All right. And the price we pay comes out exactly when?

02:47:35.500 They're still floating the date, but it's going to come out when they line it up with

02:47:38.800 the media, but it'll be very soon.

02:47:40.900 All right. Well, Marty, thank you so much, man. Awesome to get to hang with you two days

02:47:44.800 in a row.

02:47:45.360 Great to be with you, Peter. It's just so awesome to see what you're doing, educating people

02:47:49.040 and promoting good health and re-educating us. And I'd like to see some humility from the

02:47:54.340 American Heart Association just to say, we're sorry. We got it horribly wrong, but I think

02:47:59.860 it's going to be individuals like you that just say, hey, stuff I was taught is now

02:48:04.580 outdated and this is the new science. So thanks for pushing us on that.

02:48:08.080 Well, I'll tell you, that seems like a much easier problem to sort of be working on than

02:48:10.960 the one you're working on. So I think you are actually working on the single most important

02:48:13.840 problem in all of medicine. And I don't say that lightly because I think there are a lot

02:48:16.900 of problems in medicine. But if we don't get this one fixed soon, we're going to be in,

02:48:21.440 I think, a degree of pain that most people can't fathom from an economic sense.

02:48:25.880 Great to be with you, Peter.

02:48:26.620 You can find all of this information and more at peteratiamd.com forward slash podcast.

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The Peter Attia Drive - August 26, 2019

#68 - Marty Makary, M.D.： The US healthcare system—why it's broken, steps to fix it, and how to protect yourself

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