Why Your Hospital Bill Keeps Going Up (And Who's Actually Cashing The Check)

When Obamacare passed, there was a section nobody read out loud. A single provision that quietly banned the most highly trained people in healthcare from owning hospitals — the same hospitals that, across the board, were delivering better care at lower prices with happier patients. That's not a coincidence. It was on purpose.

In this conversation, I sit down with one of the sharpest minds in healthcare to pull back the curtain on what's really running American medicine. We talk about the cover story Congress was sold to ban physician ownership, why nonprofit hospitals are sitting on billions of dollars in cash while bankrupting the families next door, why the people in the suites have far less power than they want you to believe, and the single move physicians could make right now that would change the entire industry.

If you've ever wondered why care keeps getting worse and bills keep getting higher — this is the episode.

In this episode, you'll learn:

• The real reason your local "nonprofit" hospital is sitting on a fortune while sending your neighbor to collections
• The hidden contract trick that quietly rewards doctors for ordering more, not for healing more
• The one source of power every physician already has but almost none of them are using

Connect with Tiffany:

• Webiste: https://www.tiffanyryder.com/
• LinkedIn: https://www.linkedin.com/in/tiffanyryder/

Chapters:

00:39 – The Section Of Obamacare Nobody Read 02:36 – The Cover Story Sold To Congress 
03:53 – Why Nobody Has Heard About This 
05:57 – Nonprofit Hospitals And The Tax Trick 
07:59 – Why Banning Physician Ownership Makes Zero Sense 10:05 – How Physicians Are Wired To Reduce Risk 
12:48 – The Numbers Behind Physician-Owned Hospitals 
14:11 – The Stark Law Double Standard 
17:33 – The RVU Contract Trap 
19:41 – How Self-Referral Got Worse, Not Better 
21:58 – The Population Of Pittsburgh Quietly Owned 
26:55 – The Tens Of Millions Wasted On Autopilot 
29:51 – Where The Next Physician-Owned Hospitals Are Coming 
32:01 – The OB Deserts Of The Frontier West 
36:47 – We Don't Need More Money. We Need Different Money. 
38:39 – Why Hospitals Want To Become Insurance Companies 
45:14 – Advice For Medical Students And Residents 
50:13 – What All Doctors Should Unite Around 
53:11 – The Empty Suits Behind The Curtain 
58:13 – What CMS Could Fix With One Memo 
01:08:04 – Why The Medical Staff Is The Real Power 
01:11:35 – When Doctors Thrive, Patients Thrive

Transcript

SPEAKER_02 0:00

The mainstream media loves to criticize social media. And what they say is there's all this medical misinformation. But this is actually not the truth. I found out better medical literature actually in Substack and on X. When I'm on X, I'm working with the top physician, top healthcare policy people in the country. And I'm gonna give one example of what I found on Substack. When the Stewart Hospital system debacle was just starting in 2024, all of the mainstream media was really just reporting a press release that Ralph DeLore, the CEO, was putting out. All of a sudden, one day it was on Substack and it started covering the whole sordid mess. How the hospitals had to take out loans on the real estate, they stole the real estate off, then they were encumbered with these huge payments that they had to make for a mortgage, and it just brought these hospitals down. So actually, the opposite is true. We desperately need real journalists, and the mainstream media, healthcare journalists, usually don't know anything about healthcare. That's kind of the dark secret about it. And they were also under a lot of pressure to pump out lots of articles. So, what do they do? They turn to the AP wires tourists and they say, whatever they put out, we're just gonna just re-replicate this. And that's what they end up doing. So I'm excited today. We have a great guest. We have Tiffany Ryder, who is a real healthcare journalist. She understands healthcare and she brings great insights and she also can report on whatever she wants to. She doesn't have an editor saying, oh, we can't go after big pharma because they're a big advertiser. So I'm very excited about this. And as always, this podcast is for informational, educational purposes, only not medical advice. Please take the advice of a physician if you have a problem. Tiffany, welcome. Thank you so much for being on.

SPEAKER_00 1:53

Thank you so much for having me. I uh I do a lot of these things, and um, as I'm sure you do, right? And sometimes it's more comfortable than others, and sometimes you're more excited than others. And I just can't tell you. I woke up this morning, I got like four hours of sleep. I was traveling yesterday, and I said, Oh, oh, I can't wait to talk to Jim. So anyway, I'm just really, really grateful that you had me on. I'm looking forward to hanging out for a bit.

SPEAKER_02 2:18

Excellent. No, I think this is great. Could you please tell me about your medical education? Because it's fascinating. You were in Germany, and what now, what were you studying in Germany and what did that look like?

SPEAKER_00 2:29

Yeah, so um, you know, I will spare you all the long, boring details, but I was, you know, I really started my career as a professional dancer. I thought I was gonna do that for a year or two and then move on to something else. Um, but as I was in that space and doing some volunteer work with the USO, I was exposed to the hospital system and knew that medicine was sort of where I was headed. Um, but also as a professional dancer, right? You can only do that as long as your body cooperates and continues to allow you to do that. So I said, well, I'll just play this out till it's natural end and then I'll leave. And um, and then I was in Germany and uh its natural end just kept happening, right? Like I ended up dancing for 10 years. Um, but I was, you know, as I got towards the end of that career, I was like, my body was falling apart. I was exhausted, you know, doing performances and dances till, you know, the middle of the night sometimes. Like, and I said, Well, I'm gonna want to do something else. What else can I do? I like Europe. And uh, and so I was going to day school because most of our events were in the evenings. And so during the day, I would go and learn German full time. And then at night I was doing these performances. And um, and anyway, and so then when when the time came for me to retire, I actually applied to medical school at uh the university in Frankfurt. And so I was learning medicine um in a class that was designed specifically. Uh, you know, we had our own little cohort for immigrants, so for non-native German speakers, um, where we got some extra language support, but we were still expected to do all of the, you know, the calculus and the physics and the uh medicine things, pharma um pharma studies. Anyway, uh it was a great experience. So I did that for a while and was planning on being a doctor in Europe and came to the realization, which is funny because one of the things I enjoy reading on Twitter from you is uh just commentary about medical residencies and how do we solve this problem of getting more doctors into the system, but also making sure that we prioritize uh doctors who went to medical school here in America and, you know, so that they can have a residency. Um, but anyway, I became aware of that problem and realized that it was not um guaranteed for me to be able to practice in the US, especially as an American studying overseas. And that was just a risk I did not want to take. So I moved home, did some research with Hopkins uh that allowed me to get into PA school, uh, became a PA, and here I am. Without doing either.

SPEAKER_02 5:22

That is great. You know, the interesting thing, it is hard because a lot of people say, well, what if I do medical school in Europe? But the further away you get from the U.S., the further you get away from a US style curriculum. And I'm not saying we have the best curriculum, but just from a practical matter, it's really hard to transfer. And people are looking, you know, and I think in Germany, the medical school is six years after high school, and ours is eight years, and then you're and then it's just hard to do that. And I've literally, we all have. I have worked with surgical techs in the middle of the night who are from Afghanistan who were physicians at Afghanistan for decades. Yes. And I was like, what did you do in Afghanistan? Oh, I was a physician. They I was a surgeon. I was like, really? But they couldn't transfer that to over here. So it's really you know, it's a tough problem, and we definitely need to have people looking at this and solving it. And I don't think people are really that motivated to do it the right way. But I mean, there's a lot of, I mean, we we kind of lose out on a lot of great American pre-meds. Half of them don't get admitted to medical school. A lot of them are really great, which makes no sense. And then they go offshore and then they have to come back. And it's such a burden, and we desperately need them. And then now you went from PA school and then you said, I'm just gonna jump, I I'm just jumping right into the fire. I'm going right into the ER. I'm not gonna do family practice or you know, some other thing. And you would feed first.

SPEAKER_00 6:56

Yeah, I did, and that was on purpose. Um I think coming in as a second career as like a transition really gave me some perspective. Um and and what I wanted was there were a couple of things. Okay, so I was drawn to the ER because the whole reason I was drawn to medicine was because I'd grown up um in a very um poor community, in a rural community. And I saw what happened to people who had low levels of health literacy and just really didn't understand how the system worked, had never had insurance, things like that. So I was drawn to it for that reason because I felt like um having a clinician, having someone care for you who understood sort of where you came from is probably valuable. Uh, so that was one thing. But strategically, uh the other piece is, you know, when you look at being a PA, which one of the really cool things about being a PA is that you're not really locked into a specialty. And um, and I wanted somewhere where I could get a wide range of experience, right? Like to be able to see, well, what is a urological emergency? Let me learn more about OBGYN because you you you learn the foundation, but none of it's enough. And so I did want to get that generalist experience. But also, um, and I know this is something that you and I have talked about privately, it was really important to me. I was sold the line that being a PA meant that I could practice medicine as independently as was comfortable for me and the position that I was collaborating with. And I really just bought that line. Like I thought that's what I was going to school to do. I thought I'm gonna have like a best friend at work, and uh, they are going to have done more education, more training than me. And um, and we were gonna be able to collaborate on patients and talk about things, and I would be able to take some of the um, you know, the more straightforward cases, the easier load. And that when I ran into a problem, I could go to my bestie and say, Hey, like, what do we think about this? Can you kind of lay hands on this patient? And really, I thought that's how medicine worked. Um, I found out a little differently uh after I got into the work field, but I found that emergency medicine does work that way. Maybe to more, you know, to greater or lesser degrees. But um, but my experience in the emergency room was that I really was sitting next to my ER doc, you know, four feet away. And while I didn't want to bother him or her, because the hospital schedules us, schedules PAs and NPs as if we are doctors, which is really a problem for us and for the attending physician. Um, but but the attending physicians were always willing to say, yeah, man, like let's go, let's go tap that knee together. Like let's let's get it done. And so I did feel like um almost like I had more access in the ER than I did in other specialties, and that was attractive to me.

SPEAKER_02 10:14

And that does make sense because you're right there next to them. It's fast paced. And most of my career, I didn't work with nurse practitioners or PAs. And towards the end of my career, I worked nurse practitioner, and it was funny because they would say, okay, you know, it's your turn to kind of sign off on the charts. So I would read through it, and then I'd have questions. I go over to her, I'm like, Yeah, I have a question about this. And she was shocked. She's like, Oh my God. She said, you know what? Nobody really reads the charts or asks me any questions. I'm like, really? I said, well, isn't that the role? We're supposed to go through it, make sure everything's right. And then after a while, I just we really got along well. And I just said, you know, why don't you do just bring the charts over to me when the patient's still here? Keep them here, let me look at it. That way, if I have a question, we're not bringing the patient back if I think we need an additional test, or if I would want to examine the patient with you. And then it got to the point where I was like, you know, if you are examining somebody, you're like, I'm not quite sure, just grab me. I'll come over, take a look at it real time. Because in my mind, if you don't do that, you're doing a disservice to everybody. You're doing a disservice to the patient, you're doing a disservice to the PA or nurse practitioner, because then they're starting to feel uncomfortable, like, okay, no one's really watching, I'm not quite sure. And it's stressful. And that's not what you should have to be. So and my concern is I think for institutions, they look at nurse practitioners, PAs as a great way to bring money in. And you know, there's a soft encouragement for the docs to not really do that level. But I think you definitely need to do that. And as a specialist, I would always do that as well. I get called, I worked as a hospitalist for a while. I could call the ER and I could tell somebody really had no idea. And I would just sit down with them and go, hey, let's talk about a topic pregnancies or miscarriage or whatever. Here's what's important. Here's what I look at, and they're like, oh, this is great. So I try to do that because you know, and did did you have specialists do that with you? Did you run into that? Or I did.

SPEAKER_00 12:12

I did. And that was one, I mean, that was one of the best parts of working in the ER. And like I said, I I will go to war for my ER attendings. Like they are all amazing. And I've never, I've never had an attempt. I've rarely had an attending, you know, not just be on my be on my team 100% and be willing to teach me something if I'm like, dude, I just don't know how to do this. I've never done it. Like, help me out. Um, but the specialists are interesting, and I think it's just a systemic difference. You call ENT in and you say, hey, like I've got this thing going on. Can you, can you come lay hands on this patient? If they drove to the hospital, they're only here to see that patient. And I have had really great experiences with specialists that, you know, after they examine the patient, like you go with them, you go into the room, they explain all the things. And I mean, that's really where I feel like you can learn above and beyond and and and get good at your craft is by spending time with people who are just willing to sort of pour into you. And I assume, I don't know, but it is my guess that that is essentially, you know, a huge part of what you get out of residency. And it's really unfortunate that you know, we're really not in a position to get that sort of learning without inconveniencing the doctor, you know, allowing patients to wait much longer. And and obviously, you know, it's inconvenient for uh the PA or NP, who is like, you know, that time is not really built in, but it's essential. And you know, we don't know what we don't know sometimes, also. And so um, you know, it's really unfortunate the way it's in my my view been sort of corrupted to um maximize profit as opposed to maximizing creating this NP or PA who can be just a rock star member of the clinical team. And and really we're taking that away when we're taking new grads who don't know what the heck is going on, just saying, go practice as if you've been doing this for 20 years.

SPEAKER_02 14:22

No, that's definitely true. And I think just looking at the nurse practitioners that I've seen, the ones that work really well are ones that have been a nurse in a hospital, you know, for OB, they've been on OB unit for 20 years, they they know it, and then they do OB. You know, that makes sense. It's an easier transition. But for a brand new grad, and especially now there's a big push for online for the nurse practitioner programs, that's very difficult because they have trouble getting the clinical exposure that they need. And those programs don't have that built in. They're like, just go find somebody on your own. And I just feel that we have to honestly look and just say, okay, if nurse practitioners' PAs are important in the system, how do we do it correctly? And that's and I agree with that. Instead of like, this is another billing widget in addition to the physicians, and let's you know, just crank that up and maximize the billing. Now, what happened to you where you're in the ER? Sounds like you had great docs around you. You know, you're obviously very bright, very motivated, you're driven to help people, but at some point you're like, oh my gosh, this is something I can't keep doing. I I have to exit the system.

SPEAKER_00 15:36

Yeah, it um, I mean, looking back on it, it was always what was going to happen. It was, it was, there was never a chance for me to um not have like it's like the veil was already so lifted that I couldn't unsee the things that I'd seen. Um, and I think that started even just living in Europe and having started my medical education in Europe. So, you know, there were things like like mammograms is a great example because everyone gets very, very emotionally attached to how whatever they believe about mammograms, which is amusing to me. Um, but you know, when I was in school in Germany, we had a discussion in uh about mammograms, you know, we brought someone in. I believe it was like, you know, in the context of uh just the physics of of how things worked. And and I remember discussing it with uh the specialist they'd brought in, and I was like, you know, you're like, you're like basically I don't know if I can curse on here, but you were like uh disparaging this whole idea of mammograms um in favor of ultrasound. Like, why are you doing that? I'm a good American woman, and like here is our recommendations and here are the things that we say. And, you know, and he takes me through the process and he's like, look, you can believe whatever you want to believe. I challenge you to go read the studies and look at the science and decide what you think about it. Um, but he said, you know, our process is that, you know, if you have something on a mammogram that we see that we find, our next step is always going to be to do an ultrasound. So why wouldn't I just start with the ultrasound? Like we're all trained in ultrasounds. We all have ultrasounds in our offices. We use them every day. Like they use that in their as part of their annual uh well check, and and they're very comfortable with them. It's like I challenge you to come up with a good reason that that I should start in this other place that requires the woman to go to a special facility to uh undergo something that sounds scary and feels weird, and you know, it wasn't like he was anti-mammogram, right? He was just like, why would why would you do it this way? And why would that be the only way to do it? And I said, huh, that's interesting. Didn't care, you know, it wasn't on the exam, you know, whatever, and moved on. And I remember sitting in school here in the US, and you know, we start talking about mammogram and like what the what the what the recommendations are and um you know, whatever the process was. And um and I was told that exact line that he had explained, you know, the logic of was void, we'll say. And uh, and so I raised my hand and I'm like, oh, well, you know, I've heard this argument. What do you think? And um, and it was completely shut down, right? It wasn't like, well, some people believe this, but we believe that. And here's the evidence that supports that, even anecdotal. Here's the common sense that no one's done the study. There was no explanation. It was shut up, stop asking, stop asking that question. This is the rule. And I had that experience many times throughout school, right? Uh, which antibiotic you said all of these antibiotics are um good places to start for a bladder infection. How do I find out how much the antibiotics cost? How do I find out what's covered for my patient so that I can like prescribe the thing that's gonna work best for them? You know, shut up. Don't ask that question. It's your job to you know treat your patient in the best way possible, not to be their uh their accountant. Okay, well, you just said all these antibiotics are essentially equal in this particular situation. So how do I choose? You know, and so there were just tons of inconsistencies like that that I said, okay, there is more to this story. And, you know, I don't know if it's like it's financial incentives or what it is, but um, but the idea that thinking is discouraged and compliance is expected is not gonna be an occupation where I'm gonna be able to thrive, but I'm already here, so let's get through it. And that's sort of like how that how that played out.

SPEAKER_02 20:07

No, and that that's interesting. And I do agree, you always have to be a skeptic because I just I can think of many things that came in my career where they said you absolutely have to do this. And one of them was the whole pain scale. That came out of nowhere. We didn't used to have that. And then they were like, okay, doctor, and we're doctors are uh criticized for under medicating people. This is Institute of Medicine, you know, all all the mainstream folks were doing it. They said, you know, Surgeon General, we are undertreating people. Now nobody remembers that because they're like doctors cause the opioid epidemic. But there was huge pressure on physicians to up the amount of opioids and narcotics that we prescribed to patients. And you know, the the poor nurses on the floor were judged, and that was part of the whole Jaco thing, you know, the the patient satisfaction with their pain relief. We get calls all the time, you know, it's 10 out of 10 pain. And I'd say, okay, well, I'll go see the patient. And they literally, this is how long it goes, they'd be reading the paper. And I was like, okay, let me explain the whole pain scale. You know, they weren't writhing in pain, they were sitting there. I'm like, here's what this means. Oh, oh, oh, it's a two. I'm like, okay, fine. So that's usually what I ended up doing. And but there's all this pressure, but that takes time to do that. So it's easier for the doc to just say, okay, just you know, give them give them some oxycontin, whatever. Boom. That's the quick, easy thing. And I remember I got a letter from the Surgeon General, as every physician did. This was after the opioid epidemic, and saying, you've been over-prescribing, you need to dial it back. So I wrote back and I said, you know what? Actually, I didn't, because the first push you guys did, I didn't follow it because I knew it was wrong. So now I don't have to change anything. But thanks for letting me know that you've actually corrected this down. But there's many things like that. You were wrong, but it was a little snarky letter, but no, those are all great things. When you left, did you have a plan B in mind? Or did you just say, you know, I just have to change and then I have to see what happens?

SPEAKER_00 22:09

So it's interesting because I left for a very specific purpose. Um and you know, but it's all intertwined. So I ended up in the emergency room. I'm training patients, I'm seeing all the things that you can imagine, right? Like patients that are falling through the cracks, patients that should be at primary care, patients that are dying that don't need to be dying, you know, and it's um it's demoralizing, it's stressful. It was the middle of the COVID pandemic. I was uh watching things on the news, like the news was saying things that uh were not consistent with the experience I was having in the hospital. So there was a lot of that. Um but there were there were specific things that really bothered me. Again, like I, you know, I hate to always bring up my up my upbringing, but I think it was just so key in the in the way that I see the world, right? And I would, I would see these people. I always took the the patients that nobody else wanted to pick up. So if if you've never worked in an emergency room or you're not in medicine, like it's basically there's patients in the waiting room, and you know, you can sort of see a little bit of information about how sick they are. And you obviously want to prioritize the the sicker people if you can. You can see how long they've been there. Um, but we do a little bit of like talking about it too, and be like, hey, I'm gonna, I'm gonna grab this, you know, back pain. Do you want to grab this other person to just sort of negotiate and make sure we can keep the flow? And I would always take the patient that people were like, oh God, this guy again, not interested, right? Like those were my people because I just had such a big heart for people, because nobody wants to be in the emergency room. Why are you here again? Like clearly there's something that's being missed. Maybe I can help with that, right? And and it was uh it was in those patients that I think changed my perspective. So things like, you know, I remember seeing uh an 18-year-old man who had come to the emergency room with chest pain for the third time that week. And, you know, he had reflux. That's why he had chest pain. But but if you spent time talking to him, it's like, you know, what's going on? And he was basically living, you know, in a in an abusive household where there were drugs and there was a lot happening, and he was taking the um the ambulance to the emergency department because these things were happening in his home. He was freaked out. His family had told him he had a disability and couldn't work. So then now he's in a situation where he can't leave and he had no car, right? So it was like all of these social things. Or I had another patient who had a cat bite. And, you know, I was very clear that this was okay, given, you know, the status he came in in. But I said, you have to take this antibiotic. If I let you go home, like you gotta get it by tomorrow. We'd given him like uh IV antibiotics or something. Um, and you know, you've got it, you've got to get this taken care of. I called him like three days later. I'm like, how you doing, man? Uh, I'm uh I'm sweaty, I think I have a fever. My arm's the size of my leg. You know what it's like, what happened? I told you you would die if you didn't do this. And the answer to what happened was always something that wasn't medicine, right? So I wasn't catching mistakes that I'd made. I wasn't prescribing the wrong antibiotic, I wasn't going down the wrong clinical pathway. It was always some social reason or some insurance reason or what have you. And it was very demoralizing because it was like, it doesn't matter how many hours I stay, it doesn't matter how many patients I see, how many like charts I comb through. I can't actually solve this problem because that is not it is not in my purview to do. And um anyway, it was sort of it was demoralizing. I was like, what am I doing? How can I fix this? Like, where are the levers to be pulled? And someone mentioned Marty McCary's book, The Price We Pay. I don't know if you've read that. Have you read it?

SPEAKER_02 26:29

I've not read the whole thing. I've kind of you know looked at it on a cursory level.

SPEAKER_00 26:35

Yeah. Yeah. So you have so you gotta check it out.

SPEAKER_02 26:37

So I'm definitely gonna read it though, because I keep hearing about it. And I I yeah, I definitely want to do that.

SPEAKER_00 26:44

And it's definitely like stuff that you will particularly find interesting. You know, it's talking about um exactly how PBMs work, which you know, uh you and a lot of your audience, I'm sure, are very familiar with that. But it's it's told in a in a storytelling manner, but it really just pulls the cover off of like all of this corruption and misaligned incentives in the hospital system. And like as I read that book, I was like, oh wow, this is why that kid couldn't get his antibiotics from the pharmacy down the street and was supposed to go to the CBS that was a half hour away. This is why he was dying of the cat fight, right? Like, and it really was just like uncovering all of these, all of these things that are very obvious to me now, but weren't at the time. And um, and I went through that book and I highlighted all the names that were in it that Marty had had, you know, interviewed for it or had talked to. And I started, I started writing these people on LinkedIn and saying, like, is this true? Is this a real thing? Um, and having conversations with people and realizing that just the system was so broken from the outside that, like, me killing myself in the emergency room trying to save the world was never really going to do much, right? That was never really gonna um move the needle in the way that I wanted. And it just so happened that during that same time, um, I had met Dr. McCary, um, I had gotten to know uh, you know, Jay Bodichary's work, like I had formed relationships and um really done a deep dive on a lot of different people's work, trying to figure this, figure out this question of how can I be of help? And right around that time, the election happened and um and I had supported Bobby Kennedy for because he had bravely spoken out about some things that were important to me. And um, and I lost all of my friends. I lost all of my friends, like all in one fell swoop. Like one day, um my phone was just silent. And um and you know, a week later, all of these other people who I had been following and supporting were suddenly sort of in the same boat, right? We're we're getting appointed to government positions, we're in positions where I truly believed they could push back on some of the things that I'd been learning about, some of the things they'd been talking about on Twitter. Um and uh and I said, you know, I think this may be the work that can be done, right? These people are giving up their careers and they are um stepping into these new roles. And uh the mainstream media is so conflicted that it is just completely undeniable, in my opinion, uh, that there are nefarious forces and things going on and lies being told. And I said, I think this is an opportunity for me. And that's kind of how it happened. So it was like, I'm not sure that I would have left had all of those things not come together, but they all came together in the right moment. And it was clear that that was what I needed to do.

SPEAKER_02 30:18

The universe lined up, and I agree 100% with the mainstream media does have a lot of conflicts, and there's obviously things they can't write about. And you could see it in the stories. I've been reading the Wall Street Journal since the 90s, and I've seen their change, and I've seen editorial boards attack on people, which to me is the ultimate cowardice because it just it's the editorial board. There's no individual put their name on it. If you're gonna attack somebody, put your name on it for God's sakes. And you know, so that kind of gets into you're you have press credentials now, which is awesome for FDA HHS. And could you tell me how was it? What was the first big thing you went to? Was it the hormone replacement therapy announcement or what was your bigger?

SPEAKER_00 31:08

No, I don't I don't even remember at this point because I've been through.

SPEAKER_02 31:14

Because it had to be exciting to walk in the first time and say, I'm there with my press credential, I'm next to the Washington Post, New York Times, Wall Street, I'm here with them. It's gotta be pretty exciting to do that.

SPEAKER_00 31:28

It was interesting, right? It was interesting. You know, I'm like, I'm I'm combing my memory now. I think the first press conference I went to was the one on pre-authorization, actually.

SPEAKER_02 31:42

Okay, I remember that one.

SPEAKER_00 31:43

Which is particularly interesting in a discussion with you because, you know, one of the one of the examples, uh, because they had a congressman there who's an OBGYN, and one of the examples they were talking about was pre-authorization for birth-related procedures, right? They're like, well, we know this woman is pregnant, right? We know this baby's coming out.

SPEAKER_02 32:05

Exactly. And they would do that. They would say, when is she gonna deliver? We're like, I don't know. If I knew that, I'd be picking lottery numbers. I don't know. I can give you your due date, which means a general idea, and that's about it.

SPEAKER_00 32:18

You know, plus or minus a couple of weeks. At best likely, there's a bell curve or something.

SPEAKER_02 32:23

Right? Absolutely. No, that was a really good press conference, and there was a couple of interesting things there. Now, one of the most interesting things on that, there's a couple of different things. I remember that very well. Because I looked through it, it was about an hour and a half, maybe-ish, and I, you know, went went through that a couple of times. But Bobby Kennedy said, why do we even have these? Because I think he realized that they don't do the state of goal, which is improving patient care, protect the patients, because these denials, fire offs just come out, you know, just now they're generated by AI in a couple of seconds. So nobody's looking. And it's not like the insurance company is saying, okay, you're set up for a spinal fusion at P5P6, and we're going to get a world-class spine surgeon in to look at the records and see if that's about that's not what's happening. And he asked the right question. And the most interesting thing to me is where prior authorizations really started out big time was 1973 with the HMO Act, which was one of the sponsors that was his uncle, Ted Kennedy. So it's kind of an interesting circle. He was kind of closing the circle. It's like, what is it doing? So it's kind of interesting. Sometimes someone who's not in healthcare asks the right questions. And, you know, so I love that as well. There's a couple of things that were disturbing to me. One of the congressmen who's a urologist, Dr. Murphy, came out and he was kind of blaming the physicians in the beginning and saying, well, they do this because people overutilize, whatever. And I thought, okay, that's absolutely not why the prior authorizations are about cash flow management. You're holding on to the money, and that's what that's really about. It's not about the patients. And the weirdest thing to me is over 50% of the time, you can get a prior authorization approved, and then they deny the care. And you're like, wait a minute, you said we could do this, you already approved it. But that was a great one to start with.

SPEAKER_00 34:23

It was good, and it was something that I was really interested in. And I I agree with you. I love that you tell that story about Congressman Murphy because it really is, it really highlights that these guys just don't know what they don't know. And that's not an insult, right? No, no, I agree. But these these questions are not black and white. And by questions, I mean the multitude of issues that desperately need to be addressed. None of it is black and white. You know, we started this conversation by talking about um PAs and MDs and uh how that ecosystem works and the hospital and the patients, and like it's never as crystal clear as oh, well, this person shouldn't be giving care, or this person should be getting help, or this is and and all of these issues I think are that way, including pre-authorization. And I agree that like having um having Bobby in the place that he is as secretary is interesting because really that job isn't a medical job. Like that job is a job about asking questions and looking at the incentive structures and pushing back. And um, and I and I I think that's been an asset for us. I think that's been something that's been useful.

SPEAKER_02 35:51

And I was disappointed with Dr. Oz on that because he was really coddling up to the insurance companies. He, you know, was very, I would say he was very positive when he was talking about them. I was like, are you kidding me? Now I know he hasn't practiced medicine for a long time, but I can tell you that prior authorizations are one of the most uh irritating parts of physicians' practice. And the average physician has 40 prior authorizations a week. So insurance companies know you can't really handle 40 a week. So they're counting on you, not handling them. That's the game. They're flooding the zone. Everybody knows it. And I honestly, if it's up to me, I just say no more prior authorizations. Because I look at it, people spend thousands of dollars in premiums, then they get their deductible, then they're thinking, okay, I finally get my first dollar coverage of care. And then now we get a prior authorization. It's too much. So they're abusing the system. I I love that you were there. And then you were also there for Dr. McCary's hormone replacement therapy, the black box removing that, which was huge. And I think it was very exciting for you in that one.

SPEAKER_00 37:02

Yeah, I mean, that that certainly was. It's um, you know, it's interesting because all of these things, even just talking about prior authorization, is a big step.

SPEAKER_02 37:14

It is.

SPEAKER_00 37:15

But the fact that that is a big step sort of defines the problem. Right. Like, I the the women's HRT, the removal of the black box warning, I thought was just such a significant shift. Like a lot of these issues that the FDA, HHS are addressing are really just small steps in the right direction, which is good, I'll take it. Right. Um, but it's almost just evidence that if we're waiting for the government to be like have their selves together so that we can be healthy, we're going to like go extinct before that happens. Right. So it's like, this is not the play. But what I loved about um about the black box removal is it really did say like we don't have to believe, we don't have to say the same things over and over again because this is what's always been said. And it's okay to say that we were wrong and the uh the study was manipulated through the media, not ironically, right? The headline was released, uh, people were told to shut up and um and not weigh in. And um, and I also thought that that whole story about the way that the black box warning came to be, and that we came to have this belief about hormone replacement therapy, was that you know, the villain in this story, in my opinion, is uh is the doctor who knew that the the confidence interval didn't support the headline and put the headline out there anyway. But what's interesting is that even though he was the villain in the story and he arguably did not do the right thing and hurt people, he did it from a place of care and love. He did it because he believed that what he was saying was true was was what was true. He didn't have the evidence, but he was, you know, that that was his belief. And not that that makes it okay, I'm not endorsing that. Uh, we should read the studies and we should care about confidence intervals. But I just thought, you know, it's it's really interesting the way these things happen, the way dogma comes to be, the way that, you know, we we play it safe or a narrative gets started, we perpetuate that to the public. And uh, and when things change, the the change doesn't always get out, doesn't always, you know, generate as much momentum as the original lie or the original um misconception. And um and HRT being flipped was just symbolic, I think, uh, for a lot of us that said, you know, maybe there is a way for us to go back and um and write some of these things that as clinicians, like I know that you you have protocols that you could list or medications that you could list that, you know, the dogma says one thing and you know that you know that you know that there's 16 brand new studies that say that that is just all made up.

SPEAKER_02 40:34

There's always that. No, you're right. I remember when I was practicing OB, there was a mandate that came out and said you should never use magnesium sulfate during pregnancy. Now, I always like just cringe when I hear never. And it had to do with a study that if you had people on it who are pregnant for a long period of time, it might cause some demineralization of the baby's bones. Basically, is the concern. But the thing is it was kind of funny because you know, you use it for stopping preterm labor, taking it steroids on board. But then there's another study that came out not too much longer afterwards, and then it was actually protective against cerebral palsy in a certain subgroup. So you have these people like stake this claim. And I remember talking to one of my maternal fetal medicine guys. I'm like, listen, I've got to stop this labor. You know, it's probably 26 weeks. I've got to get the steroids on board. You know, the only thing that's going to be working is MAG, and the guy's like, go for it. You know, but it just like it really puts you in a box because now if something went wrong, now luckily it went well, somebody could have said, well, they came out and said, don't use it. You have all these people. So that's where it's really hard for the physician because you can't just go rogue anytime you're doing something against whatever your specialist society is saying. You really have to say why you're doing it. And they're meant to be guidelines. They're not meant to say yeah, 100% can never, but it does put an extra burden on us. And you know, it's interesting with uh thinking back about the prior authorizations. A lot of what we're doing prior authorizations for are things that insurance companies shouldn't be involved in. There's $250 CAT spots, right? Why are they involved with it? $6 medications, why are they involved in it? And that to me is the bigger question. We've turned over everything to the insurance companies. They should really be there for catastrophic events. Somebody gets a can't somebody gets other things that are huge. That's when we need them. We don't need them for all these little things, and that's when they exploded in size and power by taking over these things that we should take back through. I would love to see an expanded HSA that's not tied to a high deductible health plan. You could sign up like an IRA. So everybody would have, you know, $10,000 a year. All of a sudden, you can buy a lot of $250 skins, $1,200 colonoscopies. You can use that. Because I say that and people are like, oh, people can't afford that. Well, then all of a sudden you're in control. And that's ultimately what I think we need to get. And you and I agree on that. And the other thing was fascinating with the studies, that brings me to a beautiful ballroom that you're in. You're in the Willard ballroom for Dr. Jay Bodichari's. Could you talk about what he was addressing there? Because that was a really important story.

SPEAKER_00 43:27

Yeah, so I mean, I had to start with the fact that I just love Jay and I fit a lot of people put me in the journalist category. And I'm always careful to say, well, I'm not really a journalist because really I have a bias. Um and my bias uh in a lot of these conversations is that I've followed Marty for a long time. And uh and I believe that he does great work. And I give him the benefit of the doubt when he says something and I look it up and I go to the source. Same with Jay, right? So, so we had this um this round table on how to improve research. And I've done some clinical research, um, behavioral research and pharmaceutical research. I was not particularly impressed, to be honest, like with my personal experience. Um, I thought that uh I thought that just being honest and ethical and uh paying attention to details and reporting everything in the way it should be reported would be enough to produce good science. And it turns out that is just 2% of the picture. So um, you know, that was the extent of really what I knew going into this meeting. And so I was really excited to hear well, how are we gonna magically transform science? Uh and Jay did not disappoint. And, you know, one of the one of the things that he talked about, and people who are into research are probably laughing because they're like, this is obvious. But, you know, one of the things he talked about was that, you know, it's so much easier to get a blockbuster study for a new compound that treats a new shiny thing published in the New York Times, published in an academic journal. Um, and that what it ends up doing is it biases us to studying the things that are going to get our work published and get us on the front page of the of the big newspapers and um and get us more grant money so that we can continue researching and doing our jobs and um and getting promoted. That's really a problem. Yeah, yeah, get promoted, get tenure, get like whatever notoriety amongst your amongst your peers, feel like you're making a difference, which is what I think we all go into this for. And he said, you know, but the but the study showing that, you know, this particular drug is actually terrible is just as important, if not more important, than the one that said that, you know, it cures cancer. So how do we incentivize either the studies that are sort of fact-checking, the duplication studies, to make sure that, you know, study number two is actually confirming what study number one showed us? Uh, how do we get those published? And also, how do we get studies published that just didn't work? Because why should we be testing the same thing over and over and over again when uh, you know, the an apple a day actually doesn't keep the doctor away. So why are we continuing to run that study? And um, anyway, he had he had some really brilliant ideas. I love the idea. Um, you know, he basically talked about how you can use funding to prioritize some of that thing. So maybe setting aside a certain portion of funding to go towards studies that are confirming things that we believe are foundational in cancer research or in different areas of research. And um, you know, for anybody who's interested in that, uh he has done, he was actually on a New York Times interview that was a succinct, probably an hour and a half sort of compilation of what was discussed at that video at that round table, or you can watch the YouTube video on the round table. But, you know, it was really interesting to see, again, creativity coming from the government, which is not normally where creativity uh expresses itself, um, and seeing some of the unique ideas that scientists have for actually making the system work better for us.

SPEAKER_02 47:53

And the research integrity issue has not really been addressed. And one of the first things I wrote about when I got on X was the Dana Farber Cancer Institute. They had 53, 57 studies that were problematic. And there's a gentleman by the name of Schlotel David, who threw a pub here and using sophisticated software was able to show the images that were in these studies were from other studies, they were manipulated.

SPEAKER_01 48:22

Yes.

SPEAKER_02 48:22

And they had to retract seven studies, they had to change 37 studies in around through there. And the problem is that is a Harvard hospital, that is a classic hospital. So there's all this follow-on research based on these studies. So the government not only wasted money on the original studies, but so many other studies are cited thousands of times, and it creates so much harm in the system. And not really much gets done. They filed a false claims act against Dana Farber, they paid a small fine, they're still in the research business. And the you know, the beat goes on as day to stay. And the problem is there really is no real repercussions for these large institutions. And it's always the same ones that the money goes to, and they're the ones that have the higher indirect costs. So the government's wasting money on this, and they try to direct money to the ones that are more efficient. There's all this pushback. Oh my God, they're gonna crash, all this great research. You know, but but there's so much we need to do. Yes, yes, but but it's a real thing.

SPEAKER_00 49:38

I mean, everything that the administration does is just disparaged by the media. Yes. I mean, I remember Jay making that effort and and making the effort to do that. And it's just it's uh definitely difficult.

SPEAKER_02 49:52

It is, and it's so important to do that. Otherwise, we're wasting money. And what ends up happening is if you have phony research, it's gonna delay really finding the true cures for cancer and it's gonna harm patients. That's the ultimate cost. And that's what people you know, and I really would say if there's an institution that did have a false claims act, I I would at least give them a timeout for research that you don't you have to regroup, you have to show us that you're not gonna do the same thing again. We need to have more teeth in it. The other thing is you have peer review. Peer review is different or busy, and they don't get the data set. All they really look at is do the design of the study seem reasonable, that the conclusions seem to fit what the data shows, but you don't get the data, you don't have sophisticated tools. And then a lot of the journals now are owned by publishing houses, and the more they publish, the more money they make. So all the incentives are exactly backwards. I know Dr. Bodhichari knows that. And the other thing I want you to address is please give me your thoughts on Dr. McCary's resignation from the FDA. And obviously, I I don't know the inner workings of the FDA, but obviously it wasn't a true resignation in my mind because last week they said we're gonna fire him. So, you know, it's kind of a polite way of exiting him from the system. But what are your thoughts? You know him well.

SPEAKER_00 51:22

Yeah, I have so many, I have so many thoughts on this. Um you know, I feel like every topic we've talked about today has been about how can we make what we're doing fractionally better, right? How can we make the billions and billions of dollars that are being spent supposedly to help patients, supposedly to support doctors, right? For all of these like moral reasons. Uh, how can we maybe nudge that a little bit closer? But I think the reality is that the fact that we have money going to institutions that are literally falsifying research, right? Like this is not like oopsie, we forgot, we use the wrong statistical measure, that our confidence interval was too wide. Like this is you falsified, you fraudulently essentially stole money from the taxpayer.

SPEAKER_02 52:23

Correct.

SPEAKER_00 52:24

From some you know, plumber who owns a business and is like trying to raise his family. You stole money from that person and then you lied. And I and what happened, and I bring this up in the context of uh Dr. McCary because that's what all of this feels like. Like, you know, the the news started reporting things about, you know, maybe he was going to be fired, maybe he was on his way out, and it was it was all very funny to me, because it's like well, that has been obvious to me since day one for him, right? Because anyone who is sitting in that seat and isn't just willing to say, yes, approved, yes, whatever you want, yes, pharma, I will do your bidding. Like if you are not willing to just bow down to industry forces and say, I don't care who it hurts, then you're on your way out. It's just a matter of time. And um It's like Vinay Prasad. You know, the wall same thing happened to him. Yes. I mean, I I mean that's exactly where I'm going. I am so I try to, I try to not be super emotionally involved in the um failures of the mainstream media. But the Vinay Prasad issue really got to me. Uh the Wall Street Journal reported um disparaging comments on him, uh, said that there were sexual harassment claims that never existed, just said things through them out in the air and let them sit there for 19 days before correcting it. You know, essentially tried to ruin this man's career uh on several occasions. And if you go back and you look at when the hit pieces happen, you just look at it temporarily. It's like, oh I told Moderna they needed to use a comparator that was reasonable. Like, don't give your 75-year-old um patients the flu shot that's meant for a 20-year-old. Give them the one that you would give them in the clinic. Uh why don't you do that? Right. And like that was a problem. Um, so it's just like you trace it back to like the things that that that were denied, or like the things that someone's just said, no, let's not do that. Let's actually do real science. And um and then, you know, and then the hit piece follows a few days later. And then dad says no, the hit pie hit piece follows a few days later. And like this was the trend for Vinay, and it was just so glaringly obvious to me and um and so unfair and unreasonable. But also, anyone who knows Vinay Prasad knows that he is or knows of his work, knows that he is very direct, he's a very good speaker, he's very clear, he's good with words, he's written a bazillion papers. So um it's sort of not surprising, right? He has high standards, he's very articulate, he had to go. Like if you're trying to control the narrative, you need this guy out. But I think Marty has always had a way of really um maintaining his standards, but in a in a quieter way, like in a in a more uh diplomatic way. He he didn't have a YouTube channel where he was yelling about all of the things that you know people were doing wrong, uh, rightfully so. And so, so, you know, part of me thought, well, they're doing this to like they're going to do this to Marty too, if he draws the line in the sand and says, okay, I'm gonna do the thing that I believe to be right. Um, I'm not saying that either of those men are infallible. Of course, they can make mistakes like the rest of us, but I believe with wholeheartedly that they are acting from a place of good science and good conscience and good faith. Um, but I thought, well, Marty will be like more careful about it. Like he's not gonna tweet about it. Or, you know, when he does it, like he'll be able to hang in there. But I it's it does appear that, you know, with Vanai leaving, it sort of just emboldened more hit pieces. You know, the Wall Street Journal did I think a half dozen editorial pieces.

SPEAKER_02 56:54

They didn't see my editorial board thing, you don't have anybody's name on it. And in the United States, you're always supposed to be able to face your accuser. And I think it's the ultimate cowardice of the Wall Street Journal to hide behind the editorial board. And uh, the thing that's frustrating for me when I looked at these issues with Benai, looked at it with uh Marty McCary, the only time I could find anything good was on Substack or on X. There was nothing in the mainstream media that really explained the nuances of what you brought out with the Moderna study, the comparator. And that's what's frustrating, and it shows you that you know the media is bought. And I can't think of, and I don't know a lot about the federal government, but I can't think of an agency that is more conflicted and has more problems than the FDA, up and down. I mean, everybody is an FDA commissioner, goes back to industry, and the government is uh up the butts oppositions for star claws. We can't do anything. But yet these guys go work for industry, no problem. They came from industry. You have the advisory boards, they're industry guys, okay? The industry funds the FDA and they have negotiations with them every five years saying, here's what we want. They're in control. They have the orange book with the patents, which the FDA doesn't have any patent attorneys, and that gets manipulated. It goes on and I'm an outside, I've never been in the FDA building. I know very little about it, but everything I know about, I'm like, oh my God, this is awful. And it's so important because we don't want people harmed by medications that aren't safe. And that happened with disruptive treatment for chain muscular dystrophy, it was approved. Two young boys died of liver failure, you know, then you have to pull it off the market. You don't want that. And I understand it's a difficult job because on one hand, people are desperate for rare disease treatments, and that's where the Wall Street Journal is pounding and you know, Senator Ron Johnson, same thing. But on the other hand, you have to keep people safe and make sure that actually the studies are meaningful and not some obscure data point that means nothing. And like you said, you know, they massage the data to come up with something. And you know, so I I think all those things are very concerning. And I and I'm not an expert on the FDA or Dr. McCary's time there, but you know, I do have a lot of concerns because of the conflicts there. And you know, I think whoever's gonna find it. Oh, go ahead.

SPEAKER_00 59:28

No, it's I I'm not trying to be an expert either, right? And that's that's what I think is interesting, is like I'm not I'm not running these studies, right? Maybe Vinaya's wrong. I don't believe that he is, like, based on my reading of it and what it looks like. But like maybe that argument is just not a scientifically sound argument. Well say that. But say, but say what make the argument, right?

SPEAKER_01 59:55

Absolutely.

SPEAKER_00 59:56

You know, Vinaya Prasad, director of C Bird, you know, says he denied this thing based on X, Y, and Z. Here's his reasoning, here's why we disagree, whatever. But like that's not even happening. And and what the reason, and this is just speculation, but I believe that the reason we're seeing just such vitriol is because there's nothing to say. Like, because there's no scientific way to reasonably push back, then that argument is pretty difficult to make uh if any thinking person might happen upon your paper. So instead, you can just point and yell sexual harassment.

SPEAKER_02 1:00:42

Or you could make vague claims of Dr. McCarey is a bad manager. I'm like, I don't even know what that means. And you know, I know I would be a bad manager, but the thing is, I don't know the structure. I mean, is he really managing the FDA? I does he have a career assistant who's probably managing, probably. I would imagine he would.

SPEAKER_00 1:01:01

Can you can anyone manage things when like you're you're uh you know you've got career people there who are resistant to change and don't want to be told that everything they've done for the last 20 years of their career is uh is not good enough? Like, or when pharma is paying the bills for all of the newspapers and I don't know, a large percentage of FDA's budget. Like, yes, are we telling them no? And I guess like my problem is I don't really care what the science is, I don't really care what the FDA does. I I just don't care because I know that FDA approved is made up, essentially, right? Like I feel like I am privileged enough to know first that people make mistakes, right? That doctors are not God, that the uh the regulatory structures have a lot of misaligned incentives, they have a lot of issues. And so, in addition to mistakes being made, there are also incentives that can skew people's viewpoints, even when they can still delude themselves into believing that they're like doing the right thing, whatever that is. And then there's like fraud and nefarious behavior. They're bad things that are happening. Okay, I'm aware of all of those things. So before I take a drug, or before I have some interaction with the medical system, I'm privileged enough to know I'm not believing the line that anything is 100% safe and effective. I'm not believing the line that any procedure is without risk. And so I go into it with eyes wide open. My real problem is that I think the existence of the FDA and the existence of these governmental government structures makes the average person who is not who hasn't made healthcare their entire life, it makes it impossible for them to actually have informed consent and to do a proper risk-benefit ratio because they believe that FDA approved means safe. They believe that, you know, whatever. If a if a doctor says it's safe and effective, then whatever it is is safe and effective or risk-free or what have you. And that is dishonest. Like I have a moral problem with that. And um, and I guess for me, Dr. McCary resigning yesterday, whether it was under pressure or not, like just says, okay, that sneaky sensation that I had, like I wanted to be saved, but I didn't really think I that we could be. But I really wanted it, but I was like, nah, that's just like a childish dream. But maybe it's true. But but watching what happened to Vanai for upholding standards, watching what happened to Marty for I believe upholding standards just says, okay, this is if those two men couldn't even stay in the game to make incremental progress without being pushed out by pharma in the Wall Street Journal, then uh then I was right. There there isn't any any value here coming from these institutions, or there isn't much value. And uh and we really are on our own. And we it really is up to us to find um like a crowd, a crowd health, right? That isn't affiliated with the insurance companies to help me pay for my health care and to find an independent surgical center like Dr. Keith Smith's and and talk to them about things. So like it's it really is on the consumer to do everything they can to get away from these big industry and interests. And um, I think the unfortunate thing about all of it is that that's hard to do.

SPEAKER_02 1:05:18

I think it's getting easier though. Here's the good thing. And I agree with all that. And part of what you're saying, you know, when you were saying if I have a course of treatment, a medication, it back in the day, that's when physicians had time, they could go through the nuances. Physicians don't have time anyway. If you're employed, it's like 15 minutes, get the next person in, or you're gonna get fired, basically is it. But the good thing is there's a movement and it's strong, the direct primary care, we're gonna start seeing direct surgical care. Physicians have had it. They're done. I don't know why anybody would want to be employed. I was not employed, you know, I was uh in a private practice most of my career. And when I was employed, I was a very bad employee because I didn't really care about the rules. But I think that's a good idea. That's where we need to go because when you have direct primary care, you're paying that physician, he or she is working for you. And that's powerful. Then you could sit down and you can look at what you need, and you could sit there and say, Hey, you know what? If I lose 25 pounds, if I start working out, I don't even need these medications. And Dr. William Steelman, who was on one of my podcasts earlier, said his favorite thing now that he's direct primary care, he gets people off of medications now. He never did that before. So he's like, that's the best part. So to me, that's the future. And all of a sudden people can start saying, wait a minute, I don't need the insurance company to pay for my $6 prescription. My direct primary care doc will get me $250 CAT scan. I don't have to argue with the insurance company over an $8,000 one because I don't need that one at the nonprofit hospital.

SPEAKER_00 1:06:55

So I think all and the other thing is a lot of the well, I mean, like, I just want to like interject because what you're saying is is completely directly related to this FDA stuff. Like, that's why it matters what the indication for testosterone replacement therapy is, is because insurance only pays for it. You know, they look for excuses to deny things and they will pay for things under specific circumstances. But that's why the FDA has all of the power that they have. It's because we're relying on the insurance companies. So once we move into this new space, then our doctors and and we as patients can make decisions based on what's best for us. Screw what insurance thinks or what the FDA thinks. I can take the medicine that that that's best for my condition and I can discuss those risks and benefits, honestly.

SPEAKER_02 1:07:52

Absolutely. And one of the things that's kind of fun with cost plus care, or cost plus drugs, rather, when you use that, your insurance company's not involved. So it's not this like, well, we'll only give you a 30-day prescription, or you can only have refill so often. They're out of it. You know, you're like just went off that whole plan. So you can do whatever you want. There's a freedom to all that. And I think once people start seeing that, they're gonna say, wait a minute, this other thing is a disaster. All this large insurance and these large hospitals are not making people healthier. And, you know, and I see it as a patient now. As you get older, you spend more time as a patient. It's interesting. And I try to go to independent people as much as I can, but sometimes you have to go into these large systems and they're awful. The first thing I notice, I walk in a large system, is everybody there sitting there is sedentary and obese, all the workers. I'm like, okay, if we're in a healthcare business, we should be showing people. Let us show you how you should be. I'm like looking at them, I'm like, well, this doesn't incent people to walk in the door. You know, it's, I mean, and all these things are important. You can act like, you know, when I had a private practice, you worried about every little detail, how your office looked, how the front staff talked to the patients, how they felt. Everything matters to people. And you could think something small doesn't matter at all. I I'm amazed through the years, patients telling me things. I'm like, wow, stuff I didn't even think about. I mean, I learned so much. Just shut up and listen. Patients will tell you what matters. You're like, okay, that mattered to you. Then it's important. It doesn't matter if I don't think it's important. And we understand it, they don't. But what I want to do is I want to do something a little fun because you're a social media influencer and a journalist and a great speaker. So I want you to rate from one to five, one being bad, five being great, social media platforms. So I'm just going to throw them out and you can say, like I'll say X, and you can say, I like it because of this or that. So just kind of a quick thing. So one to five scale. First one is X, formerly Twitter.

SPEAKER_00 1:10:00

Oh, okay. And five is the best. Five is to the best. One is the worst. Okay. Five is the best. Okay. X is my favorite platform. Um, and I will say why before uh your listeners are like, okay, turning this off. What's that?

SPEAKER_02 1:10:14

Is that a five? Then you have to jump out. You got to say one, two, three, four, five. Okay. X is five. All right.

SPEAKER_00 1:10:19

Yep. Um, and what I love about it, I love a couple things about it. Um, I actually love the trolls on X because I feel like when you make an argument, like, let's say I wanted to tell that mammogram story on Twitter, I would go, I would tell the mammogram story, and I would get a bunch of people who would say, Oh, yeah, just do ultrasounds, have them in the office. That's great. Good job. Mammograms are bad. And then I would have a bunch of other people who would say like something even more extreme than that. And then I would have a bunch of people who are like, you're killing people, and here's why. But what I love about it is because people are so unhinged, they're willing to be argumentative. They're willing, it allows you to pressure test your ideas in ways that you just can't pressure test them in any other way. And also it gives you access to people like that's how I discovered um Jay Boditaria. That's how I feel like I got to know him is by seeing his stream of consciousness on Twitter for years. And I think it's uh it's hard to do that on any of the other platforms because there is more censorship and uh and other things. Anyway, so Twitter is my favorite.

SPEAKER_02 1:11:36

All right, so five out of five, LinkedIn.

SPEAKER_00 1:11:40

Uh LinkedIn is like a two or a three. I you have to commit, you gotta give me a number. It's a two this week. It has been a three in the past.

SPEAKER_01 1:11:54

Okay.

SPEAKER_00 1:11:54

LinkedIn is great because it you can actually access people. So because there are less trolls on LinkedIn, um if you wanted to have a conversation with someone top of your field, you can message them on LinkedIn, send them a DM, and they're gonna assume they might assume you're selling them something. But if you're not selling them something and you're like just trying to have a conversation in earnest, I think that people respond well to that. And people, you can you can actually engage with people that you otherwise wouldn't have access to. I've met some really nice people there. Uh, you can post longer form content, but uh the censorship is out of control. So, I mean, it is really like if you want to say, um, let's say you want to discuss the merits of um Smith Pristone, since you're an OBGYN, right? Like, and um, you know, is this a drug that's safe for women or not? And what are the complications? And what are they, you know, how would you, how is it being used? What do we think about mail order? You can't have that conversation at all. You can't even have a very clear academic discussion about safety because it has that drug name in it. And so they do have a lot of keywords. Um, if you were to discuss the flu shot efficacy for the next season, you can't have that conversation. Um, so anyway, I'm uh I'm not a fan of that. I think it's uh I think the solution to misinformation is more information, and I think that more discourse is needed. I want to argue with people, and LinkedIn doesn't allow that, but it's a great starter platform for like newbies who want to get on get on online and they're maybe a little nervous about it. I think it's a good place to start.

SPEAKER_02 1:13:43

All right, Instagram.

SPEAKER_00 1:13:47

I'm not really an Instagrammer. Uh they have some funny stuff on there.

SPEAKER_02 1:13:52

That's true. So what would you give me your number?

SPEAKER_00 1:13:54

I don't know. I'm I'm gonna say I'm gonna say it's a two, but I don't I don't use it that much. You can't put a link. You can only put a link in your bio, as far as I know. Gotcha. And so it makes it hard to use it uh to funnel people to longer form content, and that's been my biggest issue with it. But I know it's uh it's something people love.

SPEAKER_02 1:14:17

TikTok.

SPEAKER_00 1:14:20

TikTok. I was on TikTok. TikTok is great because it really does lean towards virality. Uh so you really can take an idea. I I took a video, a phone video of Bobby Kennedy at that prior authorization uh press conference that went viral and you know, had hundreds of thousands of views. And um the so the good part is you can get ideas out. The bad part is it's uh you know, death threats, like it's trolling at a whole new level, like trolling at the most cruel, um violent, scary level, much worse than X, in my opinion, from what I've experienced. Um, and uh and that's a little scary. So I'm not on TikTok, but I have dabbled and it's interesting.

SPEAKER_02 1:15:12

YouTube.

SPEAKER_00 1:15:15

YouTube, I love. I just love YouTube. Um, my nugget for YouTube, I've I've played a lot in social media, so I have opinions on all of this. So I don't have opinions on everything. Um, but YouTube is really great uh at getting long form content out. I think the short form to long form funnel works very nicely. It basically, my experience has been when you put a new channel on YouTube for the first 12 to 13 weeks, you get three views, eight views. I mean, it's very hard to get traction, but they reward loyalty. So if you keep putting videos and you're consistent with it, they'll start to like let your things go out further. They also were horrific uh for censorship in the beginning. I still get you know their their little nasty grams when I'm a guest somewhere about the CDC says this and that, and you're like, yeah, yeah, yeah. Okay, I got it. Um, I'm just talking about risk and benefits, but you know better, YouTube. Um, anyway, so there's like some of that, but it's it it seems to have gotten less since uh COVID response is over now, and I'm sort of sort of on board.

SPEAKER_02 1:16:30

Excellent. And how about Facebook? Last one.

SPEAKER_00 1:16:33

I don't even have a Facebook, I just don't know.

SPEAKER_02 1:16:36

All right, I like that. Just forget forget about Facebook.

SPEAKER_00 1:16:39

And Substack.

SPEAKER_02 1:16:40

Oh, Substack, oh yeah. Yes, yes. I love Substack.

SPEAKER_00 1:16:43

Are you on Substack?

SPEAKER_02 1:16:44

I am. I I wrote a couple pieces on Medium when I first started, and then I but I follow a bunch of people on Substack, such as you and Katie. There's a ton of people I follow on there. Anish is on there, Anish Coca does great stuff on there.

SPEAKER_01 1:17:01

Yeah.

SPEAKER_02 1:17:02

And there's a whole group of people, Dutch is on there, Dutch Rojas. Yeah. So I'm always going on there. Yeah. And I found, like I said, I've done some deep dives of stories, and you could just go down the rabbit holes on Substack, and you get stuff that nobody will print in mainstream media. It makes them afraid.

SPEAKER_01 1:17:21

Yeah.

SPEAKER_02 1:17:22

The editors wake up in the middle of the night in a cold sweat if they even read some of these stories. So I do love Substack. It's fun. And what was the biggest lesson you learn running a successful podcast? Because you said you did 41 episodes. Is that correct?

SPEAKER_00 1:17:38

I don't even remember how many, but I did a ton. I loved it. I was able to build to like from zero to like, I don't know, I think it was like 15,000 listens. Wow. Um, I don't remember if that was a week or a month now, though, that I'm thinking about it. But like over like a six-month period, it's cool. Uh, it was fun. I I think that for me, if I had to do it again, I would try to get more into the in-person space. I would try to get people to like come in studio. So I think that was probably the biggest lesson for me was that the emotional connection, and I know we're on a virtual thing right now, um, but the emotional connection that you can have with someone in person like really shines through in the content. And um, and I think that with some people, like you and I know each other, and I I think we like each other and respect each other. Like I really enjoy interacting with you.

SPEAKER_02 1:18:40

Yes.

SPEAKER_00 1:18:41

So I was excited about today because I was like, oh, good, I get to see my friend. But but for strangers, sometimes it's really challenging. It can be awkward. So yeah.

SPEAKER_02 1:18:54

It's you know what? The other thing I noticed.

SPEAKER_00 1:18:57

That was what I learned.

SPEAKER_02 1:18:58

Yeah, the other thing I noticed too, in my little bit, I mean I'm very new at this, but sometimes people haven't been on these before, and you know, they just don't really understand, and they might wear things, or they might be in a room with the bright light behind them, or it's hard to get like that good visual, or the audio might be poor, where it's hard to control all that. Where if you're in studio, you control that. So I'm that at home. Like, you know, I wasn't worried about you because I know you've done this, you're professional, you're like, boom, you've got it down, but that's not always the case. So that's been my little learning episode. And, you know, so so that's been interesting for me. And and you're right, it is harder. The other thing for me, I love speaking in front of a room because I can watch the room, I can interact with people, I can move around. Well, here there's an audience beyond you, but you don't see them. So it's a little bit of a disconnect there. So you're right, doing it all virtual.

SPEAKER_00 1:19:56

It really is.

SPEAKER_02 1:19:57

Yeah.

SPEAKER_00 1:19:58

I mean, even today I found myself like having cover talking to you and then forgetting where I'm like, oh, I probably should have talked about that WHI study and like, you know, what the deal was with the confidence interval or whatever. Probably probably should have gone back, but I knew you knew, so just like moved on. Oh, yeah, absolutely. Some of that where you can forget.

SPEAKER_02 1:20:20

You know, you you can. And you're right. And I always put in the show notes in some, and you're really good at this, but other people throw out a lot of medical terms, abbreviations, whatever. So I always put those in the show notes so people don't have to sit there and say, what the heck is this?

SPEAKER_00 1:20:33

That is nice. Yeah, I try not to do that. I mean, that is so I I'm gonna shamelessly pitch if that's okay. Absolutely. But I write on signal and noise.online. Um, and you know, there's a paid, there's a paid portion and there's a free version, but mostly I just publish everything as free. And then like after 12 weeks, I think it just like defaults and like makes those paid, but like sign up for the free thing, that's fine. But like that's really my whole jam. And again, like like back to, you know, coming from a community where there was low health literacy, it's like people aren't stupid. They just don't that this is just like not their world. This is not what they're focused on every day. And so I think it's I think it's really important to be able to go to people and um and explain whether it's health policy or it's like medical stuff, like this is why this is important to you. Like, I know you think it doesn't matter why your doctor says you need testosterone replacement, like, but it actually does matter what your diagnosis code is because your insurance is gonna do this and this and this. And like people don't know that unless someone tells them. And I feel like a lot of a lot of medicine and a lot of policy is um is just us being wonks, like talking back and forth to each other. Correct. But we forget that like there's this whole group of people who would love to know more if we would just like speak in you know, $2 language instead of $10 language for no reason.

SPEAKER_02 1:22:03

Absolutely. And there's so many things, just simple things like, you know, going to a freestanding surgery center versus a hospital outpatient department. People don't know in these facility fees, just simple things. People are like, why am I charge an extra $400 for a service? And that was recently on the front page of the USA Today. A woman went in somewhere in Massachusetts. Yes, that was on the front page of their, and it's someone went in and she had a procedure done on her eyelid and it was somebody's large hospital system out east. And it but you know, it's in a shopping center 30 miles away from the main hospital, the mothership, but you still charge this extra $400. Because I think you can be up to 35 miles away. It's very sketchy. And if there's any congressmen or senators listening, there's absolutely no reason you shouldn't pass site neutral payments today. It's a scam. And but yeah, so that was something that I agree that's really important for us. Uh the other thing I think everybody in healthcare needs to push back. There's a lot of misinformation. They want to put the bad stuff on physicians, PAs, nurse practitioners or frontline people, and the patients see us, they have a bad experience, and they just associate it with us. They don't know, they don't know we're frustrated as well. And we need to really make the case we're there with you, and you, you know, the patients, physicians, and the patients, all the health folks need to come together, work together. And that's when the system will work. And that's how it used to work before it was taken over.

SPEAKER_00 1:23:38

Yeah.

SPEAKER_02 1:23:39

But but I'm gonna go ahead.

SPEAKER_00 1:23:41

That's such a good point. And I and I and I have to take up for the the front desk staff that we were talking about a while ago. Like the front desk staff that's like grumpy and maybe they're overweight, and like they're just like sitting there. Like the system has arranged it to where their lives are miserable too.

SPEAKER_02 1:23:59

Absolutely, 100%.

SPEAKER_00 1:24:01

Everybody who is interacting with the healthcare system is miserable, including the doctor and the PA and the nurses. It's just like everybody goes into their job because they want to help, and then everything is aligned to make that more difficult. And so you're right, we are all in it together. I do see some doctor shaming on the internet, and it's uh it's not helpful.

SPEAKER_02 1:24:24

No, we're we're all in it together. And you know what's funny? Every time I would got called an ER, if I got called for a stupid consult, I would look around the ER and it looked like a bomb went off. There's people on stretchers, there's people screaming in a car. Everybody's frazzled. I'm like, okay, well, you know, there's a good reason I got called when I didn't need to get called because they're overwhelmed and they're hoping that I'll just come in and take care of this problem for them because they're drowning. So the last thing they really need to need to do is yell at them and tell them they're idiots. Now, I they like if I could say, hey, listen, let me just explain, you know, how I'm addressing this, you know, things to look out for. People love that, but that's a whole different conversation. But you just go in and smile, say, hey, thanks for calling me. You know, what do we have? And you just low-key, and then they love you in the ER. You're like, oh, you're like the favorite person, you know, because you always smile at them. It's so funny. It's such a simple thing, but just come in and so all the docs listening, you could call the ER and you're upset, you know, cursed in the parking lot and smile when you get through the door because that's you know, they need that support. They really do.

SPEAKER_00 1:25:30

And we didn't want to call. We swear we didn't want to call when we picked up the phone.

SPEAKER_02 1:25:35

I know. You could tell. I could tell that they well. My last job was a hospital, so I was in house anyway, so I didn't really care. I'm like, whatever, I'm here. Pop down, talk to people. And I was doing my first job. You know, I'd retired, then I came back, and it was in Vermont in a rural area. And I would get called into the ER, and it was really a slow job. I would go in. I mean, they were like ridiculous calls, but I'm like, I'm bored. I'd go in, I would talk to the patient, I would talk to the air docs, everybody's glad you came in. You're like, we love this guy. And it was like, you know, and if I was in something really busy, I'd been like, okay, you don't need me to come. But I'm like, yeah, but the deck, I got nothing going on. So I would go in, but it made such a difference, so much goodwill. And I think that's what we have to debate. But I will give you the last word. What would you like to close with?

SPEAKER_00 1:26:23

Um, I mean, I just I have to say one last time, right? The government's not coming to save us. Actually, your doctor is not coming to save you. Like, no one is gonna do this work for you. And I tell everybody that I meet and all of my patients for sure, right? That like it's your job to come in exactly with a smile on your face and with a friendly demeanor, and just say, hey, doc, like let's figure this out. Like, here's the issue I'm having. Uh, I know you said you want me to take medformen. Like, why do you think that's the best drug? Is there anything else I could be doing? How long do I need to stay? Like, ask all of the questions. And if your doctor is a jerk, that's that's their problem. That just means you need a new doctor. Um, but I think like the more that we can advocate for ourselves and find partners, whether it's these cash pay surgery centers or, like I said, crowd health, like imaging centers that are willing to work with you, the more we can engage with these transparent um facilities and clinicians, the better off we're gonna be as patients, the better off the system is gonna be, the more widespread, the better these businesses are gonna do. And I really, I really believe that that is the way. Um, as much as I wish there were someone coming to save us.

SPEAKER_02 1:27:46

That's a great close. I can't add anything to that other than I agree 100%. So thank you so much, Tiffany, for being here. That's Tiffany Rider. And please follow her on her subsect. She's actually a very, very talented writer, which writing is very difficult to do. And I think that's one of those things that people think isn't a big deal. It is until you start writing. It's very difficult. So I give hats off to that. I want to thank all my viewers. If you made it this far, thank you so much. It's been a great discussion. Please like and follow me for more. If you have any suggestions, please let me know. I have thick skin. No problem. Let me know anything that you can. And thank you so much.