The Paradocs Podcast with Eric Larson

Dr. Eric Larson of the Paradocs podcast joins me to discuss what we think RFK Jr. wants to do if confirmed as head of the Health and Human Services division, what he might get done, and some priorities he ought to do to make America healthy again. q Video - https://youtube.com/live/wt69j-XebVg This episode is brought to you by Trijent's new Universal Mech-loader - https://trijent.com/spangle Trijent, a pioneering small business, proudly introduces the Universal Mech-loader. This advanced speedloader is designed for a variety of ammunition types including 9mm, .40 S&W, .45 Auto, .223/5.56mm, and 7.62mm. It significantly reduces loading time, minimizes hand fatigue, and enhances your shooting practice. With its adjustable mechanism, the Universal Mech-loader fits multiple magazine types, ensuring a universal fit for your firearms. Transform your time at the range with efficiency and ease. Do you have comments or questions about this episode? Visit it on ChrisSpangle.com and leave one! --- Join our Patreon now for commercial-free shows, bonus content, and our complete archives - https://www.patreon.com/wearelibertarians --- Join our Facebook Group to meet other listeners. - https://www.facebook.com/groups/walnutssociety --- Visit Chris-Spangle.com to see my other podcasts and projects or to add me on social. www.Chris-Spangle.com --- Looking to start a podcast? Download my podcast Podcasting and Platforms now, and check out my recommendations for buying the right equipment. Chris Spangle and Leaders and Legends, LLC edited and produced this podcast. If you want to start a podcast or take yours to the next level, please get in touch with us at LeadersAndLegends.net. Learn more about your ad choices. Visit megaphone.fm/adchoices

Are you a decision maker at your business? If you're a CEO, CFO, the head of HR, or perhaps the owner of a small, medium or large business then you owe it to yourself to check out this fairly simple solution to save over 50% on your health care spend. Health insurance is usually one of the biggest overhead expenses after salaries for any company and it affects the bottom line of nearly every business. Imagine what your company could do if it paid out less than 50% in its health care spend - while also maintaining a similar if not improved plan for employees. Before you scoff and say that there is no way you can provide your employees high quality care at less than half the cost, just remember that only about 25% of every dollar spent in health care actually goes to caring for patients. There's plenty of room to cut. Why Health Insurance Is So Expensive?The reasons for expensive insurance is obviously a complicated question. However, it's simplest to think of it in just a few ways - especially when we look for ways to bypass the rotten system to save real money for our business. The insurance companies make money by paying out a lot in claims. This seems illogical at first glance but makes a lot of sense once you realize that the insurance companies are only allowed to use 15-20% of the total they pay out in claims towards profit and overhead. Therefore, the more in claims payouts, the higher amount they can profit. Pharmacy benefit managers (PBMs) hang onto the rebates. Instead of passing on the volume discounts (or rebates) onto the employers and employees they keep that percentage of charges. Just like the insurance companies, the more that is paid out in charges the greater revenue they get to keep leading to ever increasing pharmaceutical prices. Insurance brokers primarily make their money through commissions from the insurance companies. This incentive leads them to find only solutions for your company that involve large insurers. The only way you can actually save money is to bypass the traditional means of creating a health plan which most brokers are not aligned to do. Building a Better Health Plan?What becomes readily obvious as far as solutions go is that you must create your own self-funded health plan and find transparent PBMs and rational contracting to pay for services. Very few companies are prepared to do this which is why you need to find insurance brokers and third party administrators who can set it up for you. There are plenty around, you just need to seek them out. I've had two on in the past whom I reference in the show. Of course, they are hardly an exhaustive list of players in the field but they would be a good start for anyone investigating these solutions for their business: Katy Talento of All Better Health and David Contorno of Epowered Benefits.   show notesEpisode 176: Today's show Episode 111: Katy Talento tells us how she saves businesses money. Episode 150: David Contorno explains his business model. Episode 043: How PBMs jack up drug prices. All Better Health: Katy Talento's business where she helps others create their own health care plans. E Powered Benefits: David Contorno's business helping others create health care solutions. We Are Libertarians: The Paradocs is a proud partner and member of this outstanding podcast network. Top 20 Physicians Podcasts Made Simply Web Site Creations: This is the great, affordable website service that built my wife's podcast site. I cannot recommend this company more to someone looking for creating a website. Always Andy's Mom: Home of my wife, Marcy's, podcast for parents grieving or those looking to help them. YouTube for Paradocs: Here you can watch the video of my late son singing his solo on the Paradocs YouTube page. Learn more about your ad choices. Visit megaphone.fm/adchoices

COVID has reshaped the world and China holds a unique position in the world's approach to combatting pandemics and in the fact that it was first described in the city of Wuhan. We may never know exactly where or how COVID originated in China but we can be certain that the unprecedented strategy to 'lockdown' was one that originated in China. The Lockdown Before when the COVID pandemic was just a regional epidemic in China, the CCP embarked upon a zero-COVID policy where they took extreme measures of shutting down their economy. As an authoritarian government they were able to use extreme measures to prevent the movement of people. This was accomplished by sealing citizens in buildings and delivering essential goods (sometimes) with very harsh penalties if people tried to escape. How is the Lockdown Going? Jennifer Zeng is familiar with the CCP as one who has escaped a political prison to the United States where she now reports on the Chinese government. And that government's zero COVID policies seem to be taking their toll on their citizens as they are well into the third year of rolling severe restrictions. Protests are occurring all over the country and unlike the Tiananmen Square in Beijing in 1989 they aren't isolated in just one city. The CCP is faced with troubling questions as to whether it can really trust the military? Would easing the restrictions embolden people and lead to increased calls for freedoms? Learn more about your ad choices. Visit megaphone.fm/adchoices

History is a funny thing. Often, we think we know what happened either as we experience it personally or have trusted sources that give us an account. However, it depends on who is relaying the information, and the prior biases and perspectives. The goal of a good historian is to gather information from multiple sources and figure out what happened and why it played out the way it did. In today's episode we focus on why the US ended up with a third party payer system left to the insurance companies to dictate payment and generally how physicians can practice medicine. It Begins with InsuranceDr. Christy Chapin has focused her research on the history of health care which includes insurance and finance. She believes that you must understand how we got to where we are today with insurance (private and public) dictating how medicine is practiced through payment mechanisms. It's easy to look at Medicare and Medicaid and assume that there was always a large influence on health care's practice through insurance reimbursement - but that's not the case. In fact, most doctors assume it was the decade or two before the creation of Medicare in 1965 that insurance really came to be a big player in health care. Actually it Begins with the AMAThe standard story is that wage controls coming out of WW II left employers with limited ways of attracting top talent since they couldn't adjust employee incomes easily so they resorted to offering benefits like health insurance to entice the ones they wanted. Although that story is a handy explanation, it isn't really borne out by the evidence either in uptake in the frequency of health insurance being offered to employees or its use more broadly in the marketplace. In fact, the creation of health insurance product came from the AMA as they looked to thread the needle and avoid corporate interests taking over medicine (worked out great, huh?) and a federal nationalization. Unfortunately, the AMA, by squashing all other physician led ways of organizing the delivery of health care, removed all other alternatives to their preferred method - insurance. Initially, the insurance companies agreed to not limit any claims, pay in full whatever charged by the physician, and pay wherever the charges originated (ie, the physician's own lab, etc.). This led to cost over runs and then the endless government fixes including governmental insurance (Medicare/Medicaid) and the resulting changing of the landscape of medicine. Learn more about your ad choices. Visit megaphone.fm/adchoices

It's been a while since I've done an episode and it's mainly because I've had a COVID rant percolating for some time. So I just had to let it out now that the president (accidentally?) mentioned that the pandemic of COVID-19 is over. In this episode, I cover mandates, vaccines, public health policy and much more. A frank discussion with you about where we are and where we need to go as a country with this irritating virus and resulting policies. This is an expansion on my speech from episode 156 and a broader discussion with Dr. David Graham in episode 143. Learn more about your ad choices. Visit megaphone.fm/adchoices

In survey after survey, the number one satisfier for physicians - by a long way - is their relationship with patients. Anything you can do to improve or deepen that relationship makes the work better and decreases the incidence of burnout. Obviously, barriers put in the way that detract from creating a deeper relationship with patients makes the job of medicine less desirable. One way a lot of doctors have gone is to practice using a direct care model which removes many of the obstacles in place within modern medicine from forming that all important bond with their patients. Getting Help to Start a DPC PracticeUnfortunately, doctors don't usually receive training in how to run a business and set up a practice like this. Even if they have heard about direct primary care (DPC) there are a lot of things to overcome to start up. First, they need to understand how the model works and what space, supplies, and equipment they need to begin. Second, they need to find ways of bringing patients in the door which requires marketing and sales. Finally, there is a lot they need to learn as far as running the practice since most of their training probably came in an academic setting or at the very least, an insurance based model for providing care. That's where today's guest, Chris Habig of Freedom Healthworks, comes in. He and his brother started the business initially to help their parents (who are primary care physicians) rekindle their love of medicine. What they've built is a company that helps doctors at every stage of the process setup, start, and run a DPC practice. Doctors can use as little or as much of their services as they feel they need but essentially Chris and his team take away a lot of the unknowns and help navigating medicine in this space. Learn more about your ad choices. Visit megaphone.fm/adchoices

Occasionally, you come across an interview or subject that blows you away with incredible claims that are both out in the open - and yet invisible. Today's guest is an author and expert witness for some of the biggest pharmaceutical cases of this century, Dr. John Abramson. He reveals the rot that centers not only in the pharmaceutical industry but also the institutions that are constructed to serve as its guardrails - the medical journals, federal agencies, and guideline committees. In some What Would Physicians Say if They Knew Medical Journals Had No Access to Data for Peer Review?The most stunning aspect of the whole conversation centered around how the most prestigious medical journals conducted peer review without all of the clinical data. This means if anything was misrepresented or omitted there is no check on the truth of the claims from the study. Essentially, the journal and its reviewers are relying on the good faith submission of all important details from the study designers who are usually paid employees or have research paid for by the pharmaceutical manufacturers.  The most famous landmark case was with Pfizer withholding adverse event data (or misclassifying them to avoid statistical significance) on cardiovascular events (heart attacks and strokes) with their medication, Vioxx. Only when Pfizer was sued in a huge class action lawsuit did the actual clinical data get revealed showing that they had seen a signal for adverse events but intentionally did not disclose it (or the raw data) to the medical journal reviewers. Worse yet, once the error was presented, the medical journals spent very little time discussing the error. According to Dr. Abramson, this is in large part because up to 40% or more of medical journal revenue comes from study reprints. This financial incentive to find positive results and publish makes for a twisted system that incentivizes the promotion of new medications and devices when they may not be safe or very useful. Learn more about your ad choices. Visit megaphone.fm/adchoices

What is one common difference between the hiring process of most professionals with advanced degrees and those in sports and talent industries? The use of talent agents. People dedicated to finding their clients jobs, negotiating the terms, and essentially doing all of the analytical work to determine market value for the "talent."  What if the Talent were Physicians?Raised by a physician mother, my guest today is Ethan Nkana, who didn't enter the world of medicine as a doctor but instead got his JD and MBA to enter the world of hospital administration. Ethan cut his teeth negotiating physician contracts, running operations, and more for hospitals. But he decided to get out and start a business working on the other side of the table with physicians in the negotiation process. His model is simple in that he uses the same as talent agents for musicians, artists, and athletes except his clients are doctors.  Ethan brings his knowledge at the Rocky Mountain Physician Agency of what hospitals want, where their pain points are, and what they worry about to help doctors maximize their compensation or work situation. Fortunately for Ethan, there are plenty of physicians now employed and looking for more. Learn more about your ad choices. Visit megaphone.fm/adchoices

I confess that I hold a lot of biases when it comes to various surgical specialties. One such bias is that orthopedic surgeons - especially trauma - are not deep thinkers. My guest today completely turns that prejudice on its head as we discuss the role of nutrition and vitality in disease and recovery rates. Setting the Hammer DownObviously, an orthopedic trauma surgery focuses their care on treating patients with fractures sustained in injuries. However, Dr. Miller now looks beyond the obvious mechanical or lab-based problems that patients present with. He uses some principles of functional medicine to seek the answers to what might afflict his patients. For instance, perhaps the pain in their joint isn't from arthritis but from a dietary problem. Learn more about your ad choices. Visit megaphone.fm/adchoices

In 1973, the US Supreme Court ruled on the Roe v. Wade case and concluded that Americans have a constitutional right to an abortion up to viability of the fetus. That has been the law of the land... until now (or at least very soon). Roe v. Wade OverturnedA few weeks ago, a draft majority decision by the Court was leaked which showed that there was a majority of justices on the Supreme Court who were going to rule in favor of the state of Mississippi in their challenge to the Roe decision from nearly 50 years ago. Effectively, overturning the Roe decision would revert back the power to regulate abortions from the federal to the state level. Many states have been anticipating or preparing for the eventuality of this decision and have created 'trigger laws' which go into effect if and when Roe is reversed. Most of those states make abortion more restricted or outright illegal. However, some states have liberalized abortion making it legal right up until birth. Challenges for the StatesElizabeth Nolan Brown, Senior Editor at Reason magazine, lays out a few of the problems with this ruling coming back to the states. Primarily, although the states can regulate what happens in their borders, it is very difficult for them to restrict what people do in other states. For instance, can states really stop women from crossing the state line and getting an abortion? Can they prevent mail order morning after pills? Learn more about your ad choices. Visit megaphone.fm/adchoices

What would you do if you were fired by your employer over something you had said on social media? Would you be able to survive or would you have to scramble to find work? That scenario is exactly what was faced by today's guest, general surgeon Dr. Buck Parker. And his solution was a surprising one. Seeds of an EntrepreneurIt doesn't appear that Dr. Parker never set out to find ways to be financially secure outside of medicine. His path through medical school and his general surgery residency seemed fairly traditional. However, there were signs that he had an entrepreneurial streak about him as he began a very small online business selling gym equipment. Following that, he landed a role on a reality TV series which led to another starring role on a second show. Aside from practicing clinically as an acute care and trauma surgeon, Dr. Parker leveraged his appearances on TV and built up a following on social media through Instagram and YouTube. And that's where the trouble began. Losing Your JobDr. Parker's termination within his hospital system in 2020 happened a lot like the old joke in bankruptcy. "How do you go bankrupt? Gradually and then suddenly." Parker's CMO had been very upset with his YouTube channel and social media presence for some time and when Parker published a video stating that the highest risks for COVID are those who are obese, elderly, and with medical co-morbidities, it was the final straw. Perhaps it was because the video went viral and the light it shone on an institution that didn't want any attention paid to it. No matter the reason, it was the end of the line for Dr. Parker's Salt Lake City surgical career. Overcoming Job Loss as a MinerPerhaps by happenstance, Dr. Parker had researched and eventually took the plunge to mine bitcoin. Fortunately for him, the price of bitcoin exploded from a few thousand a coin to tens of thousands from the time he started to the time he had been let go. It more than supplemented his income lost as a surgeon and gave him the financial freedom to be able to walk away and not worry about scrambling to get another job. It's now been almost 18 months since being let go and the CMO has been replaced and the hospital has been busy. So busy they actually asked him to return but he declined. For right now, Dr. Parker doesn't see himself going back to medicine but time will tell. Learn more about your ad choices. Visit megaphone.fm/adchoices

Dr. Jay Bhattacharya returns today to further our discussion on the dysfunction within the scientific community around COVID-19. Specifically, we discuss what exactly happened to Dr. Bhattacharya after he co-authored the Great Barrington Declaration where he and two other prominent academicians laid out a case for a more focused protection plan for the elderly than the widely adopted general lockdowns and mandates at the time. Dr. Bhattacharya was not surprised to face opposition to their plan - but the way it formed and by whom did.  A Government Bureaucratic Cabal?After the publishing of the GBD, the attack against Dr. Bhattacharya and his co-authors was blistering, numerous, and seemingly coordinated. Those on the outside, and even Dr. Bhattacharya himself, believed that the scorn from media, government, and academia was due to a general disagreement with their position - not a coordinated attack. It turns out that FOIA documents of emails from Drs. Fauci (head of NIAID) and Collins (head of NIH) prove that they worked in tandem to discredit the GBD through their contacts within the scientific, media, and government communities. Learn more about your ad choices. Visit megaphone.fm/adchoices

The US health care system is fraught with all sorts of problems. Many of these have to do with consolidation in the market and scores of rent-seekers (those using legislation and regulation to maintain their market share. Those issues can probably be best resolved with fundamental changes within the halls of government. However, some of these problems can be addressed with new technology which offers solutions not even dreamed possible a few years ago. And the driver of much of this innovation rests on block chain technology. Block Chains to the Rescue? The basics of block chains have been discussed on this show where we explained the basic concept of what it is and how it works (here and here). We also looked at some helpful business applications such as decentralized finance and how that could unlock capital and make for opportunities for small medical practices. However, the real allure of block chain is whether it can solve some of the bigger problems in health care and bring about real structural change to the problems that plague doctors and patients alike: information sharing, supply chains, and payment processing. Patient Information Sharing and Storage Big Data is big money and there is no more valuable data set than patient health information. Companies pay millions of dollars for this data to develop health processes and businesses to manipulate the data to change patient behavior, physician behavior, and new businesses. However, the biggest problem is that the patient has no ownership of their information meaning that they cannot decide if the data is used or be compensated if it is. The possibilities of the block chain allow for patients to control their information and dictate those to companies - not the other way around. Additionally, patients owning and securing their own data would allow for more accurate and safer transfer of their personal medical information when traveling between medical systems, EHRs, or even health providers within the same system. In essence, a patient could only transfer the information they want and deem important to a particular provider and no more. A quick example would be to just provide personal demographic information to an imaging center and not all their health history. Learn more about your ad choices. Visit megaphone.fm/adchoices

There's no shortage of an alphabet soup of government agencies but the same exists within the nebulous public-private sphere of medical education and credentialing. These non-profit organizations were created to ensure a baseline within medical education institutions across the entire country for medical students, foreign medical graduates and residencies. However old and established these institutions are, they are still staffed by people who make decisions and are charged with maintaining the organizations financial stability. But, since they don't have any real competition, they can make financial decisions that are not always the best for the long term viability of the organization which can lead to problems in the future. Sometimes those futures become the present and people paying for their services, ie, medical students, residents, and foreign medical graduates take the brunt of their poor fiduciary planning. The real financial risk to many of these organizations is similar to what threatens governments at the local, state, and federal level: pensions. The Sorry State of NBME's Pension ProgramCharles Kroll is a forensic accountant which means he is adept at parsing financial reports and determining where money is flowing and where the inherent financial risks are to organizations. With the help of analyst Elizabeth Tremblay, they have analyzed the financial data from the National Board of Medical Examiners (NBME) - which conducts the testing for medical students - and have found troubling signs. Foremost is that the NBME has a retirement fund that is worth almost $300 million which is twice the value of the organization. On top of this, the retirement fund is still underfunded which means it is at some risk for default with an organization that clearly could not meet those extra payments since it is dwarfed by the size of the retirement fund. Of course, the great risk is to medical students which would probably be on the hook to make up for the financial offset if the retirement fund becomes grossly underfunded. The only real source of revenue for the NBME is its examination fees. And for medical students, they are forced to pay whatever fee the NBME comes up with since there is no competition and alternative testing organization in the United States. The financial mismanagement of this and other organizations will fall hardest on those with no choice and the least ability to pay. Defined Benefits are the ProblemRetirement benefits are usually of two main types, defined benefits and define contributions. It effectively shifts the risk either on the employer or the employee. In the private sector, defined benefits (guaranteed payouts over the length of your retirement) haven't really existed for 35 to 40 years. Nowadays, private companies and most non-profit organizations offer 401Ks which are specified contributions but do not guarantee your future payouts - they are whatever they returns are. What is so unusual is that all of these medical education boards use defined benefits as their retirement structure which puts their organizations and, by definition, their clients at risk for covering the gap of underfunding their benefits. According to Kroll, unless the organizations kill their defined benefits plans they will be at increasing risk for insolvency or at a minimum, jacking up fees to students.

It's easy to become despondent about controlling spending or eliminating waste through reform on government expenditures. We've all seen the headlines about the $1 million hammer or toilet seat and governments losing track of money. Also, with all the people who have been elected on the platform of 'transforming' government or making it efficient, there has been almost nothing but the exact opposite happen. It's why the joke about death and taxes not only funny but very true. To make matters worse, imagine government getting involved in the purchase of a product that is incredibly expensive and wasteful - US health care. This is a recipe for budget overruns, poor health outcomes, and a bottomless pit of spending. The opportunities for wasteful spending is so great and the lobbyists to keep the gravy train of spending so powerful that tackling it at the state level seems hopeless. Yet that is exactly what Christin Deacon did. Reforming New Jersey's Health and Benefits Plan Maybe it's because Christin Deacon didn't know any better but she looked at the amount of money being spent on New Jersey's health and benefits and actually thought she could find some meaningful savings for taxpayers. To her credit, she asked the questions that no one had asked and pursued solutions that no one had seriously tried before. Through her persistence, Deacon helped save New Jersey citizens over $500 million per year for years. Those billions of dollars have been used to fill other gaps in the state budget and most importantly, haven't been thrown away on poor contracts or inflated pricing.

Expanding Choice for Physician Board Certification (NBPAS) with Dr. Paul Mathew A rite of passage for doctors is completing a residency in a specialty. Sometimes, they complete multiple specialty trainings but ultimately sit at the end of their years of training for board certification. At one time, once a physician got board certified, they were considered a specialist for life and no further testing or training was necessary. That all changed in the 1990s as the governing board for all the specialties, the American Board of Medical Specialties (ABMS) began to require that new trainees only receive time limited certification. This meant they would have to undergo new testing or requirements in order to maintain their board certification. Initially, this expiration was every ten years and usually just involved an exam. Physicians grumbled about retesting within their discipline which required time, money, and travel usually. Eventually, over the years, the testing and continuing education modules grew and expanded requiring more and more time and expense. Now, a physician who is triple board certified, like a hematologist-oncologist, would have to do testing every 2-3 years with almost continuous rounds of studying parts of medicine that he/she no longer practices. This can cost the doctor upwards of $40,000 every ten years! Why NBPAS is NeededAs the onerous and expensive requirements for ABMS recertification continued to pile up, doctors from prestigious medical institutions from around the country decided that it was time for another choice for board recertification. The concern was not in the initial training and certification process but simply in the verification of continued mastery in the doctor's field of practice. Therefore, they set out to create a board certification that recognized prior training but focused continued medical education that the physician felt best helped them in their day to day practice. This allowed the new all volunteer board to decrease the annual certification price to only 30% of the ABMS price while also drastically eliminating all of the mind-numbing busywork that doctors say contributes nothing to their practice but grows their burnout. Doctors were upset over the perceived exploitation and lack of response to their concerns over the recertification process so another choice through the NBPAS is a welcome addition. NBPAS is Now Accepted by URAC and NCQAOne of the main limitations in the acceptance of NBPAS by hospital credentialing committees is the fact that private insurance carriers couldn't get credentialed by their credentialing bodies if they didn't use ABMS credentialed physicians only. Hospitals were very hesitant to allow medical staff who were not qualified to get paid by insurance carriers as they feel that this puts their patients at risk for surprise bills. Fortunately, NBPAS has now obtained acceptance by NCQA and URAC which are the main credentialing services for insurance carriers. This paves the way for physicians to have a choice between the ABMS certification or NBPAS and still get paid.

The COVID pandemic has created a lot of interesting surprising and challenging political dynamics in countries all over the world. In the United States, we have a clear divide between those who declare themselves Democrats and Republicans in whether they support mandates and vaccine passports. The treatment of children remains a subject of a tremendous amount of strife. However, our neighbors to the North in Canada are having the same political tension growing as exhibited by the Freedom Convoy. What is the Fredom Convoy?The Freedom Convoy began January 22nd as a decentralized protest movement in Canada led by truck drivers entering the nation's capitol, Ottawa. According to my guest today, Warren Speyers, the convoy is seeking to end the vaccine mandates for traveling and generally moving into businesses. Speyers says the truckers are not looking to fight vaccination, rather, just the mandates and edicts which they feel are restricting their freedoms and businesses. The convoy consists of not just truckers but also many other Canadians who share those same goals and values. Speyers says that there are all sorts of trucks, tractors, and even personal vehicles which line the streets around Canada's Parliament. From Speyers' description, the convoy has been met with lots of support from citizens in Ottawa. The protests have been largely festive celebrations with people packing saunas, hot tubs, and even their hockey skates along with their families. The truckers have been showered with food, meals, valentines, money, hot showers, and offers of diesel gas from well wishers. The Canadian Government's ResponseAlthough the protests have been peaceful, the Canadian government has sought to end the movement without pulling its restrictions and mandates. On the day we recorded, February 14th, Prime Minister Trudeau and the federal government invoked the Emergencies Act which is essentially grants the federal government extraordinary powers to prevent massive violence, threats to Canadian sovereignty or a threat to public safety and health. In practice, the government has threatened to freeze and seize the financial accounts of anyone who financially supports or participates in the protest since most of those involved are owner-operators and not actually parts of large corporations.

If there is one thing that seems obvious throughout the pandemic, public discourse on just about everything seems to have broken our brains. We are incapable of having discussions without vitriol and there appears to be a real desire to not simply win arguments but destroy our ideological enemies. This leads to all sorts of strange behavior like fracturing previously solid personal relationships between family members, friends, colleagues, and, in today's example, patients and their doctors. Going After Her Medical LicenseIt began with a surprising email in her gmail account in the fall of 2021 for Dr. Meg Edison. A man identified himself as an investigator for the Michigan State Medical Board and was following up on a patient complaint for 'misinformation.' After a google search to feel comfortable that the individual was an actual state employee investigator, Dr. Edison gave him a call to find out what the nature of the complaint was against her. It turns out that one of her long standing patients had lodged a complaint with the state board of medicine claiming that she was pushing misinformation at their child's last visit. The claim consisted of the 3 allegations: That cloth masks were not a very effective barrier for protection from infection by COVID and they would do better to wear a higher quality mask, That it was unlikely that the FDA would approve a pediatric vaccine, and That even 70% of the deer in Michigan have been infected with COVID as shown by serology testing. As one can see, all those statements are correct and were true by government authorities even back in the fall of 2021. Fortunately, the story has a happy ending and the Board of Medicine found the complaint to lack merit and was summarily dismissed without any action taken against Dr. Edison. How Organized Medicine Can Protect DoctorsOrganized medicine can be an extremely challenging and aggravating landscape for physicians to navigate sometimes. However, when it comes to standing up for doctors, there aren't many organizations that will do it. And when it comes to taking on the licensing boards, state regulatory bodies, or hospitals the only groups that have doctors' backs are the professional groups. Dr. Edison made the point that it is important to find your niche in organized medicine and run with it to help foster relationships with other physicians and learn more about the state of medicine and different ways to practice.  

Dr. Graham is the most frequent guest on the Paradocs Podcast and has appeared 5 previous times to discuss COVID (they can be found here, here, here, here, and here). Today, we talk a lot of COVID but also what it takes to retire amidst a pandemic. Do you need extra financial security during these times? What strategies work best? But mostly, we discuss Graham's optimistic feeling on where we are with the pandemic. The Pandemic is EndingDr. Graham's very optimistic that we are in the final stages of the pandemic. Both from a scientific, social, and political aspect. Scientifically, we are closely approaching the point where nearly everyone in America has been infected or acquired immunity to COVID from vaccination., This will significantly reduce the chances of mortality and move future infections to less severe. Socially and politically we are definitely seeing a shift away from shaming and hysterical calls for zero-COVID towards a more rational approach of accepting the virus' endemicity and learning to live with its presence without extreme mitigation measures. There also seems to be a real reckoning that most of what we did to prevent transmission was largely ineffective even within the ruling class. This is an important point that makes it less likely that these measures will be broadly pushed in the future. Of course, there are still further calls to now push vaccine passports and mandates but the utility of them is crumbling as we see that vaccination is hardly effective at preventing the spread of the virus. Pushes to continue mask mandates except to N95s are present in some communities (especially schools) has occurred but are being met with even more hostility from the lay public. One Way Masking is Now PossibleAs for N95s, it is clear that they are fairly protective for individuals and all other masks have limited utility. This means that if you are an individual who wants extra protection from others, you can simply don the N95 yourself. This also means, that others can operate in their lives in a pretty normal capacity without worrying about others. Since vaccinations and boosters are widely available, anyone can get the protection they want without having to worry about others and what their 'status' is. This is a huge leap forward and Graham argues is the way forward with schools and businesses as it allows those who want extra protection to protect themselves and those who choose not to to live a fairly normal life. It is probably the only politically feasible path forward for our schools and everyday life. Paxlovid is a Game ChangerFinally, Dr. Graham spoke a little in that he is more optimistic because Paxlovid, the novel protease inhibitor, is now approved and has had amazing therapeutic results for those at risk of serious complications with COVID. It also may serve as a platform or basis for future therapeutics in other respiratory viruses. Yet another reason to be optimistic on the future of the pandemic. You can listen to my latest discussion with Dr. Monica Gandhi to get her explanation of Paxlovid in episode 154.  

(The following is a speech I would give if I were allowed to replace the current head of the Presidential task force on COVID-19, Dr. Anthony Fauci. We have had a huge loss of trust in our public health institutions and a change must be made. This is the speech someone needs to make as they replace the current regime which has had a run through two presidential administrations.) My fellow Americans, it is a great honor to receive this appointment to head the US task force on COVID-19. I want you to realize that I approach this position with great humility recognizing that I can never have enough knowledge and must rely on others to gather the most complete picture on this virus. The fact that this is a new pathogen means that our knowledge is ever-evolving and we must be nimble in our course of action.  It has been a long and dark 22 months that we have been dealing with this pandemic. SARS-CoV-2, the virus that causes COVID-19, has killed hundreds of thousands of Americans and millions world wide. Make no mistake, this virus can be deadly. Unfortunately, throughout the pandemic's response, the American people's trust in public health, modern medicine, and government authorities has eroded significantly. Large swaths of our population no longer trust voices whom they deemed trustworthy just two years ago. This is mostly the fault of those in charge of public health and I seek to reestablish that trust. Of course, regaining lost trust is not easy. It requires those who were in authority to accept their missteps. It requires a whole profession to admit it was wrong.....

Whether you are in medicine or not, you are affected by the board certification and board recertification process. The certification and recertification process is not only expensive but also stressful contributing to burnout with physicians. After completing a specialty residency training, candidates for board certification have to jump through a number of tests to become board certified. These include a written exam and then possibly other components like oral exam, case review or something else. That something else is the subject for today's show - the Objective Structural Clinical Examination (OSCE). What is the OSCE? The OSCE is a new addition to the board certification process by the American Board of Anesthesiology whereby the trainees are subjected to various tests with 'standardized actors' to see how they can perform various personal skills like informed consent, canceling cases with surgeons, etc. This type of extremely subjective exam (despite the title) is ripe for interpretation that puts residents at the whim of cultural, personal, and acting disadvantages. The further question would be does this actually add anything to the skills of the physician? What do Residents (And Program Directors) Think of OSCE? The study conducted by Dr. Goudra looked at what residents thought of the value of OSCE was not good. In fact, 90% felt that it was a useless component that provided no benefit to determining whether someone was a good physician or better clinician. A previous study conducted by the ABA actually found that a majority of program directors also thought the exam was not worthwhile - yet it was implemented and still exists. This is about as good an example of the specialty boards' complete lack of accountability and focus on revenue. We've talked about all their problems with recertification here, here, and here.

Throughout the pandemic that has raged over the past two years, the press and public have leaned heavily on experts on navigating our way through uncertainty. The most prominent member of this class of public health experts is Dr. Anthony Fauci who is essentially the face of the pandemic response and sets policy used by most state, county, and local public health officials. Unfortunately, through a number of missteps and poor communication techniques, the trust in Dr. Fauci and public health in general have suffered tremendously this year. How Mistrust Develops Dr. Pomerantz points out that the loss of trust in public authorities is multifactorial and influenced by things like over reassuring the public, panicking and overreacting, flubbing the rationale for lockdowns, abandoning the flatten the curve plan, and insisting that public health be in charge of many aspects of the pandemic response. All of these points were areas where the public health authorities made mistakes leading to a continued erosion of trust in their abilities, motivations, and perception of expertise. Can We Rebuild Lost Trust in Public Institutions? Losing trust in public health, or the health system in general, is not one that should be viewed lightly. It can have profound long lasting effects. This is exhibited by the research from Dr. Sara Lowes (from episode 120) where she found distrust towards modern medicine generations after unconsented medical experimentation in parts of previous colonial France (Congo). What is amazing is the passing down of distrust towards medical authorities for years despite obvious advances in medicine and ethics. Unfortunately, for trust to be rebuilt there must be a tremendous effort put in by public health authorities. This begins with a big mea culpa for all their mistakes in messaging and getting things wrong (like mask flip flops, vaccines stopping transmission, etc.) and also the endless shaming and 'othering' of those who run contrary to their edicts. The most critical aspect of all of this is to bring back the part of the public that has been pushed out of the group by showing empathy. Unless that is done - and soon - we risk delegitimizing public health for generations.

DonorSee is a New Innovative Way to Run a Charity with Gret Glyer When Gret Glyer decided to search for meaning in his life after a short stint in corporate America by flying on a whim to Malawi, he never expected that in less than ten years he would create and run a multi-million dollar global charity. In his search for a fulfilling life, Gret found much more - an innovative way to raise money for those in need. Using Video to Fundraise Soon after arriving in Malawi - one of the poorest countries on Earth - Gret recognized the tremendous material needs for so many and he sought to find ways to help. He began by blogging and asking for help but found that it didn't resonate the way he had hoped. So on a whim, he figured he would harness the power of video and document those in need and then follow up after people had provided the financial support. He was struck by how capturing the need and success in video brought people the personal connection they rarely got with traditional charitable organizations was so powerful. Later, he harnessed the powerful draw of video to launch an incredibly ambitious project to build a self-sustaining all girls high school - in 12 weeks. Building a School Prior to crowdfunding for the school, all of the projects Gret had done were small in their scope. He had never embarked upon a project this ambitious He would need to raise a little over $100,000 in just twelve weeks in order for the school to open in time for school that year. Perhaps the most critical steps of this project were that there was overwhelming support for the creation of the school within the village and he had a local partner who had a plan. Her plan was not just to build a school but how to fund it, staff it, and educate girls in a self-sustaining manner throughout the years. So he then embarked on a fund raising plan to document by video weekly laying out the vision and then the construction of the school as they raised the money. Through this concept Gret pulled all the donors along the way to show exactly where their money went and the progress it made. Amazingly, his efforts raised the necessary capital to complete the school and it opened that fall in 2016. To this day, the Sunshine Academy is doing great graduating girls in a country where girls almost never receive secondary education. DonorSee is Born With this proof of concept, Gret launched DonorSee a few weeks later where people anywhere in the world can donate directly to a project and then receive a video update afterwards where they are usually personally thanked by the receiver of the funds. Projects range from buying a goat, paying for simple medical expenses, building homes, and paying for education. You can either pick out individual projects or donate monthly to random projects. No matter how you choose to contribute, you receive video feedback of the impact of your donations. Relief Vs. Development An important aspect to charity is being mindful of the impact that the donations have. We must be careful to separate relief from development. Sometimes, an individual just needs relief like after a natural disaster or medical emergency. But we must be careful to not provide services and goods that result in preventing the local economy from developing properly. That is why it is so important to have people on the ground with local knowledge to vet projects and makes sure the relief allows for human flourishing and not dependence. To that end, Gret and his partners in Malawi started a very ambitious project to build a self sustaining STEM school to train the next generation of scientists, doctors, and technicians to help move Malawi into the 21st century and serve as a bright example for other African countries.

Vaccine mandates, mask mandates, boosters, and variants have been a constant source of debate and controversy with the pandemic. My guest today is Dr. Monica Gandhi, an expert in immunology and infectious disease who runs the HIV clinic at UCSF. She has been a fairly prominent voice in support of the mask and vaccine mandates in her home state of California and city of San Francisco. She returns from her visit in June where we discussed the delta variant for SARS-CoV-2 in which she guessed that it wouldn't evade the vaccine or prior infection (spoiler alert: she was right). Do Vaccine Mandates Make Sense? Dr. Gandhi is the first to point out how she has been very supportive of mandating vaccines in the general population and specifically for health care workers. She has written extensively in many local and national outlets about the case for vaccines to reduce transmission of SARS-CoV-2 and hospitalizations. However, she has begun to rethink her support for these draconian measures because of a number of reasons: It can cause a problem with mental health in those who are restricted from interacting normally with society. It erodes the public trust in public health officials and well established measures. Even when vaccinated and boosted, those individuals can still become infected and infect others limiting its value as a way to stop transmission in its tracks. The political payback for politicians who support these measures may be significant at the ballot box. Are there Good Therapeutics Coming Out? One of the more exciting developments out of the pandemic is the emergence of designer drugs for this coronavirus. The newest therapeutic drugs are protease inhibitors which can be developed with a specific virus in mind. These drugs work by blocking the ability of the virus to successfully hijack your cell's ribosomes to create more viruses. Molnupiravir has been approved by the FDA but hasn't been shown to be all that effective because it was not designed with this specific virus. However, the new drug Paxlovid has show extremely high efficacy approaching levels seen with the vaccine around 90%. The advantage of these drugs is obviously that as soon as you show signs of symptoms it can arrest the extent of the infection and prevent hospitalizations and worse outcomes. Is Omicron Worth Worrying About? Finally, the question of whether the new SARS-CoV-2 variant, Omicron, is one that should concern us was posed to Dr. Gandhi. Much like the Delta variant, she is very confident that those who have gotten an adequate immune response from vaccination or prior native infection should be well protected from serious harm. Additionally, reports out of South Africa and elsewhere have seemed to show that this variant causes a much more benign infection. She believes it is possible that this variant - if it is truly more infectious but benign - might be the world's ticket out of this awful pandemic.

What happens when you take Go Fund Me and put it into an ecosystem of likeminded folks who want to build a community to care for each other's health care expenses? You get Crowd Health which draws upon some of the concepts of crowd funding for one time health care expenses within its community. By taking people from all over the country and putting them into a community where there are expectations of caring for others, Crowd Health offers a solution to paying for health care expenses without breaking the bank. Is Crowd Health Insurance? If you've been paying attention to the US health care space for the last, well, forever, then you know that it is expensive and keeps getting more so. People stay at jobs they don't like just to keep their health care coverage which is often not very good anyway. However, for those who are self employed or with a very small business, it seems their only option is to go out onto the open ACA exchange and grab a lousy and expensive plan that hardly covers anything. Crowd Health offers an alternative to paying for health insurance. Although it definitely isn't insurance since you are asked to pay into your own bank account each month to be prepared to pay others' health expenses. There is also no guarantee that your expenses will be paid as you often have with a traditional insurance policy. However, oftentimes even with traditional insurance you don't get everything covered and have to cover up to the deductible and everything over until you hit your out of pocket maximum. And that's before considering the inflated prices paid by insurance companies. Is Crowd Health a Health Sharing Ministry? The answer to this question is more complicated. In short, yes and no. We discussed sharing ministries in my previous ventures with Samaritans and an episode with Liberty Health Share. Basically, in a sharing ministry you send your monthly 'premium' to someone in the community. If you have a health expense, you submit a claim after you pay the bill and people will then mail you checks to cover the expense. The down side of this process is that the delay to getting paid can be fairly long (months) meaning you will have to have the funds to cover the bill that might be fairly large. And people don't often have that much money sitting around in the bank. How Does Crowd Health Work? CEO Andy Schoonover describes the fairly simple mechanics of Crowd Health. You take a group of like minded people who want an alternative to the traditional way of paying for health care. Then you have them commit to contribute a small amount to run the overhead of the community which helps pay for the technology and people tasked with negotiating with local hospitals, etc. and assisting patients with their navigation through the health care space. Community members pay the first $500 of a health care event and then request the community fund the remaining amount. Each community member then has the option of helping out or not. Each member carries a social credit score determined by how often they 'help', ask for help, or shop around for less expensive health care options.

The COVID Drawdown Today we are going to discuss the COVID drawdown. Essentially, this is what must inevitably happen for us to return to lives of normalcy where we have typical interactions with others at family gatherings, sporting events, concerts, and business meetings. Unless we are prepared to radically change the way we live our lives and choose isolation (which probably has far greater physical and mental health detriments) then we have to consider how the drawdown occurs and what conditions ned to be present for it to happen. What HaS TO HAPPEN FOR THE DRAWDOWN TO OCCUR? We've talked to numerous experts who all have various opinions on how the pandemic will play out and what strategies will be needed to get to the 'other side' of the pandemic. You can find the initial conversation with Dr. Graham, immunology with Dr. Gandhi, and science ethics with Dr. Bhattacharya on the episode list at the end of this writeup. The following is a short list of what conditions need to be present to return to normal: Broad acceptance of the fact that the virus, SARS-CoV-2 which causes COVID-19, will become endemic. Recognition that the endemic virus cannot become eradicated and will absolutely infect everyone - probably multiple times. Understand that vaccination including booster shots will not significantly stop transmission of the virus but only provide protection from serious illness. Sterilizing immunity (protection from infection) for SARS-CoV-2 will be temporary whether one has had vaccination or prior natural infection. Accept that no measures to stop transmission outside of severely draconian restrictions on movement and social interaction have middling effects on the spread of the virus. We will have to be comfortable with no longer 'looking' for the virus with every respiratory illness and only test those whom we feel are at high risk or can use novel therapeutics. Public health officials, politicians, and policy makers have to accept that there is very little that can be done to 'contain' the virus. What the Drawdown Will Look Like The drawdown will look different depending on what part of life you are looking. Schools:  Most schools will continue their current policies through the end of this school year. Next year, most school systems will have returned to pre-pandemic policies of no temperature checks, mask wearing, etc. Only the most heavily unionized schools or urban will mandate extreme measures like vaccinations. This will become even harder to enforce as the majority of the country has returned to normal and we see a striking similarity of outcomes between the two ways of schooling. Universities: Already there are differing policies in place between schools and the lack of differences with outcomes will move nearly all universities to eliminate all restrictions next school year. Mask Mandates: These will disappear completely by next year in almost the entire country. The political cost for maintaining these measures will be increasingly steep and politicians will declare victory over the virus and insist that their earlier measures did their job to save lives but are no longer needed. Vaccine Mandates: Despite attempting to impose these mandates through federal fiat on transportation and for air travel - these will disappear as more and more states reject their use. Hospitals: Health care facilities will still likely be burdened with extraordinary personal protection measures like masking at all times throughout all of next year. The federal government controls this regulation and unless there is extraordinary political pressure these will continue. Perhaps the loss of workers in health care will encourage the removal of this rule but that will take longer than this year.  

  Today we are going to discuss the COVID drawdown. Essentially, this is what must inevitably happen for us to return to lives of normalcy where we have typical interactions with others at family gatherings, sporting events, concerts, and business meetings. Unless we are prepared to radically change the way we live our lives and choose isolation (which probably has far greater physical and mental health detriments) then we have to consider how the drawdown occurs and what conditions ned to be present for it to happen. What HaS TO HAPPEN FOR THE DRAWDOWN TO OCCUR? We've talked to numerous experts who all have various opinions on how the pandemic will play out and what strategies will be needed to get to the 'other side' of the pandemic. You can find the initial conversation with Dr. Graham, immunology with Dr. Gandhi, and science ethics with Dr. Bhattacharya on the episode list at the end of this writeup. The following is a short list of what conditions need to be present to return to normal: Broad acceptance of the fact that the virus, SARS-CoV-2 which causes COVID-19, will become endemic. Recognition that the endemic virus cannot become eradicated and will absolutely infect everyone - probably multiple times. Understand that vaccination including booster shots will not significantly stop transmission of the virus but only provide protection from serious illness. Sterilizing immunity (protection from infection) for SARS-CoV-2 will be temporary whether one has had vaccination or prior natural infection. Accept that no measures to stop transmission outside of severely draconian restrictions on movement and social interaction have middling effects on the spread of the virus. We will have to be comfortable with no longer 'looking' for the virus with every respiratory illness and only test those whom we feel are at high risk or can use novel therapeutics. Public health officials, politicians, and policy makers have to accept that there is very little that can be done to 'contain' the virus. What the Drawdown Will Look Like The drawdown will look different depending on what part of life you are looking. Schools:  Most schools will continue their current policies through the end of this school year. Next year, most school systems will have returned to pre-pandemic policies of no temperature checks, mask wearing, etc. Only the most heavily unionized schools or urban will mandate extreme measures like vaccinations. This will become even harder to enforce as the majority of the country has returned to normal and we see a striking similarity of outcomes between the two ways of schooling. Universities: Already there are differing policies in place between schools and the lack of differences with outcomes will move nearly all universities to eliminate all restrictions next school year. Mask Mandates: These will disappear completely by next year in almost the entire country. The political cost for maintaining these measures will be increasingly steep and politicians will declare victory over the virus and insist that their earlier measures did their job to save lives but are no longer needed. Vaccine Mandates: Despite attempting to impose these mandates through federal fiat on transportation and for air travel - these will disappear as more and more states reject their use. Hospitals: Health care facilities will still likely be burdened with extraordinary personal protection measures like masking at all times throughout all of next year. The federal government controls this regulation and unless there is extraordinary political pressure these will continue. Perhaps the loss of workers in health care will encourage the removal of this rule but that will take longer than this year.   Dr. Eric Larson is the host of the Paradocs Podcast and not a fan of many of the mandates imposed on hospital personnel. show notes Episode 152: Today's show Episode 132: Dr. Gandhi discusses why the variants for COVID should not be a concern. Episode 134: Dr. Bhattacharya explains why science is suffering so much in the current atmosphere. Episode 143: Dr. Graham and I discuss how we were so right about so much of COVID We Are Libertarians: The Paradocs is a proud partner and member of this outstanding podcast network. Top 20 Physicians Podcasts Made Simply Web Site Creations: This is the great, affordable website service that built my wife's podcast site. I cannot recommend this company more to someone looking for creating a website. Always Andy's Mom: Home of my wife, Marcy's, podcast for parents grieving or those looking to help them. YouTube for Paradocs: Here you can watch the video of my late son singing his solo on the Paradocs YouTube page. Patreon - Become a show supporter today and visit my Patreon page for extra bonus material. Every dollar raised goes towards the production and promotion of the show.    

When you run a business, one person you usually meet and hire is a health insurance broker. In theory, these brokers work with the employers to secure the best deals for health insurance to meet the company's health care objectives. However, in practice, the brokers serve as a sales force for the insurance companies who lavish them with bonuses, trips, and gifts. The seedy underbelly of the health insurance broker industry is that they are really not working to save money or get deals for their clients - the checks are written by the insurance carriers and that's who they answer to. Who do the brokers work for? You or the Carriers? I spoke to Katy Talento in episode 111 who runs a business where she unbundles health insurance for employers and helps them run an efficient and less expensive health care plan. One of the problems she saw is that insurance carriers bundle all these services and then charge a very large administrative fee to run the plan. Also, their plans rarely save you money as they build in enough profit to cover the agents who sell those plans - the brokers. That's the world that David Contorno is trying to combat with his company at ePowered Benefits. The business was founded with the intent of looking at real ways of not just unbundling but finding high quality and inexpensive ways to receive care. As Contorno said, "The only way to pay less for health care is to pay less for health care." Health Plans Are Gimmicks Through his 18 years of experience in the health insurance broker field, David points out that most of the various plans sold by insurance carriers are really just gimmicks that don't really change the cost of care. Whether it is an HMO, PPO, of some hybrid FFS plan - it ultimately just ends up being the same in failing to control costs. The reason is that the care comes from the same hospitals and with the same contracts no matter how they make the employers and employees pay with copays, deductibles, and coinsurance. Even HSAs (health savings accounts) which are held up as a way to control costs by putting the patient in charge, rarely bring about the cost control as advertised. This is primarily because even using an HSA and picking where you get your care still is within the framework of hospitals, insurance contracts, and provider networks which all have massively marked up prices. Only by leaving the insurance network entirely can one see real savings. Why Don't the Brokers Work for You? Simply put, the work that health insurance brokers do is to carry water for the insurance carriers. The carriers are the ones who pay their bonuses, provide them with expensive trips to Tahiti, and give them sales targets for selling their plans. The checks aren't written by employers but by the insurance carriers. So naturally, the brokers respond first and foremost to what the carriers want. This doesn't make them bad people but understandably their incentives are not aligned with those you'd hope. The reason most brokers don't even know they're working for the wrong people is best summarized by the quote from Upton Sinclair, "It is difficult to get a man to understand something when his salary depends on him not understanding it." David Contorno is the CEO and founder of ePowered Benefits. David spent 18 years as a traditional broker in health insurance but felt that it could be done in a better way.

  One of the scariest times for many workers is being presented with a bill for medical services. Even if they have insurance "coverage", the deductible or co-pay might be more than they can afford. For hourly workers in entry level jobs or low skilled positions, medical bankruptcy is a real fear. While barely making ends meet an additional bill for an ER visit or doctor's office stop can send you to collections and destroy your credit. Unfortunately, a lot of Americans are in this exact spot as they earn a living working these low paying jobs but have little medical security even if their employer provides them with insurance. A Plan for Those Who are Hourly Workers Just as I have recently spoken to people like David Contorno and Katy Talento who seek to make business owners more successful with their health plans by direct contracting, sometimes the employer is too small or has low hourly wages to provide health coverage that covers its employees. It's not that employers don't want to provide those benefits for its workers, but just that the packages offered by insurance carriers are too expensive or require large deductibles to make it possible for small businesses to afford. That's where Dr. David Berg and his company, Redirect Health come in to solve this problem. Redirect Health was designed specifically with small businesses in mind as it utilizes a combination of telehealth and primary care physicians to keep costs down, provide excellent preventative health, and protect workers from costly medical bills. By emphasizing primary care physicians, Redirect Health then helps find affordable alternatives to imaging, laboratories, medications, and the use of specialists to minimize the expensive components of health care. Redirect Health Has a Mutual Insurance Company Interestingly, Dr. Berg said they discovered early on that a lot of the insurance they wanted to provide for stop gap loss was costing them a fortune. By creating their own mutual insurance company, they could pool their risk and keep all the funds in house and spool it out at no gain to lower their overall costs. By having a fully transparent insurance carrier, they can offer savings that other companies are unable to provide. Additionally, Redirect Health also created their own third party administrator in order to streamline the claims process and better help them get a handle on where they can provide less expensive care. It is a really good way to understand where the opportunities are to move employees towards primary care solutions or lower costs solutions to their health care needs. Dr. David Berg is the CEO and co-founder of Redirect Health. A business dedicated to helping businesses provide high quality health care for hourly workers. show notes Episode 151: Today's show LinkedIn contact for Dr. Berg david.berg@redirecthealth.com Business Owner's Guide to Ending the Fight with Health Care: Dr. Berg's book on how to leverage health care as an advantage for your business. Redirect Health:  David Berg's company where he helps businesses provide care for their hourly workers. Episode 111: Katy Talento at All Better Health describes how she unbundles insurance. We Are Libertarians: The Paradocs is a proud partner and member of this outstanding podcast network. Top 20 Physicians Podcasts Made Simply Web Site Creations: This is the great, affordable website service that built my wife's podcast site. I cannot recommend this company more to someone looking for creating a website. Always Andy's Mom: Home of my wife, Marcy's, podcast for parents grieving or those looking to help them. YouTube for Paradocs: Here you can watch the video of my late son singing his solo on the Paradocs YouTube page. Patreon - Become a show supporter today and visit my Patreon page for extra bonus material. Every dollar raised goes towards the production and promotion of the show.    

When you run a business, one person you usually meet and hire is a health insurance broker. In theory, these brokers work with the employers to secure the best deals for health insurance to meet the company's health care objectives. However, in practice, the brokers serve as a sales force for the insurance companies who lavish them with bonuses, trips, and gifts. The seedy underbelly of the health insurance broker industry is that they are really not working to save money or get deals for their clients - the checks are written by the insurance carriers and that's who they answer to. Who do the brokers work for? You or the Carriers? I spoke to Katy Talento in episode 111 who runs a business where she unbundles health insurance for employers and helps them run an efficient and less expensive health care plan. One of the problems she saw is that insurance carriers bundle all these services and then charge a very large administrative fee to run the plan. Also, their plans rarely save you money as they build in enough profit to cover the agents who sell those plans - the brokers. That's the world that David Contorno is trying to combat with his company at ePowered Benefits. The business was founded with the intent of looking at real ways of not just unbundling but finding high quality and inexpensive ways to receive care. As Contorno said, "The only way to pay less for health care is to pay less for health care." Health Plans Are Gimmicks Through his 18 years of experience in the health insurance broker field, David points out that most of the various plans sold by insurance carriers are really just gimmicks that don't really change the cost of care. Whether it is an HMO, PPO, of some hybrid FFS plan - it ultimately just ends up being the same in failing to control costs. The reason is that the care comes from the same hospitals and with the same contracts no matter how they make the employers and employees pay with copays, deductibles, and coinsurance. Even HSAs (health savings accounts)  which are held up as a way to control costs by putting the patient in charge, rarely bring about the cost control as advertised. This is primarily because even using an HSA and picking where you get your care still is within the framework of hospitals, insurance contracts, and provider networks which all have massively marked up prices. Only by leaving the insurance network entirely can one see real savings. Why Don't the Brokers Work for You? Simply put, the work that health insurance brokers do is to carry water for the insurance carriers. The carriers are the ones who pay their bonuses, provide them with expensive trips to Tahiti, and give them sales targets for selling their plans. The checks aren't written by employers but by the insurance carriers. So naturally, the brokers respond first and foremost to what the carriers want. This doesn't make them bad people but understandably their incentives are not aligned with those you'd hope. The reason most brokers don't even know they're working for the wrong people is best summarized by the quote from Upton Sinclair, "It is difficult to get a man to understand something when his salary depends on him not understanding it." David Contorno is the CEO and founder of ePowered Benefits. David spent 18 years as a traditional broker in health insurance but felt that it could be done in a better way. show notes Episode 150: Today's show Books suggested by David Cotorno LinkedIn contact for Contorno. ePowered Benefits: David Contorno's company where he helps clients save money through finding truly less expensive care. Benefits symposium: February 6-9 conference with guest speakers like Marty Makary speaking about how to improve health care. Free Market Medical Alliance: The organization Contorno is a part of that advocates for free market solutions in health care. Episode 111: Katy Talento at All Better Health describes how she unbundles insurance. Top 20 Physicians Podcasts Made Simply Web Site Creations: This is the great, affordable website service that built my wife's podcast site. I cannot recommend this company more to someone looking for creating a website. Always Andy's Mom: Home of my wife, Marcy's, podcast for parents grieving or those looking to help them. YouTube for Paradocs: Here you can watch the video of my late son singing his solo on the Paradocs YouTube page. Patreon - Become a show supporter today and visit my Patreon page for extra bonus material. Every dollar raised goes towards the production and promotion of the show.    

  Not only has the COVID pandemic politicized our country - it has led to a lot of misinformation and a shutdown of communication. For instance, is there really asymptomatic spread of COVID? Or just pre-symptomatic and symptomatic spread? That might seem like splitting hairs but it can have a profound effect on policy for quarantining and testing. We've talked about this before on the show as well as general discussions on COVID policy which can be found here, here, and here. 12 Myths and 12 Facts About COVID-19 If there is one certainty during this confusing pandemic it is that there are plenty of myths circulating in the media and popular culture about COVID. In fact, many of the things we think we know are wrong. Public officials get them wrong. Doctors and nurses get them wrong. The CDC and FDA get them wrong. Unfortunately, once we discover the truth, often the word doesn't get out there widely enough to change behavior, regulations, or rituals. Dan Halperin points these out in his book on 12 common myths and 12 uncommon facts about COVID-19. One great example of this is the transmission of SARS-CoV-2 on surfaces. We have almost no instances of the virus transmitting in this manner and it travels almost exclusively through aerosol means. However, despite this, businesses, individuals, and regulatory agencies still act as if 'deep cleaning' and intense adherence to eliminating surface contamination will help prevent viral transmission. This is patently false but it's been over a year since we have known this and yet we are still wasting our time practicing this type of hygiene. Another example of a myth believed by many is the transfer of viral particles from asymptomatic individuals to uninfected people. There are almost no documented cases of this type of infection yet we treat asymptomatic infection almost as a common vector. It is important to note that there is pre-symptomatic spread but people who never develop any symptoms just aren't infectious. It is also true that you never know if you're about to become symptomatic but we could certainly change the way we approach close contacts if the infected person never develops any symptoms. Is the Current Environment of Scientific Debate Akin to McCarthyism? Not only has Dan Halperin written on the epidemiology of COVID but he has also weighed in on his concerns with the academic and public nature of scientific debate. He notes how one of the creators of the mRNA technology expressed some "strange views" which many did not agree with. But instead of rebutting the researcher's concerns, he was virtually eliminated from history. His contribution to the development of mRNA technology was removed from Wikipedia and he has been eliminated from all common public forums. Dr. Halperin says it feels a little like McCarthyism which happened in the 1950's over concern that the Soviet Union and communists were infiltrating American government and society. At the time, most Americans were in favor of the practice of 'blackballing' people because of the perceived threat of nuclear annihilation from our Cold War adversary. Only through the lens of time can we now look back and find the practice objectionable and he suspects the same will be the case with our current lack of public acceptance of differing opinions on COVID. Daniel Halperin is an epidemiologist and full professor at the University of North Carolina School of Public Health and the author of the book: Facing COVID without Panic: 12 common myths and 12 lesser known facts about the pandemic. show notes Episode 149: Today's show   Creeping Censorship in the Name of Public Health: Dr. Halperin's piece in the Real Clear Policy where he discusses the squelching of real discussion in science. Episode 134: Dr. Bhattacharya on the erosion of discourse in science. Episode 143: Dr. Graham and I review how were were so right about COVID back in April of 2020. Episode 146: COVID policy and what it should be summed up in 11 minutes. Top 20 Physicians Podcasts Made Simply Web Site Creations: This is the great, affordable website service that built my wife's podcast site. I cannot recommend this company more to someone looking for creating a website. Always Andy's Mom: Home of my wife, Marcy's, podcast for parents grieving or those looking to help them. YouTube for Paradocs: Here you can watch the video of my late son singing his solo on the Paradocs YouTube page. Patreon - Become a show supporter today and visit my Patreon page for extra bonus material. Every dollar raised goes towards the production and promotion of the show.    

  There are a lot of urgent care clinics all over the country. But few of them, to my knowledge, also operate as regular primary care clinics. But that is exactly what is happening today in the Houston, Texas area with the emergence of Next Level Medical. If you think about it, it makes perfect sense to leverage all the facilities needed for a primary care clinic - exam rooms, physicians, etc. and use it to deliver regular and sometimes non-urgent care. We've discussed free standing ERs before that lower the cost of care with transparency so this seems like the next logical step with urgent care. We have also discussed pediatric urgent care clinics but those never had the component of doubling as primary care. What is Urgent Care? Probably the most puzzling questions you can ask even someone who works in health care is: What is the difference between urgent care and emergency care? The answer is that it depends which is why you really need a better triage system that people (patients) can access before then head across town to either the ER or UC clinic. It's this triage that is probably the most important way to keep ER visit costs low and less frequent. This is one of the services offered by Next Level Medical to their members. Why Urgent Care Membership? At first, it seems strange that one would establish any sort of membership status with an urgent care clinic. But Next Level has made it work by basically selling it as a one stop primary care clinic. Or a primary care clinic on steroids that comes equipped with supplies for taking care of fractures, lacerations, laboratory studies, and imaging. And if you have the same staff working a regular schedule you can get physician continuity for patients making well care a very achievable goal. Employers like the flexibility as it provides the primary care for their employees with convenience since there are clinics all over town. Additionally, the clinics can care for their employees who might get injured either at home or work. This added benefit means a whole lot less in expensive ER care and probably healthier employees since their primary care is taken care of without all the copays and hidden costs that keep lots of hourly employees from staying on top of their chronic conditions. Doctors Like the Schedule Doctors looking to become employed usually have to make a lot of concessions. First in their autonomy and second in the lack of control over their schedule. The amount of work they take home or 'unpaid' time can be large at times making a forty hour a week job quickly turn into 50 or 60. This is where Next Level can offer doctors the opportunity to truly do shift work, have a regular patient panel, but not take home their work and let the sophisticated call center triage their patients overnight. Dr. Juliet Breeze is the founder and CEO of Next Level Medical which offers membership based urgent care services in the Houston, TX area. show notes Episode 146: Today's show Next Level Medical: Dr. Breeze's urgent care clinic company. jbreeze@nlucc.com - Dr. Breeze's email if you want to contact her. LinkedIn: Dr. Breeze's profile Episode 035: Free standing and fully transparent ERs is Oklahoma Episode 069: Pediatric urgent care clinics to eliminate a lot of the burden from the ERs. Top 20 Physicians Podcasts Made Simply Web Site Creations: This is the great, affordable website service that built my wife's podcast site. I cannot recommend this company more to someone looking for creating a website. Always Andy's Mom: Home of my wife, Marcy's, podcast for parents grieving or those looking to help them. YouTube for Paradocs: Here you can watch the video of my late son singing his solo on the Paradocs YouTube page. Patreon - Become a show supporter today and visit my Patreon page for extra bonus material. Every dollar raised goes towards the production and promotion of the show.    

  The COVID pandemic has brought on all sorts of changes to the way we live our lives. From wearing masks, working from home, stay at home orders, and restrictions on social interactions, the virus has caused untold disruption to the way our society functions. Although the changes COVID has brought to our schools and the lives of our school age children, it is perhaps less appreciated what changes have occurred for our infants. It is a well known fact that our environment and meaningful stimulation is necessary for normal intelligence and brain development. Infants are completely dependent on their parents to put them in environments where they can maximally interact in the world. This interaction is what spurs on their brain development and social connections to others. Early Learning My guest today was Dr. Sean Deoni at Brown University described that the first 1000 days of a child's life are some of the most critical for its brain development. Babies interact with their environment and figure out how to communicate and manipulate the physical world through exploration. The less stimulation that is present, generally, the worse their neurodevelopment outcome is. One can use the Mullen Scales of Early Learning to test infants and young children on where they are developmentally on motor and language skills. Concerning Findings - A Drop in IQ Equivalents The lab at Brown University had been collecting infant and child development testing data for over ten years. Their findings generally fell in line with what would be considered 'normal' for children at that age. But suddenly, in 2020, their lab noticed a sudden change in the scoring for children. A massive loss in development scores (which are used as a proxy for IQ) were seen in infants born during the pandemic. The losses were on the order of 22 IQ points or 1.5 standard deviations from the norm.  This was an incredible finding and one that they couldn't explain. The findings were more pronounced in those with low socioeconomic status and males. Where was the drop? One would expect that the drop in scores would be related to problems with language since we are now more frequently wearing masks. However, their findings were actually a massive drop in motor skills. This might explain why male infants were more significantly affected since early motor development seems to progress a little more in them than females What's Causing the Drop? Unfortunately, it is very hard to determine what is causing this decline in scoring for infants. The research team has been able to rule out a few factors like maternal stress or actual COVID infections. It is very probable that this is due to a general lack of physical interactions and stimulation for the infants with their parents and caregivers. Perhaps it's because of increased isolation at day care or parents working remotely at home and less capable to spending valuable time with their infants. Limitations to the Findings Whenever we get concerning findings like these we have to be sure of a few facts. Are the results corroborated/reproducible: The University of Columbia did a similar study and found the same results. However, they don't have long term validation to their testing methods so perhaps this finding is an outlier. Is this a representative sample: This study (and the one from Columbia) represent a probably skewed sample of families who live in urban areas and heavily rely on day care for their child care needs. It's possible that these findings would not be found in areas with lower levels of day care usage since parents probably don't interact that differently at home with their child. COVID restrictions: PPE, limited social interactions, and masking all varied throughout the country. It's possible that one, some, or all of these significantly affected the results of child development. Perhaps masking and limited social interactions decreased infant and toddlers' physical play. Also, maybe seeing less relatives who would physically interact with the child led to lower scores. How Permanent are these Deficits? This is the million dollar question. Can the children recover from such a huge developmental deficit. It's entirely possible that they will just reach these milestones later in life and it will have no impact on their future intellect. However, oftentimes, if one does not catch up by 2 years of age or so, one never catches up  which could put these children at a huge disadvantage in academics, athletics, and the arts. The lab will continue to follow the children but only time will tell whether they are ever able to catch up. Sean Deoni, PhD, holds a doctorate in MRI Physics and is a lead researcher at Brown University studying neurodevelopment of infants and young children. show notes Episode 147: Today's show Children Born During the Pandemic Score Lower on Cognitive Tests: Dr. Deoni's Study from Brown University Birth but not Maternal SARS CoV-2 Infection Related to Lower Developmental Scores at 6 months. - University of Columbia study referenced in the show. Baby Imaging Lab: The laboratory where Dr. Deoni works at Brown University. Legaci Long COVID Study: An opportunity for children and adults with long COVID to enroll in research. Episode 143: We were so, so, so, so right about COVID Deputy: Today's sponsor who helps you with staff scheduling. Doctor Podcast Network: The home for the Paradocs and a number of other physician based podcasts. Top 20 Physicians Podcasts Made Simply Web Site Creations: This is the great, affordable website service that built my wife's podcast site. I cannot recommend this company more to someone looking for creating a website. Always Andy's Mom: Home of my wife, Marcy's, podcast for parents grieving or those looking to help them. YouTube for Paradocs: Here you can watch the video of my late son singing his solo on the Paradocs YouTube page. Patreon - Become a show supporter today and visit my Patreon page for extra bonus material. Every dollar raised goes towards the production and promotion of the show.    

  Imagine yourself in California at a clearing in a large forest. And it's on fire. There are three groups of people standing before you. A large group is screaming and running around pointing at the fire. They're yelling that we need to do something, anything we can to stop the fire. Meanwhile, there is another group (not as large) with their backs to the fire. They are mocking and ridiculing the group running around panicking. They tell them to calm down and to stop ordering people around. They insist there isn't anything wrong at all. Of course, the largest group of people are standing between these groups and looking behind those panicking at an intact forest and behind the ones who don't notice the giant flames licking at the backs of the those ridiculing the screamers. These people aren't sure what to do but in the interest of safety feel that getting away from the flames is probably the right decision. They tend to stand with the group that's worried. Obviously, this analogy describes our current situation with COVID in America. Most are not in one of the extreme camps. But we either identify with one or are left standing unsure of what to do or think. What needs to be done, and what I did with my friend Dr. David Graham in April of 2020, is to try and be reflective and better understand what it is that we are dealing with. What are the biological, historical, and medical facts or suppositions that we can make to understand this pandemic? If we return to our analogy of the forest fire, it would be best if we could somehow hop up in a hot air balloon and look down at the situation to assess what would be the best individual actions and true scope of the problem. History and biology could be used to understand the nature of fires, how they spread, what do you do to stop them, and what they are likely to do in their course. Contrary to popular opinion, we have some rough ideas about what happens in pandemics and where we will end up. And THAT is the critical fact that we have to accept - those in all camps and in between. Because if we get THAT wrong, then we get everything else wrong. The critical question we must ask is what is the endpoint for this pandemic? What is the biological consequence for SARS-CoV-2 (the virus that causes COVID-19) and its effect on humans. We have to agree on the ultimate end point in order to get our policies and strategies right for surviving the pandemic. What became obvious to us in April of last year was that this virus, despite some government efforts at the time, would become endemic. It would join the other four coronaviruses that currently cause the common cold as a virus that will circulate forever throughout the human population. It will not get eradicated. It will infect everyone probably multiple times throughout your life. This is the biological history of endemic coronaviruses. It really is the way all these common respiratory viruses operate. Rhinovirus, adenovirus, parainfluenza virus - they infect your upper respiratory tract (nose, sinus, mouth) and cause a cold because although you don't have enough antibodies to prevent infection (because they've waned over time or it's a new variant that looks different enough to evade your antibody response) you have memory T and B cells that mount a quick response after infection to prevent a systemic or lower respiratory infection (pneumonia). We know you get this immunity as a child and anyone who has kids knows small children are always sick with runny noses as they are constantly exposed to these different cold viruses which builds up their long term immunity to them when exposed later in life. The mRNA vaccines are a medical miracle and trick your body into generating an immune response. It's not magical (except the technology) and an elegant way to get your body to do the work so when it sees the real virus in the wild, it will seek it out and destroy it. But respiratory viruses often infect us before we can mount a complete immune response so you get sick and can transmit the virus. This isn't a failure - your body has done what it needs to do - and so has the virus which just wants to reproduce and move to the next host. We live in an equilibrium with these viruses, we develop immunity when we're young so if we are exposed when we're older we can prevent really bad outcomes. But we get sick and the virus continues to circulate in the world's population with different viruses coming and going. It's a sort of dance. So what does this all have to do with our wild fire? Well, we know this thing will burn until there isn't any fuel. And fuel is considered people without immunity to the virus. There are only two ways to get immunity - a vaccine or infection. Until the virus has burnt all the fuel, it will continue to burn - there is nothing we can do to stop it. We might slow it down, we might find ways of treating the fuel on fire (although most treatments for viruses are not very good), but ultimately, everyone is going to get it. What does history tell us about coronaviruses? Well, until SARS-CoV-2, we had four endemic coronaviruses that cause colds. The youngest is OC43 which researchers believe jumped from cows to humans in the late1800s. This was at the same time as the “Russian Flu” worked its way around the world so perhaps that flu was actually a coronavirus. If so, OC43 caused a lot more problems to humans back then who were older and naive to the virus according to the news reports from all over the world. But by now, we have all had multiple infections with OC43 and its variants from when we were kids to today where we usually feel terrible for a few days or maybe a week. Over time, the virus does ‘mutate' towards becoming more benign and infectious but that usually takes a long time. Anyway, it serves as a useful road map for what might happen to us in our biological dance with this new unwelcome visitor. We also know, that immunity to these respiratory viruses wanes over time. Either with natural infections or vaccines. The only way you can develop better immunity is through booster shots or infections. But what we really care about - ending up in the hospital - is focused almost entirely on the non-immune. This is a nasty bug, it affects the obese and elderly the most and it isn't going anywhere. It has definitely killed hundreds of thousands of Americans. So this gets us to the important policy considerations - if we know that it is endemic (which was obvious over a year ago) then how should we approach our public health? Obviously, the only point to slowing the spread at this time is if you could get those without any immunity (no infection and no vaccine) vaccinated to minimize the number of people clogging our hospitals. But you can't get to any vaccination rate that will stop the spread of the virus. There is no herd immunity threshold - no number of vaccinated and immune to perfectly prevent its spread. Besides the fact that our ability to slow the spread is questionable anyway, it just doesn't make a difference in the end. We are all going to get this virus. Somewhere, there's a date with you and you and you and me with this virus. Whether you've been vaccinated or not you will almost assuredly get infected. If you have some immunity through a vaccine or previous natural infection, you are much less likely to get very sick. So mandating vaccines - if we agreed that it was wise and just - wouldn't matter much to those who are vaccinated. It may slow the spread and delay the next time they're exposed but they will still get it when their immunity wanes. And again and again. If your mitigation measures worked, all you would do right now is extend the time it takes for everyone to get immunity unless you believe you can convince those who won't get immunized to get the vaccine. Even so, that only really benefits those who have chosen to not protect themselves while inconveniencing everyone else and taking away a lot of rights and simple joys of life. It's easy to see how we got here. Mission creep is not just something that happens with the military - it happens in public policy too. By believing that we could prevent people from getting infected, we have embarked on a strategy that is unwindable and with no clear end point. There is a preponderance of evidence that people can get reinfected multiple times with COVID and after vaccination. Both through research and observational data we know that infections with SARS-CoV-2 will continue to happen forever whether you are vaccinated or not, whether you have had it before and recovered, and no matter where in the world you are living. Fundamentally, we have been chasing a zero-COVID strategy in almost every aspect of our society. Obviously, vaccines are a great idea for those who are at risk. I like to point out to how getting chicken pox (Varicella) as an adult is a completely different experience for an adult than it is a child. Adults can die from chicken pox whereas kids almost never do. Also, an infection of varicella puts you at risk of getting shingles later in life which can cause pain and a host of other problems. This is one reason why we vaccinate children for chicken pox. But clearly, vaccination (since we know it won't stop transmission in its tracks no matter how high the rate is) is a strategy to keep people out of the hospital and free up hospital resources for other things like heart attacks, strokes, cancer, etc. Masks, lockdowns, testing and quarantining and any other mitigation efforts are Zero-COVID policies which are of dubious efficacy and ultimately, make no difference since we will all get infected eventually. The most sensible reason to resist vaccine mandates, masking rules, and various lockdown measures in the US at this point is because they are attempting to stop what cannot be stopped. Even 60% of the deer in Michigan have had COVID and serve as a reservoir for the virus along with mice. SARS-CoV-2 is not going anywhere so acting like you can keep it out is akin to wrapping yourself with a towel when you go swimming to stay dry. Perhaps you could argue that you are waiting until there is a childhood vaccine but that might take months or years until you get large enough numbers of kids' parents to get their kids vaccinated. What target are you looking at? It is exceedingly rare for kids to get really sick with this virus. Do these measures justify affecting their socialization and education and all the other aspects of life we take for granted? Is it worth having every child see other people as disease vectors rather than unique individuals to whom they can get to know, collaborate, play, love, and innovate? Some might argue that the infirm or immunocompromised (like those with solid organ transplants) are at risk and we should encourage vaccination to protect them. Again, the vaccinated can still spread the virus and the only thing vaccination does is frees up hospital resources (which is important). However, once people have had an infection once or maybe twice, they are much less likely to clog the hospitals. Either way, all you're doing is maybe buying some time with these extreme measures but not significantly altering the course of the pandemic in any significant way. The effect of all these mitigation measures falls hardest on our youth. They are the ones who need socialization the most. They are the ones who need interactions for learning the most. I'd argue that right now our greatest generation is our youth, (gen Z and gen alpha) as they have given up the unique experiences of high school sports, graduation, dances, gatherings, the arts - in order to protect the elderly in our society. They have given up so much and we must recognize that and always ask ourselves how much more do we need them to sacrifice to slow the spread of an inevitable disease. We have become so locked in to thinking that we need a zero-COVID strategy to slow the spread that we have forgotten that that was only supposed to last as long as it took to protect those who wanted protection. We've gotten there and now it's time to allow those who want to isolate go do it and let everyone else go about their lives. Dr. Eric Larson is the host of the Paradocs Podcast and an anesthesiologist in private practice. show notes Episode 146: Today's show Surgery Center of Oklahoma: Dr. Smith's 100% price transparent surgery center in Oklahoma City, OK. Episode 143: We were so, so, so, so right about COVID Episode 134: Dr. Jay Bhattacharya on how science is now broken Episode 132: Dr. Monica Gandhi on T cells and long term immunity Episode 128: Dr. Noorchashm on immunity from prior infections to SARS-CoV-2 Episode 127: Independence Day from COVID Locum Story: Today's sponsor who helps you find locum work as a doc. Doctor Podcast Network: The home for the Paradocs and a number of other physician based podcasts. Top 20 Physicians Podcasts Made Simply Web Site Creations: This is the great, affordable website service that built my wife's podcast site. I cannot recommend this company more to someone looking for creating a website. Always Andy's Mom: Home of my wife, Marcy's, podcast for parents grieving or those looking to help them. YouTube for Paradocs: Here you can watch the video of my late son singing his solo on the Paradocs YouTube page. Patreon - Become a show supporter today and visit my Patreon page for extra bonus material. Every dollar raised goes towards the production and promotion of the show.    

  A lot has happened since we last met with Dr. Keith Smith from the Surgery Center of Oklahoma back in 2018. Back then, we talked about how he brought the radical notion of full price transparency to the surgery space in 2009 all without taking any government payers. We also spoke about how the system was rigged to enrich the hospital systems, insurance carriers, and PBMs (what's new right?). So what's happened since then and how has the center done with the pandemic? Is the Surgery Center of Oklahoma Thriving or Just Surviving? Not surprisingly, Dr. Smith says that the center is doing just fine and has increased its market share from other states. Additionally, the international community from Canada is now being allowed to come back into the US for their surgeries which are more backed up than ever. His surgery center is a great alternative for an increasingly backlogged health system that is strained under the COVID crush of patients. Can Other Surgery Centers Dabble in Direct Contracting? One interesting aspect to Dr. Smith and his crusade for more transparency and market forces within medicine is the development of using clearinghouses for arranging surgery. The clearinghouse is used as a quick means for posting prices anonymously and then linking the agreeable surgery center and potential payers who are either patients or employers.. This is a great way to ease into direct contracting for a lot of surgery centers that are still dealing with commercial and government contracts. What is the Future for the Free Market Medical Association? Dr. Smith says the FMMA has grown significantly over the past few years as more and more facilitators, physicians, surgical centers, and administrators gather to learn how to harness the market to increase their book of business. Now that the pandemic has caused a lot of disruption in the market people are really starting to look for fresh solutions to survive and the FMMA feels like it has just what they need. Anyone can sign up and their next conference in in April 2022. Dr. Keith Smith is the co-founder of the Surgery Center of Oklahoma which has 100% price transparency which opened its doors in 1997. He also founded the Free Market Medical Association which works to promote the free market in all health care transactions. show notes Episode 145: Today's show Surgery Center of Oklahoma: Dr. Smith's 100% price transparent surgery center in Oklahoma City, OK. Free Market Medical Alliance: The organization that Dr. Smith helped co-found to encourage using the free market in more US health care transactions. @SurgeryCenterOK: Twitter for the Surgery Center of Oklahoma LinkedIn for Keith Smith, MD Atlas Billing Company: The company that helps link employers with surgery centers without posting all their prices openly to allow some direct contracting. Episode 012: Dr. Keith Smith on a fully transparent pricing system for surgery. Deputy: Today's sponsor who helps you with your employee scheduling and so much more. Doctor Podcast Network: The home for the Paradocs and a number of other physician based podcasts. Top 20 Physicians Podcasts Made Simply Web Site Creations: This is the great, affordable website service that built my wife's podcast site. I cannot recommend this company more to someone looking for creating a website. Always Andy's Mom: Home of my wife, Marcy's, podcast for parents grieving or those looking to help them. YouTube for Paradocs: Here you can watch the video of my late son singing his solo on the Paradocs YouTube page. Patreon - Become a show supporter today and visit my Patreon page for extra bonus material. Every dollar raised goes towards the production and promotion of the show.    

  When I began this podcast in the Spring of 2018, there were a lot of things I felt needed to be said about the US Health Care system. Foremost among them was the problems with the third party payment system (using both commercial and government insurance to make most of the payments for services). Also, the system was becoming more and more consolidated and the power of those extracting that wealth continued to expand. It was a pretty depressing outlook for patients and doctors. However, most things aren't so black and white. While the regulatory capture of medicine is certainly a concern and no friend for docs and patients, there is a new movement that has sprung up in response to it. As my guest Ron Barshop says, it is leaderless, decentralized, and growing exponentially despite the powers that be. he loosely calls it direct contracting which is a way of bypassing the usual middlemen and gatekeepers in health care. It includes direct primary care (which we've discussed many times on the show here, here, here, and here) but is so much more. How big is the Direct Contracting Movement? Ron Barshop, host of the Primary Care Cures podcast, describes the direct contracting movement broadly. It involves millions of patients who are employees at small, medium, and large corporations. He estimates that direct contracting for health services comprises maybe 10% of the US population or about 30 million. But it is hard to get an exact count because it depends on your definition of direct contracting. Sometimes, just negotiating with a separate pharmacy benefits manager (PBM) or laboratory is what is done by a company. Some, however, have gone all in and are putting their employees in direct primary care offices or virtual services and contracting separately for nearly every contact their employees have in the health care environment. What is Direct Contracting for Health Services? The best way to describe direct contracting for health services is by looking at the financial transaction. If it is between the employer and the facility or person providing the care then is is direct contracting. If you are using a middleman or intermediary like an insurance company to make the payment, then it is probably not direct contracting. This isn't always the cleanest definition but it is a good starting point. Right now, large employers are finding millions of dollars in savings by directly negotiating with hospitals, surgery centers, imaging centers, laboratories, pharmacies, and primary care physicians. They self fund their health care needs for employees and usually save money and provide better services because of the incredible amount of waste spent on administrators within the typical health plan. How does Direct contracting Save Health Care? Simply put, by direct contracting and eliminating a lot of the middle men who provide no value (but plenty of expense) to health care billions or maybe even trillions of dollars can be reinvested into employees pockets. Also, by pushing for an improved model of primary care and urgent care, direct contracting has the potential to keep people healthier too. It is truly a triple win of lower costs, happier providers of care (not dealing with refusals to pay by third parties), and improved health. The beauty of this movement is that it does not reside within any particular political ideology or camp and does not really require any legislation to occur. It is happening organically and is a quiet revolution that most still don't see. Ron Barshop is the host of the Primary Care Cures podcast. He has been on a personal detective hunt on how to fix the US health care system and discovered that it is fixing itself through direct contracting. show notes Episode 144: Today's show Primary Care Cures: Ron Barshop's excellent podcast where he interviews disruptors, innovators, and thought leaders in the transforming health care in America. LinkedIn for Ron Barshop Episode 002: Dr. Amat on why she chose to become a direct primary care doctor Episode 067: Dr. Josh Umbehr on DPC Episode 049: Dr. Keith Smith and fully transparent pricing for surgery centers. Episode 037: Rheumatologist, Dr. Ellen McKnight, describes her venture into direct contracting as a specialist Episode 093: Zach Zeller of Scriptco talks about his direct warehouse membership pricing for generic pharmaceuticals. @FIPhysician: Twitter for Dr. Graham Deputy: Today's sponsor who helps you with your employee scheduling and so much more. Doctor Podcast Network: The home for the Paradocs and a number of other physician based podcasts. Top 20 Physicians Podcasts Made Simply Web Site Creations: This is the great, affordable website service that built my wife's podcast site. I cannot recommend this company more to someone looking for creating a website. Always Andy's Mom: Home of my wife, Marcy's, podcast for parents grieving or those looking to help them. YouTube for Paradocs: Here you can watch the video of my late son singing his solo on the Paradocs YouTube page. Patreon - Become a show supporter today and visit my Patreon page for extra bonus material. Every dollar raised goes towards the production and promotion of the show.    

  In April, 2020, serendipitously, my high school classmate reached out to me after one of my podcast episodes where I was talking about mask usage. I was incorrect in one of my assumptions with the use of masks and the spread of particles which he pointed out. I then read his blog post about COVID and how it pertained to his home state of Montana and recognized that the way he looked at the pandemic was completely different than most. He came on the show for episode 086 and with today's episode will have been on five times. The perspective Dr. Graham brings to COVID is one with a clear insight about where we will end up. And if you know where you are going, it is much easier to figure out the best way to get there. COVID Is Endemic The greatest insight we spoke about way back at the beginning of this pandemic was that this virus, SARS-CoV-2, would become endemic. There was no chance of eradicating it no matter what type of vaccine was developed. The virus would be ubiquitous throughout the world with individuals always having a risk of exposure and infection. There would be no place to run or hide from the virus. And now we have animal reservoirs (animals that can become infected and spread the virus to other animals or humans) which means that even if you miraculously eliminated the virus from every human on the planet, it would pop up again as soon as it found new people who don't have immunity are born or their immunity wanes. How Do We Approach Endemic Viruses Differently? Endemicity is the key point to our discussion and one which has broad reaching policy implications. Your approach for controlling the spread of the virus and expectations completely change your strategies. It is why I've personally found the strategies promoted (and currently being promoted at this writing) so frustrating. Our current strategy is pointedly directed at preventing any and all transmissions of SARS-CoV-2. Whether that is using masks, distancing, restrictions on social gatherings, vaccine mandates, travel bans, or economic lockdowns we have been attacking this viral pandemic in exactly the wrong way. For an endemic virus, we recognize that we will all get infected multiple times throughout our lifetimes. Although we develop lasting T cell immunity to coronaviruses it does not completely prevent infections. That means that people will continue to contract and spread the virus but not get terribly sick. For the vast majority of people, these reinfections will be mild not requiring hospitalization. However, just because you don't require hospitalization it still might be a miserable few days similar to when you get the flu. If You Promote Masks, Promote Ones That Work We discussed mitigation measures and the colossal failure of any country, state, or city to successfully stop the spread of COVID-19 with either masks, lockdowns, or distancing. One important point was that we ned to be honest with people and if we are going to force kids to wear masks we should at least have them use masks that have some chance of making a difference. The use of cloth masks is pointless when you have a bunch of kids in an enclosed place for long periods of time. Ultimately, even good N95s probably wouldn't work very well because the kids wouldn't have good seals on them anyway. Dr. David Graham is an infectious disease specialist and the author of the book, From Killer to Common Cold: Herd Protection and the Transitional Phase of COVID-19. He is also the author of FIPhysician.com where he is a practitioner and advocate for early financial independence and retirement. show notes Episode 143: Today's show Episode 086: Dr. Graham's first appearance Episode 096: How we transition from pandemic to endemic Episode 101: From Killer to Common Cold - We discuss Dr. Graham's book Episode 114: We're in the transitional phase right now. Financial Independence for Physicians: Dr. Graham's blog where he writes about the FIRE movement and also occasionally COVID. Vive Funds: Today's sponsor who will help you find good real estate investment opportunities. Doctor Podcast Network: The home for the Paradocs and a number of other physician based podcasts. Top 20 Physicians Podcasts Made Simply Web Site Creations: This is the great, affordable website service that built my wife's podcast site. I cannot recommend this company more to someone looking for creating a website. Always Andy's Mom: Home of my wife, Marcy's, podcast for parents grieving or those looking to help them. YouTube for Paradocs: Here you can watch the video of my late son singing his solo on the Paradocs YouTube page. Patreon - Become a show supporter today and visit my Patreon page for extra bonus material. Every dollar raised goes towards the production and promotion of the show.    

  A big struggle for doctors is when they watch what goes on in the state and national legislatures and realize that there is very little knowledge of what they do, how they practice, and what they did to get where they are. There are no better examples of this failure to understand the nature of what physicians do than the debate over the Affordable Care Act (Obamacare) in 2013.That episode was what put the fire in the belly of today's author, Dr. Matt Moeller, to write his article that went viral and later led to a book. Professional Stresses There are quite a few stresses that cause lots of problems for practicing doctors Inconsistent schedules making a home life difficult to plan Multitasking by expecting doctors to do multiple things at once No downtime to get away from work where patient concerns (following up lab results, etc.) never stop even on vacation or after hours Rules and regulations The Difference Between Income and Wealth Doctors usually command a big income but don't accumulate wealth until much later in life. This puts them at a disadvantage as income is taxed much more heavily than wealth. It also makes it much harder for doctors to catch up financially to others who began working in their 20s and compounded their wealth and were not as saddled with student debt. How Do You Discourage Doctors? Keep technology complicated and makes doing their job harder. Insecurity among medical staff with their pay and jobs in perpetual jeopardy Turning them from decision makers into decision implementers (algorithm medicine) Escalating productivity expectations Increased responsibilities with decreased autonomy leading to learned helplessness Placing more barriers between physicians and their patients Solutions to What Ails Health Care Simplify costs and reimbursement and increase transparency Reform tort laws Increase the role patients have in their own health through expanding HSAs Prevent chronic illnesses Reign in the numbers and salary of administrators Dr. Matthew Moeller is a gastroenterologist in Grand Rapids, MI and the author of What It's Like to Become a Doctor that addresses the journey through medicine training. The second half of the book spends time addressing the problems in medicine and some potential solutions. show notes Episode 142: Today's show   Dear Lawmakers: This is what it's like to be a doctor today: Dr. Moeller's seminal piece that become viral and was reposted in mainstream media in 2013. Dr. Moeller's KevinMD Page Live Free Now Podcast: Hosted by John Bush Dr. Moeller on LinkedIn: LinkedIn link for Dr. Moeller. Locum Story: Today's sponsor who will help you find locum tenens opportunities. Doctor Podcast Network: The home for the Paradocs and a number of other physician based podcasts. Top 20 Physicians Podcasts Made Simply Web Site Creations: This is the great, affordable website service that built my wife's podcast site. I cannot recommend this company more to someone looking for creating a website. Always Andy's Mom: Home of my wife, Marcy's, podcast for parents grieving or those looking to help them. YouTube for Paradocs: Here you can watch the video of my late son singing his solo on the Paradocs YouTube page. Patreon - Become a show supporter today and visit my Patreon page for extra bonus material. Every dollar raised goes towards the production and promotion of the show.    

  Bitcoin was invented in 2008 by a pseudonymous programmer (or group of programmers) called Satoshi Nakamoto. It is a currency issued in a decentralized fashion using a complex mathematical equation on a block chain. Bitcoin then launched in 2009 and was adopted by very few people but it held out a promise to usher in a new way we can look at money and preserving value of our time and labor without a central bank debasing it. Bitcoin has since gone from a value of well under one penny to about $40,000 per coin in 12 years. What's Decentralized Finance? The first question to ask is what is centralized finance? Basically, this is traditional finance like using banks to acquire loans. This means that you go to a business and offer some collateral and receive your loan. Now, the advent of cryptocurrency allows for finance through a smart contract. This allows for people all over the world who has cryptocurrency access to capital no matter who they are. This is a powerful tool that can be used in areas of the world without much capital infrastructure and by businesses in the developed world too. What's a block Chain? The block chain is maybe best thought of as a sheet of paper that has every transaction of every coin on it. And with each new creation of a block, the transactions are updated, new coins are added as rewards, and all the decentralized nodes work to verify and agree with the transactions that are on the block. Then a new block is added to the previous as the process is continued forever. One can see the utility of this technology not only in verifying that the funds used to buy something were real and in someone's possession but also in other contracts or information. I spoke to Dr. Huston way back in episode 018 where she described her plan on using block chains to protect the integrity of physicians' credentials. This means they would control the information and not some health system and would keep it far more secure. You could also use the block chains for other personal information like your health which is what my guest, Brendan Hodge, in episode 014 proposed with Citizen Health. How Do You Get Started iN Cryptocurrency? As with everything, getting started is the hardest part of process. Buying, trading, and investing take a little experimentation. But if you have any technological saavy, it isn't too hard to figure out. You merely have to decide what cryptocurrency to buy (there are 8 thousand choices and counting) and then whether or not you want to be in charge of the coin itself or have someone else hold it for you. The exchanges will hold the key to the coins you purchase and allow you to take possession, hold them in their vault, or trade them with other currencies. Most of the exchanges like Coinbase, Binance, Kraken, or others allow you to convert your fiat (US Dollars) and purchase the new currencies for a fee using either your bank account or credit card. Trading and exchanging always cost some fee which varies depending on the types of coins being purchased and exchanged anywhere from a few dollars to fractions of a penny. [caption id="attachment_9951" align="alignleft" width="300"] John Bush is the lead instructor and owner of Live Free Academy where he teaches the basics of cryptocurrency. John also works with clients to help them grow their portfolios using advanced trading techniques.[/caption]       Direct Download Link show notes Episode 141d: Today's show Live Free Academy: John Bush's learning institute where you can go for classes, one on one instructions, and much more. John Bush YouTube Channel Live Free Now Podcast: Hosted by John Bush Cryptocurrency fo Beginners Seminar: This is the signup page for his upcoming seminar. Advice Media: Today's sponsor who will help your practice in its online presence. Doctor Podcast Network: The home for the Paradocs and a number of other physician based podcasts. Top 20 Physicians Podcasts Made Simply Web Site Creations: This is the great, affordable website service that built my wife's podcast site. I cannot recommend this company more to someone looking for creating a website. Always Andy's Mom: Home of my wife, Marcy's, podcast for parents grieving or those looking to help them. YouTube for Paradocs: Here you can watch the video of my late son singing his solo on the Paradocs YouTube page. Patreon - Become a show supporter today and visit my Patreon page for extra bonus material. Every dollar raised goes towards the production and promotion of the show.    

  Bitcoin was invented in 2008 by a pseudonymous programmer (or group of programmers) called Satoshi Nakamoto. It is a currency issued in a decentralized fashion using a complex mathematical equation on a block chain. Bitcoin then launched in 2009 and was adopted by very few people but it held out a promise to usher in a new way we can look at money and preserving value of our time and labor without a central bank debasing it. Bitcoin has since gone from a value of well under one penny to about $40,000 per coin in 12 years. What's a Cryptocurrency? My guest today is John Bush, a cryptocurrency advocate and owner of the consulting/teaching institute Live Free Academy. He has been an advocate of bitcoin since 2013 where he gained some prominence attempting to travel around the country with his family using only bitcoins to buy what they needed. Since, he has been a podcaster and teacher for those who want to use bitcoin and other cryptocurrencies to improve their lives. He says all cryptocurrencies, like bitcoin, are basically computer programs that either require computers to solve complicated mathematical equations to verify all the transactions of the block. For their reward, these computers (or miners) are rewarded with newly minted coins. Likewise, with millions of computers attempting to solve this equation, there are a lot of computers that are verifying that all the transactions on the chain were legitimate and the integrity of the chain is preserved. What's a block Chain? The block chain is maybe best thought of as a sheet of paper that has every transaction of every coin on it. And with each new creation of a block, the transactions are updated, new coins are added as rewards, and all the decentralized nodes work to verify and agree with the transactions that are on the block. Then a new block is added to the previous as the process is continued forever. One can see the utility of this technology not only in verifying that the funds used to buy something were real and in someone's possession but also in other contracts or information. I spoke to Dr. Huston way back in episode 018 where she described her plan on using block chains to protect the integrity of physicians' credentials. This means they would control the information and not some health system and would keep it far more secure. You could also use the block chains for other personal information like your health which is what my guest, Brendan Hodge, in episode 014 proposed with Citizen Health. How Do You Get Started iN Cryptocurrency? As with everything, getting started is the hardest part of process. Buying, trading, and investing take a little experimentation. But if you have any technological saavy, it isn't too hard to figure out. You merely have to decide what cryptocurrency to buy (there are 8 thousand choices and counting) and then whether or not you want to be in charge of the coin itself or have someone else hold it for you. The exchanges will hold the key to the coins you purchase and allow you to take possession, hold them in their vault, or trade them with other currencies. Most of the exchanges like Coinbase, Binance, Kraken, or others allow you to convert your fiat (US Dollars) and purchase the new currencies for a fee using either your bank account or credit card. Trading and exchanging always cost some fee which varies depending on the types of coins being purchased and exchanged anywhere from a few dollars to fractions of a penny. Why Should You Purchase Cryptocurrency? The big question, is why buy this currency which seems to have so much volatility? John Bush thinks it is wise to be invested in crypto for a couple of reasons: Our fiat dollars/euros/yuan are being continually inflated away to lose their value. Many cryptocurrencies, like bitcoin, are very limited in their creation and can hold their value over time much better. The world is moving more and more to online and digital currencies will be more commonplace. There are a lot of other uses like decentralized finance (which we will discuss in episode 141) which are available if you have cryptocurrency to use as collateral. It is a way for the unbanked to have access to capital in many parts of the world opening paths to financial freedom. John Bush is the lead instructor and owner of Live Free Academy where he teaches the basics of cryptocurrency. John also works with clients to help them grow their portfolios using advanced trading techniques. show notes Episode 140: Today's show Live Free Academy: John Bush's learning institute where you can go for classes, one on one instructions, and much more. John Bush YouTube Channel Live Free Now Podcast: Hosted by John Bush Cryptocurrency fo Beginners Seminar: This is the signup page for his upcoming seminar. Advice Media: Today's sponsor who will help your practice in its online presence. Doctor Podcast Network: The home for the Paradocs and a number of other physician based podcasts. Top 20 Physicians Podcasts Made Simply Web Site Creations: This is the great, affordable website service that built my wife's podcast site. I cannot recommend this company more to someone looking for creating a website. Always Andy's Mom: Home of my wife, Marcy's, podcast for parents grieving or those looking to help them. YouTube for Paradocs: Here you can watch the video of my late son singing his solo on the Paradocs YouTube page. Patreon - Become a show supporter today and visit my Patreon page for extra bonus material. Every dollar raised goes towards the production and promotion of the show.    

  Today we're going to wade into the uncomfortable land of mandatory vaccinations for COVID. You're already seeing these spring up in hospital systems, federal work forces, and universities.There's a lot to understand with these and I only offer my own perspective while hopefully acknowledging accurately my own biases to help you better understand the topic. We will review some science, the underlying political tension, and my conclusions. For the foundations of knowledge that you should have I'd recommend you read/listen to the following episodes: Moving from pandemic to epidemic Is myocarditis in COVID a really big problem? Understanding PCR Vitamin D and it's role in COVID The ethics of a vaccine passport Independence Day from COVID - June 1, 2021. Why we shouldn't ignore natural immunity Don't sweat the variants and explanations of how the immune system works. COVID is Real and Vaccines Work We need to start our discussion with some facts. SARS-CoV-2 is a virus that causes COVID-19. It is a potentially deadly disease that preferentially causes mortality in the elderly and frail. Young adults are relatively spared from the worst effects although on very rare occasions they can get seriously ill from COVID. For most though, COVID is somewhere along the spectrum of asymptomatic to mild/moderate disease rarely requiring hospitalization. Fortunately, children are almost entirely spared from the worst parts of the disease and rarely get very sick. Likewise, the mRNA vaccines are extremely effective at preventing people from getting severe disease requiring hospitalizations and death. That's why you see a disconnect now in many countries where even though people may get infected, they don't get severely ill.  We've Figured out a Little with Treatment We've figured out a few treatments that work like avoiding ventilators, prone positioning, early dexamethasone for hospitalized patients. Monoclonal antibodies seem to help. Most other treatments are anecdotal or unproven at this time. We Still Don't Know a lot Just as we have learned a lot about COVID, there is still a lot we do not understand. We don't know how to limit its spread outside of massively restrictive policies like those seen in communist China and the island nations of New Zealand and Australia. Rolling house arrest lockdowns and almost total bans on travel have been the only government policies which have mitigated the spread of the virus. Mask mandates, economic lockdowns, and travel restrictions have shown zero correlation with the spread of the virus. There are also a lot of confounding factors making it almost impossible to prove any specific measure works or doesn't work as we've seen the virus indiscriminately affect every state and country on a timeline of its own. Tension Between Freedom or Bodily Autonomy and the Protection of Others The current debate with the mandatory use of vaccinations centers on the tension between our freedom to do as we wish with our bodies (refuse medical care, exercise or don't exercise, etc.) and the concern that if we carry an infectious agent we could unintentionally harm others by getting them infected. This is where the debate really stands and I believe it is necessary to look at the real risk, the locations for the risk, and the costs. We can't make decisions on our policy without taking those factors into account. As I stated before in episode 127, there is no reason why any adult in the US should be at risk for COVID because they have now had months to get a vaccine if they do not already have natural immunity from an infection (est. ~30% of Americans). Therefore, it would be unreasonable to require people to go to extreme measures in order to protect those who chose not to protect themselves. If the vaccine were not very effective, then we might have a different argument but when one is vaccinated, they are almost assuredly safe from serious illness. If someone is still concerned, they always have the option of avoiding social contact  but others should not have to bow to their risk assessments. This would be more difficult if children were highly vulnerable because they are not yet allowed to get the vaccine. But despite the higher infection rates because of the newer variants, they still show no higher signs of significant disease than April of 2020. Again, the threat to children is almost negligible so those who find that level of risk too high can certainly find alternatives to getting by in life to avoid that small risk until a vaccine is out. Where is it OK to Mandate Vaccines? I definitely believe because COVID is mostly harmless to those vaccinated or who have natural immunity there is no reason to have any sort of mandatory vaccinations for most people. This means also that 'nudging' is not ok whereby the government restricts people and their ability to travel, earn a living, or leave their home. This soft house arrest or removing a means for supporting yourself financially is repugnant and should not be tolerated. That said, I do believe it is reasonable for some places to have mandatory vaccinations (or more accurately, immunity). Although it is unreasonable for those rare people who are immunocompromised to restrict the lives or most or to inject medications in their bodies against their will, it is probably reasonable for people who are most at risk to be able to safely get care when they are sick. These are places which can't be avoided by the sick and an extra level of safety is probably a reasonable expectation. SARS-CoV-2 just won't go away and the controversy keeps us fighting each other. Now some are calling for mass mandatory vaccinations. show notes Episode 139: Today's show Advice Media: Today's sponsor and a sister show on the Doctor Podcast Network hosted by Care Cloud that will give you a free assessment of your practice business. Doctor Podcast Network: The home for the Paradocs and a number of other physician based podcasts. Top 20 Physicians Podcasts Made Simply Web Site Creations: This is the great, affordable website service that built my wife's podcast site. I cannot recommend this company more to someone looking for creating a website. Always Andy's Mom: Home of my wife, Marcy's, podcast for parents grieving or those looking to help them. YouTube for Paradocs: Here you can watch the video of my late son singing his solo on the Paradocs YouTube page. Patreon - Become a show supporter today and visit my Patreon page for extra bonus material. Every dollar raised goes towards the production and promotion of the show.    

  Ask any primary care physician and they will tell you the toughest thing about helping their patients change lifestyle is that they don't have enough time or contact with the patient. Especially when it comes to weight loss control, primary care docs are stretched so thin on time that they struggle to have the impact they'd like on their patient's healthy habits or lack thereof.  Weight Loss Begins with Awareness It's no surprise that a successful weight loss program begins with awareness that you have a problem with weight and your lifestyle. Dr. Egan, says that to be successful one must stay focused on a number of things. All of these are a priority with her management style at her new practice:  Relationship with food. One must pay attention to why they are eating and to recognize healthy and unhealthy options. This is all with an awareness of how we are often left with no perfect options because we don't have the right ingredients, time, or abilities. Movement. This goes beyond just saying someone needs to exercise. The movement program must be created with the specific patient in mind and their input. Medications. Sometimes once the other parts are optimized, it is best to look at medications to supplement the rest of the weight loss program. A well designed drug regimen including hormonal treatments can be the difference between success and failure. How to Pull Off Weight in Primary Care Dr. Egan is teaming with Dr. Bitner (from episode 115)  and using an entirely new model of care to help women lose weight. Instead of trying to develop a multidisciplinary clinic through an insurance based model, they have decided to go with a membership model where they limit the number patients to allow for more time and contact with the physicians. It's similar to direct primary care but probably more accurately described as direct contracting. I suspect it will be a much more successful model for getting patients the results they want than through the traditional insurance model. Dr. Egan is an internist who is board certified in weight management and will be starting at True Women's Health in August, 2021. show notes Episode 138: Today's show True Women's Health: Dr. Egan's new practice where she will work with Dr. Bitner. True Women's Health on LinkedIn Dr. Celia Egan on LinkedIn True Women's Health on Facebook @truewomenhealth on Twitter Physician Advocacy Institute: This is organization who conducted the survey and is committed to keeping a vibrant marketplace for physicians by helping advocate for them and providing resources to aid in their practices. @PhysAdvocacy: Twitter for the Physicians Advocacy Institute. Episode 115: Dr. Bitner on leaving corporate medicine to practice OB/GYN in an innovative model. Episode 102: Dr. Fung on the advantages of intermittent fasting. Episode 107: Dr. Fung on cancer and how excessive weight puts you at increased risk for cancer. Care Cloud: Today's sponsor and a sister show on the Doctor Podcast Network hosted by Care Cloud that will give you a free assessment of your practice business. Doctor Podcast Network: The home for the Paradocs and a number of other physician based podcasts. Top 20 Physicians Podcasts Made Simply Web Site Creations: This is the great, affordable website service that built my wife's podcast site. I cannot recommend this company more to someone looking for creating a website. Always Andy's Mom: Home of my wife, Marcy's, podcast for parents grieving or those looking to help them. YouTube for Paradocs: Here you can watch the video of my late son singing his solo on the Paradocs YouTube page. Patreon - Become a show supporter today and visit my Patreon page for extra bonus material. Every dollar raised goes towards the production and promotion of the show.    

  Being an expert has a lot to do with muffins. Or rather, when I was eating a fresh muffin the other day for breakfast it certainly got me thinking about experts. You see, I eat my muffins differently than the rest of my family. They break off the top of the muffin and butter the top and then the bottom. I felt like it would be better to cut my muffin down the middle so I could eat a muffin top with every bite (since the tops are the best). Well, this brought teasing from my kids and wife. The other day, my daughter got a broken muffin so she had to eat it 'my way' by buttering it down the middle. She admitted after eating it that I was right and my way was better. We both considered ourselves experts in what we liked to eat. Who Is an Expert? The definition of what an expert is is fairly well defined but the exact qualifications is not. Being an expert is probably more a matter of degrees of knowledge and mastery than any absolute number. I am certainly more an expert in all things medical than most people, but when compared to other physicians that would sometimes not be the case.   Is the Expert Really an Expert in What We Are Discussing? The biggest problem with the use of the term expert over the last year and a half of the pandemic is that we proclaim people experts when they can't possibly be experts. No one has lived through a unique respiratory viral coronavirus pandemic such as we are having. Yet, many proclaim that they know the best treatments, mitigation measures, and modeling predictions. Certainly, some have a better foundational knowledge than others but since this is brand new there is no way anyone can be an expert in this particular disease/phenomenon. Stay Humble Ultimately, if you are in this space where you might not really be an exact expert in what is being discussed, you need to acknowledge it and accept some humility that you can't know. Also, you have to be open the possibility that you may, in fact, be completely wrong. Even experts in their own specialized field are occasionally wrong and must recognize that and be even more cautious when giving 'expert opinion' on topics in which they can't know as much. Self reflection on who an expert is and whether they might be wrong is critical. show notes Episode 137: Today's show Doctorpodcastnetwork.com/advicemedia: Advice media helps you fix your online social media engagement issues. Click now to get a free $60 amazon gift card just with a complimentary consultation. Doctor Podcast Network: The home for the Paradocs and a number of other physician based podcasts. Top 20 Physicians Podcasts Made Simply Web Site Creations: This is the great, affordable website service that built my wife's podcast site. I cannot recommend this company more to someone looking for creating a website. Always Andy's Mom: Home of my wife, Marcy's, podcast for parents grieving or those looking to help them. YouTube for Paradocs: Here you can watch the video of my late son singing his solo on the Paradocs YouTube page. Patreon - Become a show supporter today and visit my Patreon page for extra bonus material. Every dollar raised goes towards the production and promotion of the show.    

  Essentially, there are two main ways to classify physicians - independent or employed. Today's health care in the US is becoming increasingly consolidated as  health systems and corporate entities (venture capital groups, etc.) are purchasing physician practices. With the advent of the pandemic of COVID-19 and the partial and complete shutdowns in medicine over 2020, the trend of selling practices accelerated. More and more physicians are now employed by someone - either a hospital system or corporation - eclipsing 70% of all physicians. The era of independent physicians may be coming to a close if these trends don't turn around. The question we should be asking is why is this happening and should we care? What are the Trends? The Physician Advocacy Institute surveyed physicians over 2019-2020 and found that there was an acceleration of physicians selling their practices to hospitals and corporate entities. This was not unique to any specific region of the country. You can see their paper here and it is clear that this is a trend that is not going away any time soon. Over the last two years, 48,400 doctors left independent practice and moved to employed status. Nearly half of all physician practices are now hospital or corporate based leaving an ever smaller base of people who can be nimble and innovative in the health care space. It is important to point out that many I have spoken to over the past two years have left big systems and struck out on their own to be disruptors in the space like Dr. Randy Lovell, Dr. Richard Rosenfield, Dr. Diana Bitner, and others. Reasons Docs Become Employed Cash out for retirement Avoid overhead/business frustrations like meeting payroll, etc. Market swings Paying off student debt (usually ~$250,000 from med school and undergrad) Perceived stable/reliable income Increasing regulations and reporting for things like value based care. MediCare reporting and data mining. Electronic medical records Audit processes Why Docs Leaving Independent Practice is a Problem for Us All Increased health care costs Less competition Less innovation in how to deliver care Prescription drug plan restrictions (and increased costs) Worse autonomy Increased utilization of midlevel providers Stagnant pay because no risk taking Doctors are increasingly becoming casualties of bigness in medicine. Both through health systems and corporate entities like venture capital groups. show notes Episode 136: Today's show Survey on Physician Practice Trends in the US 2019-2020: This is the article we discussed regarding what's going on with physician practices. Physician Advocacy Institute: This is organization who conducted the survey and is committed to keeping a vibrant marketplace for physicians by helping advocate for them and providing resources to aid in their practices. @PhysAdvocacy: Twitter for the Physicians Advocacy Institute. Episode 088: Dr.Lovell in leaving corporate medicine to practice orthopedic hand surgery in a new way. Episode 115: Dr. Bitner on leaving corporate medicine to practice OB/GYN in an innovative model. Episode 117: Dr. Rosenfield on leaving corporate medicine to practice surgery in a more innovative way. Doctor Me First: Today's sponsor and a sister show on the Doctor Podcast Network hosted by Dr. Errin Weisman. Doctor Podcast Network: The home for the Paradocs and a number of other physician based podcasts. Top 20 Physicians Podcasts Made Simply Web Site Creations: This is the great, affordable website service that built my wife's podcast site. I cannot recommend this company more to someone looking for creating a website. Always Andy's Mom: Home of my wife, Marcy's, podcast for parents grieving or those looking to help them. YouTube for Paradocs: Here you can watch the video of my late son singing his solo on the Paradocs YouTube page. Patreon - Become a show supporter today and visit my Patreon page for extra bonus material. Every dollar raised goes towards the production and promotion of the show.    

  There has been no shortage of people or schemes to fix the US health care industry. US medicine consistently fails to deliver quality care at affordable prices and manages to irritate both doctors and patients alike. Politicians and think tanks come up with grandiose plans every day to treat what plagues the system. Likewise, big tech companies like Apple are now entering the fray and bringing their technology as solutions. Unfortunately for Apple (and its tech cousins like Amazon), the health space is extremely complicated and can't be solved simply using technology. Its attempt to "make it" flopped just as other ventures by tech companies have in the past. The common thread in all of those is the belief that they could replace doctors. Doctors Make it Work, Not Expensive A common misconception found at tech companies like Apple is that people are easy to replace with algorithms and gadgets. But humans aren't machines so you can't always predict how they will behave. Even with sophisticated devices monitoring heart rate, blood pressure, etc. that information is not useful in isolation. You must have someone who can figure out if any of the data is important based on examination, intuition, and experience that can't be found in any algorithm. Also, the companies believe that by removing the physician, they will find the cost savings they need to cut costs and deliver an equivalent service. But anyone who has been paying attention (or looked at expenses in medicine) will find that doctors are one of the smallest parts of the cost equation. They are easily surpassed by imaging, laboratories, pharmaceuticals and the biggest and baddest of them all - administrative. Middle men and the third party payor system in general are what are driving the majority of price inflation in health care. How to Really Solve the Shortage on Care - Hint: It's not getting rid of doctors My guest today is Dr. Doug Farrago, founding member of the DPC Alliance, newly retired direct primary care doctor, author of books on how to start your own DPC practice, and inventor of the knee saver for catchers and the cryo helmet for sufferers of migraines and concussions. Dr. Farrago points out the most obvious flaw in the plan from these tech companies - data is only as useful as the one applying it. Just as it wouldn't be recommended to get random batteries of tests to arrive at diagnoses, accumulating massive amounts of vital signs or rhythm data  is just as useless without the context provided. A good example is familiar to any doctor who has ever ordered a chest x-ray. When you get the reading from the radiologist, their diagnosis of the problem is dependent on the history of the patient. Maybe that fluffy infiltrate is extra fluid, or pneumonia, or blood. You need to correlate what is going on to get the most out of that film. Without a correlation, it is just a random test that may or may not be significant. The Solution? Direct Primary Care So what is the solution to the cost and quality problem facing primary care in medicine? Dr. Farrago (and many others whom I've spoken with here, here, here, and here) is direct primary care. The personal membership based relationship between a doctor and patient without insurance or any of the middle men allows for the best care. It is affordable and allows the doctor to use his or her intuition and clinical judgment based on their prior relationship with that patient and their previous  health history. That's why Dr. Farrago thinks DPC is the clearest solution to what is plaguing us - not some new piece of tech. Tech are just tools that the clinician can use - they can't replace a human touch, physical exam, and experience. Dr. Doug Farrago is a recently retired DPC physician previously of Forest Direct Primary Care. He is the writer at Authentic Medicine and DPC News. He is the author of many books on DPC and the inventor of the Cryo Helmet and knee saver for baseball catchers. show notes Episode 135: Today's show Apple Can't Even Get Primary Care Right This is the article we discussed focusing on Apple's failure getting into the primary care space. DPC News: This is a great resource for those interested in what is going on in direct primary care. A news accumulator with some original content. Authentic Medicine: Dr. Farrago's blog of 20 years where he has commented on medicine. DPC Alliance: This is an organization founded by Dr. Farrago that is committed to helping DPC doctors organize and learn from each other to become successful clinicians and business men and women. LinkedIn for Doug Farrago Episode 002: Dr. Amat describes why she went into DPC. Episode 045: Dr. Neuhofel explains what it was like starting one of the first DPC practices in the country. Episode 049: Dr. Gross describes how DPC is a cornerstone for rebuilding our health care system. Episode 067: Dr. Umbehr speaks about the resources he has created to help DPC docs be successful in their new practice model. Locum Story: Today's sponsor for the show is Locum Story and how they help doctors find locum tenens positions.s Doctor Podcast Network: The home for the Paradocs and a number of other physician based podcasts. Top 20 Physicians Podcasts Made Simply Web Site Creations: This is the great, affordable website service that built my wife's podcast site. I cannot recommend this company more to someone looking for creating a website. Always Andy's Mom: Home of my wife, Marcy's, podcast for parents grieving or those looking to help them. YouTube for Paradocs: Here you can watch the video of my late son singing his solo on the Paradocs YouTube page. Patreon - Become a show supporter today and visit my Patreon page for extra bonus material. Every dollar raised goes towards the production and promotion of the show.    

  There has been no shortage of casualties in the last year and half with the COVID pandemic. Schools have been closed, businesses shuttered, and families torn apart with different levels of concern for the virus. But one surprising victim has been science itself. The practice of scientific inquiry, discussion, and debate disappeared. Instead of science - which we can loosely define hypotheses that are then tested and either proven or disproven - is longer present when it comes to COVID. We've talked briefly about this phenomena before on the show with Dr. David Graham and also Dr. Rohin Francis. But 2020 brought about the end of serious discussions in much of the scientific and medical communities as people who chose to take unpopular views or question the mainstream opinions were removed from the public square, harassed, and even fired from their jobs. My guest, Dr. Jay Bhattacharya, has not only been willing to risk holding opinions and theories against the mainstream consensus, but he is also looking to help science return to open, honest debate. The Great Barrington Declaration One of the most publicized controversial statements on COVID in 2020, the Great Barrington Declaration, was written by three prominent epidemiologists. They were Dr. Jay Bhattacharya of Stanford, Dr. Martin Kuldorff of Harvard, and Dr. Sunetra Gupta of the UK. All of them agreed that a more prudent approach to fighting the pandemic would be to focus the majority of our resources on protecting those most vulnerable to COVID - namely, the elderly. They emphasized that the use of broad sweeping closures or mandates with a focus on disease count was the wrong strategy. Instead of focusing on infections, it would be more important to use a laser focus on protecting residents in nursing homes. This could have bein done fairly cheaply and easily with significantly less disruption to education and business. Why the Wrong Goal Led to the Wrong Policy Dr. Bhattacharya says that the key problem with public health officials' approach to the pandemic was to focus on infections (or cases) in the population rather than on how to protect those at greatest risk. Because they had the wrong objective, it led to ineffective programs like broad lockdowns and school closures which did nothing to help slow the spread the pandemic but left many seniors at greater risk to getting SARS-CoV-2 infections and dying. Also, because the policy focused on controlling all infections, not just in those most at risk, the release of the vaccine was muddled too. Instead of deploying it quickly and efficiently into nursing homes where 40% of the COVID deaths have occurred, public officials were generally aimless in its distribution handing it out to young health care workers or non-clinical personnel within health care organizations. This further put those most at risk in peril unnecessarily. Can Science Heal? Ultimately, the greatest failure in the whole response to the pandemic has been the lack of honest scientific debate and discussion. The robust challenges to dogma have been squelched leading to big policy mistakes (not including the fracturing of society along ideological lines). Public health authorities can  only issue effective decrees and statements once science has had an opportunity to come to a real consensus in which there is honest and open debate. That never happened this time and it has set the public trust towards the abilities of science back. Dr. Bhattacharya hopes to change this situation and bring back real scientific discussions. Questioning, rigorous debate, and testing are pillars of the scientific method and he seeks a way to reactivate science's roots through his organization at Collateral Global. Hopefully, we can perform an honest assessment of what was done correctly and incorrectly throughout the pandemic. The goals would be to better prepare us to handle the next pandemic that will surely happen some time in the future. Dr. Jay Bhattacharya is a professor of medicine at Stanford University and one of the co-authors of the Great Barrington Declaration. He argues for a return to real scientific debate and inquiry. show notes Episode 134: Today's show Collateral Global: This is the organization that Dr. Bhattacharya is a part of to return science back to its roots of rigorous testing and discussion. Great Barrington Declaration: The statement issued by Dr. Bhattacharya, et al regarding a more focused protection for those most vulnerable to COVID. LinkedIn for Jay Bhattacharya Episode 099: Dr. Francis discusses how most of science around COVID is garbage. Episode 114: Dr. Graham talks about how science is not serving the public well on COVID. Locum Story: Today's sponsor for the show is Locum Story and how they help doctors find locum tenens positions.s Doctor Podcast Network: The home for the Paradocs and a number of other physician based podcasts. Top 20 Physicians Podcasts Made Simply Web Site Creations: This is the great, affordable website service that built my wife's podcast site. I cannot recommend this company more to someone looking for creating a website. Always Andy's Mom: Home of my wife, Marcy's, podcast for parents grieving or those looking to help them. YouTube for Paradocs: Here you can watch the video of my late son singing his solo on the Paradocs YouTube page. Patreon - Become a show supporter today and visit my Patreon page for extra bonus material. Every dollar raised goes towards the production and promotion of the show.    

  If you want to get a doctor's blood pressure up or make her sweat, just tell her that you have a great electronic health record (EHR) to use. EHRs are the bane of a physician's life because they don't work well with your work flow, create extra work and inefficiencies, and cost a ton of money. That's why I spoke to Dr. Richard Sztramko of Hamilton, ON who is co-founder of Arya health technology company that has designed a new EHR. To this American, I found it very surprising that an innovative EHR product would ever be developed in Canada with a nationalized health care system. The secret is that Canada's health care system isn't that different than ours in many ways. You can catch other episodes where we spoke about EHRs and why we hate the ones we use here, here, and here. Canadian Docs Have Private Practices Much like the United States, the Canadian health care system is made up of private practices for generalists and specialists. They bill in a manner very similar to US doctors except that their payors are just governmental. They still have to collect billing information, diagnostic coding, visit or procedure types, and time spent with the patient. It would be very similar to if every service in our country went through with Medicare and Medicaid. Not all Canadian physicians are in private practice, many work in academic settings, like Dr. Sztramko, where they are employed and have the private non-profit hospitals employ them and provide the personnel to run their clinics and practices. This leaves the country with a non-uniform, disjointed medical system with software that doesn't communicate with each other and is often expensive to operate. The computer systems are the same as in the US in that it is becoming dominated by Cerner and Epic. Ultimately, our medical systems look very similar in their dysfunction for clinicians. What Makes a Good EHR? A good electronic health record is hard to find in the marketplace. But what constitutes qualities that make an EHR good? It maximizes your revenue capture. This is important that you get paid in a timely fashion by collecting all the coding information to get prompt payments and minimizing collection work. Improves daily workflow. A good EHR will make things more efficient from a scheduling standpoint and allow you to see more patients and get to the solution faster. Decrease time charting. The EHR should be quick and make charting even faster than it is on paper. Information should be easily accessible. Most EHRs make finding simple questions complicated. They aren't intuitive or they can only be found after multiple clicks Help your bottom line. The cost of the EHR should be easily outweighed by the increased efficiency and revenue that you bring into your practice. Does Arya Pass the Test? Not surprisingly, Dr. Sztramko feels that his new EHR product does what most do not. It is relatively inexpensive (only $300/user/month), intuitive, and actually decreases the time necessary to actually do your charting. One of the biggest benefits according to Sztramko is the fact that the program is so intuitive that training is very easy. He reported that in contrast to EPIC and Cerner training which takes days or even weeks to be a super user, Arya training is so easy that doctors usually only need an hour or just to watch the short introductory training video. Dr. Richard Sztramko is internal medicine and geriatric medicine trained and is an associate professor at McMaster University. He is the co-founder of Arya Health tech company. show notes Episode 133: Today's show Arya Health: Arya Health's website where you can learn more about their EHR product. LinkedIn for Arya Health LinkedIn for Dr. Sztramko @RichSztramko: Dr. Sztramko's twitter handle. Email for AryaHealth: info@aryaehr.com IGericare is a website that helps caregivers of loved ones with dementia. Free and teeming with information. Going from medical school to medical technology: Story in the Vancouver Tech Journal Episode 067: Dr. Umbehr and his EHR for DPC docs. Episode 028: Who doctors are and what they love and hate about medicine (guess what? it's electronic health records.) Episode 023: HIPAA and electronic records. Episode 015: Physician burnout due to things like EHRs. MR Insurance: Today's sponsor for the show is Michael Relvas who helps physicians with their insurance needs. Doctor Podcast Network: The home for the Paradocs and a number of other physician based podcasts. Top 20 Physicians Podcasts Made Simply Web Site Creations: This is the great, affordable website service that built my wife's podcast site. I cannot recommend this company more to someone looking for creating a website. Always Andy's Mom: Home of my wife, Marcy's, podcast for parents grieving or those looking to help them. YouTube for Paradocs: Here you can watch the video of my late son singing his solo on the Paradocs YouTube page. Patreon - Become a show supporter today and visit my Patreon page for extra bonus material. Every dollar raised goes towards the production and promotion of the show.    

  "Beware the variants!" scream the headlines all over the news. Now that the vaccine is available for SARS-CoV-2, we are pounded with an almost endless daily fear-filled stories about how the variants of COVID are coming and will continue to put people in the hospitals, ICUs, and funeral homes. But are the variants really that dangerous? Are there really wholesale mutations occurring in this virus that will make our natural immunity or vaccine immunity ineffective? According to my guest, Dr. Monica Gandhi of UC San Francisco medical school, the answer is a simple no. How Does Immunity work? Our discussion begins not with the variants but in talking about the basic units of our immune response - T cells and B cells. In short, B cells are the ones that make antibodies and persist for life (usually) in our lymph nodes waiting to get reactivated when the virus reappears later in our life. T cells function to clear the virus from our body and also persist long after the infection has gone. They too have life long memory to help us clear infections when the same viruses try and get us sick a second time. An important point to consider is that we expect the presence of antibodies to wane over time. That is a perfectly normal process in our bodies. That's why we have B cells and T cells which are left to provide the memory or past infections and at the ready to ramp up a quick response if a virus returns. If the antibodies never left our blood would be too thick with proteins said Dr. Gandhi. Will the Variants Evade our Immune Systems? The concern a lot of doctors, public health authorities, and elected officials have expressed is that SARS-CoV-2 is mutating. They worry that its variants will not become more infectious or dangerous and they will make the immunity gained through natural infection and vaccination ineffective. This is not something we should worry about according to Dr. Gandhi. Our immune system is designed to protect against just this very occurrence in nature. Viruses may evolve and change but SARS-CoV-2 is still the same virus. When we develop antibody defenses it is against around 100 sites on the spike protein so if a few of those change we will still have dozens of antibodies still that will work against the virus. This is why despite newer variants showing up they are turning out to be just as susceptible to our immune systems. Did the Lockdowns Work? How About the Mask Mandates? Dr. Gandhi also has an MPH in epidemiology and biostatistics and we briefly discussed the effectiveness of the various non-pharmacological interventions like the economic lockdowns and mask mandates. She takes a fairly sanguine view of these measures and feels that there isn't very good date showing that any of them were all that effective. Certainly, more research has to be done but it was clear that strict lockdowns or no lockdowns did not have a clear benefit when comparing various state policies. It that were the case, then California which has had the most stringent rules would have fared significantly better than other states instead of being right in the middle for cases, hospitalizations, and deaths. Should Children get Vaccinated? Dr. Gandhi is not sure what the best policy is for kids and getting vaccinated, however, she thinks we should all be glad that COVID rarely causes severe disease in children. What is more pressing, in her opinion, is moving the vaccines we are giving to our kids and distributing them throughout the world where the potential to prevent a lot more serious illnesses in the elderly is far greater. Equity in treatments should be near the top of our considerations right now since the benefit to children and the population at large is so small. Especially when there is an opportunity to do so much good elsewhere in the world. Transparency is Key. Finally, we spoke about the controversy with gain of function testing that has been occurring in laboratories around the world and whether that was a wise decision. The key for all these issues including public health is to be up front, honest, and transparent with the public. Every white lie or justification further erodes the public's trust with doctors and the government. One good example is that the push to get children vaccinated really has more to do with protecting adults that kids unlike a lot of childhood vaccines for viruses that affect children (whooping cough, mumps, measles, rubella, etc.). Dr. Monica Gandhi is a professor of medicine at UC San Francisco medical school and an infectious disease specializing in HIV. show notes Episode 132: Today's show @MonicaGandhi9: Dr.Gandhi's prolific twitter feed where she actively promotes T cells and provides a refreshing alternative voice to the echo chamber on COVID. No, You Probably Won't Need a Booster Shot for COVID-19: An opinion piece by Dr. Gandhi in the SF Chronicle. American Kids Can Wait: Dr. Gandhi and two other colleagues make the case for sending the vaccines we're using for our kids who are at low risk to other parts of the world where the elderly and vulnerable would have the most to gain. Episode 128: If You've Had COVID-19, Don't Get Vaccinated Episode 114: We're in the Transitional Phase of COVID-19 Now. Episode 127: COVID Independence Day Advice Media: Today's sponsor for the show on getting a better handle on your online presence for your practice. Doctor Podcast Network: The home for the Paradocs and a number of other physician based podcasts. Top 20 Physicians Podcasts Made Simply Web Site Creations: This is the great, affordable website service that built my wife's podcast site. I cannot recommend this company more to someone looking for creating a website. Always Andy's Mom: Home of my wife, Marcy's, podcast for parents grieving or those looking to help them. YouTube for Paradocs: Here you can watch the video of my late son singing his solo on the Paradocs YouTube page. Patreon - Become a show supporter today and visit my Patreon page for extra bonus material. Every dollar raised goes towards the production and promotion of the show.    

  This year, the Colorado legislature introduced a bill to radically change the way health care would be delivered in the state. HB 21-2132 was introduced this year with the hope of creating a public option health insurance for everyone in Colorado. In essence, the insurance product created by the state would set minimum standards for coverage and be available to anyone. Of course, their expectation is that they will lower health care expenses by over 10% with this plan. If this doesn't happen, the hammer comes down on everyone providing care. What Happens if it Doesn't Save Money? Not surprisingly, the legislators recognized that health care systems and people who provide care might not actually provide the care needed at the reduced rates the new insurance was offering. If that happened, then medical care wouldn't be cheaper and the plan would fail. But how would the lawmakers get doctors and physical therapists, pharmacists, chiropractors, etc to accept the low reimbursements to make the plan work? Well, not surprisingly they decided to force all the people who provide care to accept those reduced rates or lose their ability to work. They accomplish this by taking away professionals' license to practice medicine, PT, OT, etc. by claiming that it is unprofessional behavior to not accept their fee schedule. And that is where the real opposition to the bill began. What Happened to Phase 2? The threat of losing your ability to practice for anyone who accepts medical payments generated a huge amount of resistance within the state. And not just from doctors but large health care organizations, massage therapists, chiropractors, physical therapists, chiropractors, podiatrists, or basically anyone who provides any sort of medical service. Everyone was at risk of losing their ability to practice if they failed to accept the insurance or perhaps go bankrupt if they did accept the payments and they didn't cover their costs. Naturally, when insurance companies, hospitals, and medical organizations are all lobbying against the bill you have just too much money to fight as a legislator. It is easier and safer to acquiesce and amend the bill to remove all of the punitive provisions. In a moment of honesty the lawmakers have to know the plan will then fail without and provisions to force cost savings but it is easier to just pass a symbolic bill and maybe hope you get what you want later when it fails in practice. What was the Risk to Direct Primary Care Doctors? Obivously, the great risk to DPC doctors was that they already work outside the insurance system by directly contracting with their patients. So any plan that forces them to take insurance immediately removes a lot of the efficiencies they gain by running a lean office and not using billing services. Also, they operate outside the insurance system which jacks up the prices as we've discussed on numerous occasions here, here, here, and here, among others. So suddenly DPC doctors, who operate entirely outside of the system, were going to be required to jump into the third party payment system or risk losing their medical license. It was total madness and fortunately the bill was amended before some doctors had to look for work somewhere outside the state. So What's the Takeaway from this Near Miss? It's simply this, you have to pay attention to what is going on at your statehouse or have someone close to you who is paying attention to warn you when bad legislation rears its ugly head. It's probably also important to meet with your state senators and representatives to talk to them about what you do and how you practice. Maybe show them your office or explain how you care for people who are too rich to get medicaid but too poor to be able to afford their own insurance. It's always best to do this when there isn't legislation pending so they know that you exist, how you operate, and the vital service you provide for so many patients. You never know when they will need a phone call to discuss amending a bill to let you practice the way you want. Dr. Belen Amat is a direct primary care physician serving the greater Grand Rapids, MI area. She also serves as a board member on the Michigan State Medical Society.       Direct Download Link show notes Episode 131: Today's show DPC West Michigan: Dr. Amat's DPC Practice Colorado HB 21-2132: The legislation in question that seeks to create a public option for residents in Colorado. Since amended to remove the more onerous portion that stripped medical practitioners of their licenses and ability to practice. How did HB 21-2132 Change?: This is a good accounting of how the legislative process unfolded and the various political players involved. Episode 002: Dr. Amat talks about her journey away from third party payment medicine to direct primary care. Episode 105: What is the One Question You Wish You Knew Before Starting a DPC Practice? Panacea Financial: Today's sponsor for the show on banking for physicians. Doctor Podcast Network: The home for the Paradocs and a number of other physician based podcasts. Top 20 Physicians Podcasts Made Simply Web Site Creations: This is the great, affordable website service that built my wife's podcast site. I cannot recommend this company more to someone looking for creating a website. Always Andy's Mom: Home of my wife, Marcy's, podcast for parents grieving or those looking to help them. YouTube for Paradocs: Here you can watch the video of my late son singing his solo on the Paradocs YouTube page. Patreon - Become a show supporter today and visit my Patreon page for extra bonus material. Every dollar raised goes towards the production and promotion of the show.    

  Dr. Anthony Fauci has been the head of the United States National Institute of Allergy and Infectious Disease since 1984 and the presidential chief medical advisor for two presidents. His rise to prominence began in February and March of 2020 and continues to this day as he was thrust forward as the main spokesman for the US federal government in its response to the COVID-19 pandemic. Dr. Fauci served as the lead for establishing policies and recommendations at the CDC and FDA to combat the virus. What's Wrong with How Fauci Led the Response? In many ways, Dr. Fauci's failure to properly handle the pandemic response with COVID was inevitable. Men like him - according to my guest Peter Suderman of Reason.com - believe in the general infallibility of the bureaucratic process. They think that by following a mechanical paperwork process that they will come to the best, safest, and correct conclusions. These public health bureaucrats also hold a paternalistic view of the average citizen and that those citizens need their protection.  As it turns out, Dr. Fauci's hubris and mistrust of the public led him to make a lot of errors in his communications and recommendations. He outright lied at least a few times including initially saying masks didn't help in order to prevent a run on masks by the public. He later admitted that they knew all along that masks were basically useless outdoors despite insisting earlier that they were effective. He also admitted to lying about the necessary level of vaccination necessary to reach herd immunity because he didn't think people would think it was possible to achieve. He very consistently eroded the already weak trust of the public in public health authorities through those deceptions. What Errors Did the CDC Have in Its Response? The CDC had been an absolute disaster in its response to the pandemic - ostensibly the sole reason for having a CDC. Initially, the CDC blocked the use of tests for COVID that were being used elsewhere in the world. Instead, the insisted on using only their own tests which turned out to be defective and delayed any meaningful testing in the US for weeks leaving our understanding of the extent of the virus in the dark. It has also decreed many contradictory statements on the use of masks, lock downs, projections of surges, and real risks to the public. Was the FDA any Better in its Response? Sadly, the FDA has probably done even worse in its reaction to the virus. It prevented the creation of rapid home tests, commercial tests for COVID from university and private labs, mask manufacturers from converting their masks for hospital use, and the production of antiseptic by various companies like distillers. These actions undoubtedly led the failure to detect or protect millions of Americans as well as the probable death of many by preventing us from having adequate and plentiful ways to assess the virus in our communities. But worst of all is the FDA handling the vaccine rollout. Even though the vaccine got into bodies in a record time, Suderman said they didn't do it nearly as quickly as they could have. Partly by delaying the approval process by weeks or even by allowing the deployment of the virus into public before gaining full approval. They also blocked the use of challenge trials which would have probably shortened the time for vaccine rollout by two months. Imagine how many thousands of lives could have been saved had they had access to the vaccine months earlier. Why Do They Mess Up? Peter Suderman puts it very succinctly, much like my previous guest Dr. Hooman Noorchashm, the bureaucrats like Fauci don't trust average people to understand or be able to figure out how to respond to the virus on their own. The authorities rely on a "science" based top down centralized solution that carries the risk of not coming to the correct conclusion. In that scenario, a wrong process or judgement has enormous repercussions because there isn't any other way of finding a solution to the problem. Decentralized systems use a discovery process that appears messy but usually comes to a more nuanced and useful conclusion in a faster period of time. This is the fatal conceit that bureaucrats like Fauci are plagued with - trusting the public. Peter Suderman is managing editor of Reason Magazine/Reason.com and specializes in writing about health care, the federal budget, and culture. show notes Episode 130: Today's show Imperfect Dad MD Podcast: Dr. Toffle's show. Reason.com: The site for Reason magazine @petersuderman: Peter Suderman's twitter handle Reason Roundtable Podcast: The weekly news show that Peter Suderman stars on . Episode 128: Dr. Hooman Noorchashm talks about how the CDC is misdirecting who should get vaccinated. Episode 123: Why vaccine passports are a bad idea. Episode 087: The deception by our leaders on the coronavirus. locumstory.com: Today's sponsor for the show on locum tenens for physicians. Doctor Podcast Network: The home for the Paradocs and a number of other physician based podcasts. Top 20 Physicians Podcasts Made Simply Web Site Creations: This is the great, affordable website service that built my wife's podcast site. I cannot recommend this company more to someone looking for creating a website. Always Andy's Mom: Home of my wife, Marcy's, podcast for parents grieving or those looking to help them. YouTube for Paradocs: Here you can watch the video of my late son singing his solo on the Paradocs YouTube page. Patreon - Become a show supporter today and visit my Patreon page for extra bonus material. Every dollar raised goes towards the production and promotion of the show.    

  Perfection. We all strive for it. Some more maniacally than others, but we all look to be better versions of who we are. In medicine, we tend to be high achievers so, of course, we want to 'conquer' parenthood and be the best we can. But being perfect isn't any more possible in parenting any more than it is in medicine. Human relationships are messy and raising children up to be the best versions of themselves has no handbook. The push and pull of you trying to get your kids to be who you think they can and should be is often at odds with who they think they should be. What are the Keys to Being a Good Dad? Although he focuses on how to be a good dad, my guest today, Dr. Jeremy Toffle, says we can't expect that. Instead, we should focus on the six B's of parenthood Brain Body Beliefs Better Half Business Bucks To be a successful father, one needs to focus on all six of these aspects of our lives to be the best we can be. Each one is important and requires attention and work. Oh, and no matter what you can't be perfect in any of them! Let's Look at a Few of His B's - Beliefs Beliefs. We all have beliefs and thoughts about how we should raise our kids. We have values and we usually want to instill those same values into our children. But how do we do it? How do we teach our kids to work hard, get up after they've fallen, and deal with disappointment? Dr. Toffle says there are two ways this is done. One is by direct teaching. This is simply telling  the child what to think. An example would be telling your child, "we don't fight. We forgive seek forgiveness when we are wronged or wrong others." Indirect teaching of beliefs would be asking others for forgiveness in front of your children or maybe with them. They indirectly learn how 'our family' responds to things by the way you behave. What About Bucks & Business? Although these seem the same and may be related, they are not identical. Business is a reflection of how you work. How do you act when you have to go to work or what do you say about working. Are you positive or negative? The children will be affected by whether work makes you happy or frustrated as your emotions will spill into other parts of your life. (Some of these strategies we've discussed before on the show here, here, and here. Likewise, bucks is how you handle money. Are you miserly? Are you a spendthrift? Do you worry all the time about whether you have enough money? Do you gamble it all away? How you handle the bucks in your life obviously can affect everything else including your relationships with your children and spouse (or ex-spouse). Can I Be Perfect? Simply put, no you cannot. You can only react to the situation you are in which is unique to you and your family. Staying aware of how you react, what influences you have guiding your decisions, and recognizing when you have made mistakes so that you can be better in the future. Dr. Jeremy Toffle is a pediatrician in Omaha, NE and the host of the Imperfect Dad MD Podcast. show notes Episode 129: Today's show Imperfect Dad MD Podcast: Dr. Toffle's show. Dr. Noorchashm's Medium Page: This is the easiest way to find the writings of Dr. Noorchashm including his letter to the FDA and President Biden. @mdimperfect: Dr. Toffle's twitter handle. Imperfect Dad MD: Facebook link to Dr. Toffle's show. Episode 033: Dr. Leif Dahleen in the FIRE movement (Financial independence and retire early) Episode 038: Dr. Cory Fawcett in how financial decision affect physician burnout. Episode 097: Dr. Anzalone in investing in real estate.  panaceafinancial.com: Today's sponsor for the show Doctor Podcast Network: The home for the Paradocs and a number of other physician based podcasts. Top 20 Physicians Podcasts Made Simply Web Site Creations: This is the great, affordable website service that built my wife's podcast site. I cannot recommend this company more to someone looking for creating a website. Always Andy's Mom: Home of my wife, Marcy's, podcast for parents grieving or those looking to help them. YouTube for Paradocs: Here you can watch the video of my late son singing his solo on the Paradocs YouTube page. Patreon - Become a show supporter today and visit my Patreon page for extra bonus material. Every dollar raised goes towards the production and promotion of the show.