Ask Dr. Drew - Why Are Doctors Being Censored? ZDoggMD / Dr. Zubin Damania Discusses - Ask Dr. Drew - Episode 34

Episode Date: March 17, 2021

Dr. Zubin Damania hosts the #1 medical news and entertainment show under his pseudonym ZDoggMD, reaching millions of viewers every week through viral songs and humorous videos about health and medicine. Prior to becoming a star online, he spent a decade as a hospitalist at Stanford and also founded a healthcare clinic called Turntable Health. Follow ZDoggMD and his shows at https://zdoggmd.com/​  ZDoggMD on Instagram: https://www.instagram.com/zdoggmd/​  Dr. Damania on Twitter: https://twitter.com/zdoggmd​  Dr. Zubin Damania on YouTube: https://youtube.com/ZDoggMD  About ZDoggMD: Zubin Damania, M.D., is an internist and founder of Turntable Health, an innovative healthcare clinic that was part of an ambitious urban revitalization movement in Las Vegas. During his decade-long career as a hospitalist at Stanford, Dr. Damania began a shadow career under the pseudonym ZDoggMD, performing stand-up comedy and creating parody videos for medical audiences worldwide. Dr. Damania examines how we can all work to build Health 3.0, an ideal model of care where technology and evidence-based medicine seamlessly support healthcare teams in achieving the outcomes that actually matter to our patients, while improving the wellbeing of the caregivers themselves. He subsequently founded ZDoggMD Industries, the digital production studio behind the Internet’s #1 medical news and entertainment show, The ZDoggMD Show. Reaching millions of viewers weekly, Dr. Damania leads a passionate tribe of healthcare professionals towards this vision of Health 3.0, with in-depth interviews of medical thought leaders, mixed with merciless satire and hilarious takedowns of popular pseudoscience. Through song, humor and creative storytelling, Dr. Damania delves into the challenges of delivering compassionate health care in our severely dysfunctional medical system while proposing collaborative ways to revitalize it. He explores how we might work individually and collectively to transform the current system and ensure that the future of medicine is a bright one. Get an alert when Dr. Drew is taking calls: http://drdrew.tv/ Ask Dr. Drew is produced by Kaleb Nation ( https://kalebnation.com) and Susan Pinsky (https://twitter.com/FirstLadyOfLove). THE SHOW: For over 30 years, Dr. Drew Pinsky has taken calls from all corners of the globe, answering thousands of questions from teens and young adults. To millions, he is a beacon of truth, integrity, fairness, and common sense. Now, after decades of hosting Loveline and multiple hit TV shows – including Celebrity Rehab, Teen Mom OG, Lifechangers, and more – Dr. Drew is opening his phone lines to the world by streaming LIVE from his home studio in California. On Ask Dr. Drew, no question is too extreme or embarrassing because the Dr. has heard it all. Don’t hold in your deepest, darkest questions any longer. Ask Dr. Drew and get real answers today. This show is not a substitute for medical advice, diagnosis, or treatment. All information exchanged during participation in this program, including interactions with DrDrew.com and any affiliated websites, are intended for educational and/or entertainment purposes only. Learn more about your ad choices. Visit megaphone.fm/adchoices

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Use code DrDrew20 for 15% off your first month of daily symbiotic. That is seed.com slash drdrew. Use code drdrew20. Our laws as it pertains to substances are draconian and bizarre. Psychopaths start this way. He was an alcoholic because of social media and pornography, PTSD, love addiction, fentanyl and heroin. Ridiculous. I'm a doctor for f***ing sake.

Where the hell do you think I learned that? I'm just saying, you go to treatment before you kill people. I am a clinician. I observe things about these chemicals. Let's just deal with what's real. We used to get these calls on Loveline all the time. Educate adolescents and to prevent and to treat. If you have trouble, you can't stop and you want help stopping, I can help.

I got a lot to say. I got a prevent and to treat. If you have trouble, you can't stop, and you want to help stop it, I can help. I got a lot to say. I got a lot more to say. Welcome, everyone. We will have calls in just a few moments. Of course, that usual call-in number is 984-237-3739. We have a very special guest today. But before I get to the guest, a couple of opening comments here. I've been watching you guys on the restream and Chad Quackenbush wants to know,

how do you guys do a nightly show of sane, coherent discussion? We'll give you a good example of that tonight. I think mostly the way you do it is you book good people who have something to say and who know what they're talking about. That's how it stays sane and it stays on track. And Andrew Ashkosvili, of course, who's in my stream as well, says numbers looking good. Lots of doctors and scientists saying they believe this is over at the end of April, maybe, or May. I think that's a reasonable position. We're going to talk about that with my guest.

Let's bring him up right now. Z-Dog, Dr. Zubin Damania. Welcome, sir. It's such a pleasure to see you across the Zoom here. Dr. Drizoo, it's an honor, man. I'm excited. This is fun. And you and I shared a screen for Dave Rubin, did we not? We did. And that was a lot of fun because we got to rant and rave about how we get canceled by social media. Oh, boy. And things have continued since then. Yeah, for me, that was a problem. And we have done everything in our power to try to understand what the parameters are of propriety within their context of their standards, as they say. Can't figure it out.

Cannot figure it out. It's like being charged of a crime and they don't tell you what the crime is, and then they give you the punishment. You still don't know what the crime is. The only thing I could find, I read through all of their criteria and all of their guidelines, I think they call them, and they're reasonable. They're not unreasonable. They are things I would never say, you know, things I would never get near. The only thing I could find that was close to something I was talking about is I was discussing my feelings about my immune status after having had COVID. I probably quipped, I made a joke about being highly immune or the most immune man in America or something, which I'll say once in a while. Since I had to monitor a severe COVID case, I've been monitoring

my antibody profiles and I'm orders of magnitude above vaccine level antibodies, which is great, but somehow that violated their standards. Well, you know, at least you didn't use the H word herd immunity. Because that'll, you'll get yanked immediately. I mean, for me, that seems like, so let me do what Scott Adams always does on his screen. I didn't say the H word. That's my guest opinion. And he didn't say anything about the H immunity. He just used the word. I think he was talking about bovine, a cow or something.

I was literally talking about a herd of animals and they're immune. Deer. I mean, because we were talking about ivermectin, which is sheep. Oh, another word. Another word. Another word. Another word that's going to get me canceled. He is talking about elk and how to deworm elk right now. And what, oh my gosh.

We're already, we're three minutes out of the box and we're already canceled. My goal is to demonetize this episode for you. Don't worry, we don't try to monetize because we're hoping that that reduces the heat on it a little bit. All right. That's true. But you know what I want to get into you on is what you're, I have some thoughts that are fairly well formulated, but they're not fully formulated yet, about what we've just been through in this pandemic. And one of the topics that I don't get a chance to talk to anybody about, but you're a perfect person to do so. And by the way, should we promote anything before we launch

into this? No, I got nothing to promote. I'm a promotion. All right. Because I'm going to forget as we dig in deep to this thing. So what happened to our peers? What happened to them? I don't, it's the weirdest thing. Let me just frame my experience. My experience was, and then I'll later tell you what I think is happening, but I'll just tell you what I experienced. What I experienced was a complete paralysis, particularly in medicine, ER, and maybe a little bit on the ICU hospital side. But general medicine particularly froze in place and took the position that when somebody gets COVID almost at any age, just send them home and watch. Maybe some oxygen, maybe some budesonide at the most. And to me, it is the most bizarre thing in the world as someone who's trained to improvise and determine what my best approach is, apply my judgment for the given clinical situation at hand. Oftentimes, waiting for the science to catch up.

The science often doesn't catch up with the clinical experience. For years, there was things I used for years that there was not double-blind placebo-controlled trials to substantiate. And many times there were things I did for years, like hormone replacement therapy, that when the trials came out, turned out to be totally wrong, and we damaged millions of women because of the Women's Health Initiative. So if we're not going to allow physicians to improvise and apply their judgment, have nurse practitioners and physician's assistants do everything. That's fine. You don't need physicians if they're not going to apply their judgment. It seemed like they were

afraid that if some orthodoxy wasn't handed down from on high, they wouldn't do it. Was that your experience? So what I suspect here is we're seeing the indoctrination, the sort of conditioning of physicians to be fear-based. So again, the do no harm oath means, almost sometimes it means do nothing or stand back. But that's harmful. I think that-

That can be harmful. It absolutely can. I think in the case of this disease, it's interesting because it's a viral syndrome. So people said, okay, well, it's kind of like flu. We don't really have a lot of therapeutics that work that well. Go home, rest, the brat diet, all the usual stuff. And the truth is, well, this is brand new. Now, the problem is then you have people who are coming out with kind of out of left field ideas that kind of have some theoretical sense, but maybe they do cause harm,

but we don't know. And then that scares doctors more. And then everybody's afraid of being judged on social media or media as being some kind of quack. So they step back. Now, my feeling is just even doing anything has a placebo benefit when someone's suffering from a viral syndrome. And just that therapeutic relationship

of connection is important, but we were stepping away from that. And I think there's a fear component. Well, here's what really disturbed me. Because it went from paralysis during the viral phase of the illness. And I get it. It was confusing. And it's not clear we have anything that really works yet.

And I get it then. But to not be loading up and preparing to jump on the cytokine activation and everything that follows. For instance, when I got sick, day three, I was talking to my doctor about decadron and bamlanivimab. Because what if I'm not getting better in three more days? You better have signed up for that bamlanivimab because you wait in line to get that. And I don't want to be 10 days out getting it. I want to be five days out getting it because it's going to have a better effect then. When I went on Instagram live and chronicled that story, I heard from patients all over the country saying, my doctor doesn't know anything about this. That was astonishing to me. Astonishing. It doesn't surprise me at all for a couple of reasons. And I think, and it should astonish us,

but it doesn't surprise us because we say, well, wait, we're a very inertia-driven, fear-based profession that is the result of a hierarchical training that indoctrinates us in this kind of way of being in the world. We're very afraid of causing trouble and drawing the eye of Sauron onto us. And I think that's why we're really good at pointing the finger too, because it's a kind of projection. Well, you know, if the nephrologist hadn't screwed up putting in that fistula, well then, you know, I wouldn't have had this infectious complication that now I'm having trouble managing in the ICU. And so it really is part of our culture. The other thing is I don't think medicine moves so fast. So in this case, here we have this new dynamic challenge and we're not

designed to quickly update. So you have these groups online forming where critical care docs are sharing ideas. Now in those circles, actually, I saw a lot of innovation, a lot of quick progress. And so I have to tip my hat to those. That was good, I agree. But that's the group. But a lot of quick progress. And so I have to tip my hat to those. That was, that was good. I agree. But that's, but that's the group. But a lot of that was, it should have been just as robust early on. So the critical care guys didn't have to see these patients. That's the thing that bothered me. It was very disappointing to me. And, and you should know. So I was open to a lot of, I was sharing a lot of ideas. I was, you know, like, you know,

I don't know if you know, I have this friend, Dr. Yogendra, who's an anesthesiologist, and he put together this panel of physicians. We were sharing information from all over the country, all over the world, really. And so I was hearing and seeing and getting, accumulating information that it just wasn't happening, you know, anywhere else, except my surgical colleagues. Whenever I would talk to a surgical colleague, it seemed like they were up on it. They knew it. And if their family or friends got sick, they were using these improvisational techniques to great advantage for their patients and loved ones. But the medicine side was stuck in this fear of improvising. And I think some of it is how we've treated the sort of primary care arm of the healthcare apparatus. We devalue it, we underpay it, we get it with a lot of bureaucracy. I mean,

we're our own court reporters, Drew. We're typing in notes while we're talking to the patients, and we're the lawyer at the same time, whereas the surgeons actually have a couple levels of buffer so they can actually practice that high-level intuitive medicine that only human beings can do with a ton of training. But with primary care, it's just been beaten out of them. And it's tragic because, I mean, that's why we have all these failures. You said it. If you end up in the ICU, that's a failure of medicine. That's a failure of outpatient primary care.

And so it doesn't surprise me. But I mean, that's the fundamental reason why I think we started this particular clinic we did in Las Vegas called Turntable Health, which was this new model of preventative, team-based, interdisciplinary, repersonalized medicine. Kind of like what, I mean, you've been doing it one-on-one for a year. It's what I do. It's what I've always done. It's what I was trained. It's what I thought medicine was going to be. I thought that's why I went into medicine. You know, I wanted to, when I got to my internal medicine rotation in my third year, I was like, oh yeah, that's right.

That's why I wanted to become a doctor. I want to do all these things and be at the center of this and help the patient navigate and be the one person that's there for the patient all the time. I mean, that doesn't exist. It's just very sad to me. This was an eye-opening experience. We've been commodified. And you've been through it now as a patient. We've been commoditized. We've been turned into an assembly line of the business. People have descended, the private equity people have descended and they've said, okay, well, these are the widgets we need to measure. By the way, you enter the data that we're going to measure that you're paid on, which means now I'm not looking at the patient. I'm not making eye contact. I'm not present in the room. Instead, I'm present with a machine that's really not an electronic

health record. It's an electronic cash register. That's how the employer gets, you know, the big system gets paid and how I get paid. And then I have to sit with an administrator who's an MBA, who's never touched a patient who says, oh, here are all the 20 things you did wrong with this patient. It's like, are you high? Is this crazy? And then when a pandemic hits, it shows how fragile our system is, that we're dependent on this fee-for-service elective machine. And when that dries up, then you're furloughing doctors and nurses during a pandemic. And then we're like, oh, they're not able to respond to the pandemic. Yeah, we've totally screwed up this whole systematic thing and the whole culture of it. It's all backwards. Yeah. Uh, I, I tempted to ask you

what we do about it, but it's too big a question. Do you, do you have any, yeah, I, I, you know, I, I don't know what the answer is. I, I keep thinking that a great way to save a lot of money in medicine is to reinstate, re-empower primary care in the patient, you know, that give them the, the sort of give some liability relief, give some administrative relief and put the physician and the patient back in control of healthcare. I've got stories of blow your mind in terms of dealing with insurance companies and administrations. I mean,

we've been so disintermediated from our patients that the deep relationship that's at the heart of medicine, I mean, that's why we called our clinic Turntable Health because we believe that medicine is an analog old school process that you can digitally amplify. Nice. So, but if you ignore the analog heart of it,

then what you're doing is you're turning everybody into these widgets, but that's, you know, you know this. It's this more than anything. You know, there's all the chemicals and reductionism that we can do, but it's really this mind-body continuum. And so you're right. I think if you get the doctor and the patient here at the center, you empower them with the tools, resources, and autonomy to do what they do.

They do well financially by doing good for the patient and for each other. Then you've solved the problem. And that's what we call health 3.0, this new emergent of healthcare that we have to work together. You've got to have, you have to actually put the power in the hands somehow of the patient and the doctor. And then you have to give liability and tort relief. Liability, tort relief, and administration relief. Liability, tort relief, and administration relief. And a simple tort relief,

in my humble opinion, is the defense for malpractice is, this was my judgment given the clinical situation, and here's what I based that judgment upon. That's defense. That's it. That's your inadequate defense. Now, if somebody is making mistakes all the time using their judgment, I think we can then say, okay, there's a problem here. But if physician judgment is not a defense we will let terrible doctors slide. We all know, Drew, you know the docs, you would never let touch your dog, but our patients don't know that. And they can't know that until there's a board action or something like that. And that's rare. So we have to do better about how do we treat our own tribe in terms of weeding out people that we know are problems and helping lift people who have weaknesses or just focus on their strengths.

Like, okay, you're really good at this. You should focus on this and stop the other stuff that's not good. Right. But it's hard. So let me go back to viruses again. I want to talk more about what's going on there. Why do we think flu didn't show up this season? What's your theory?

So this is interesting. Yeah. So I think there's four pieces and I'll put them in the order of importance, I think. One is we closed international travel. I think that that really dropped the spread because influenza is really one of those things that comes from China. Then it goes here. So that broke the global chain of transmission. Then you have the closure of schools, which unlike coronavirus,

unlike coronavirus, flu is really loves kids and loves to spread through kids. So closing the schools, then you have- Stop, stop on number two. But I agree with you. That is probably the second most important thing.

I agree with you. And let's remind ourselves that the whole theory of lockdown was invented by a 14-year-old high school student in Albuquerque, New Mexico, building a model about the flu. And it was her idea that closing down schools locally in a controlled manner would help reduce the risk of flu, which it would. Not an airborne pathogen, not a pathogen that doesn't bother children, but go ahead.

And that's a key distinction that influenza has a reproductive number and are not, that's quite a bit lower, meaning how many people does one infected person infect on average? Much lower than coronavirus. Coronavirus is much more contagious, especially newer variants. So, you know, it's easier, like, so the same things,

like the little bit of, so that's number three, the distancing and the masking and stuff. I think to some degree, it's easier, so the same things, like the little bit of, so that's number three, the distancing and the masking and stuff. I think to some degree, it's easier to affect flu than it is to affect coronavirus with those measures. So what we've done for coronavirus would really, really affect flu. But then the fourth thing is something called viral interference,

which is an interesting phenomenon. Because if you look in Europe, colds and flus peak at different times, even though the viruses are circulating. It turns out with respiratory viruses, humans really don't get infected by more than one virus typically at a time. And some of that theory is that the innate immune response, the broader frontline immune response to viruses, tends to knock out competing viruses. So if coronavirus is the predominant circulating respiratory virus, flu doesn't really have a chance because humans are already secreting interferon and already have their immune systems

jazzed up. And so that's another theory that I thought was quite interesting. I thought I thought I a thousand percent agree with you that all those are for sure. They've got to be figured into this. Right. But the numbers don't quite fit for me on the host theory. You know what I mean? So we have like 30 million people

that had coronavirus in this country. I would want to see more like 70 million or a hundred million people to say that fought the flu off. So I'm wondering, is there some ecology of viruses too? Where just like there's ecology in the Savannah, you know, the lions move in and the hyenas are pushed out. You know what I mean? There's some sort of competitive phenomena

we don't really understand yet. I think you're absolutely onto something because the ecology of viruses, again, these viruses, they're not as simple as we like to make them, these little shards of DNA. They've co-evolved with us for hundreds of millions of years.

They are wise in that sense, that wise meaning ecologically wise. They do things-evolved with us for hundreds of millions of years. They are wise in that sense, that wise meaning ecologically wise. They do things that we don't understand. And one caveat to that is RSV, respiratory syncytial virus, that typically infects children around a little earlier in the winter. It is gone. So pediatricians, I talk to them, they just, no one's seeing it. Oh, that's interesting. I did not know that was out too. And we don't think that we did a better job vaccinating the kids because of all the vaccine talk or anything? Well, so, you know, that would work for flu, but we don't have an RSV vaccine. I thought they had one recently.

So they're working on it. That's the thing. You know what? Actually, a little side note on that, Drew. So RSV vaccines were attempted in the 60s and they were halted because they had a phenomenon called immune enhancement where they had a vaccine that was actually not quite right. So it generated non-neutralizing antibodies that would bind to parts of the virus

that all it would serve is to bring the virus into lung cells. Oh boy. So it was like a Trojan horse thing. So people who were vaccinated actually got sicker from the infection and there were a couple of deaths. So that scared everybody off RSV vaccine. But now with the new mRNA technology, you can make very, very focused antigen targeted vaccines that RSV now may have a chance to be a vaccine preventable illness, which would

be great because it causes a lot of suffering. A friend of mine asked me a question about the flu virus this morning, and I had some interesting kind of thoughts that I can't answer, which was he asked, would the mRNA technologies change the flu vaccine? And my first answer was, no, it's what the virus does. That's the problem with the flu vaccine. And then I thought, now, wait a minute. We can ramp up mRNA viruses so quickly.

Maybe we could actually change mid- flu season to get the right virus. Do you think that's going to happen? I think it's feasible, right? Because right now you've got to grow that influenza virus and these egg based cultures. And there's some, you know,

there's some purified protein, like I think it's flu block that's purified protein, but it takes time to do those because you got to grow them in these cell cultures and so on. And people get icky about cell cultures. There's like, you know, that's a whole nother discussion. Do you want to tell them why? So the idea with cell culture is there are these, what they call immortalized lines of human cells that we do a lot of research on. We can develop vaccines and we can do things like, but where do those lines come from? Electively aborted fetuses in the seventies and eighties.

That's right. So imagine you're Catholic and the doctrine is, Hey, that was an immoral act. Well, now you're reaping benefits from an immoral act and that becomes complicated to say the least. So the mRNA vaccines don't do that. So that's an, it's a, it's clean in that sense from a Catholic ethics standpoint, which is another, if you see that as an advantage, that's an advantage. I'm just dying to tell you my insurance story. So I have to tell it. I've sort of told pieces of it on the stream before, but I'm going to

take this opportunity just to tell the whole story. So I ran a large addiction recovery program for many years. And early on when HMOs were starting to take over, one of the physician administrator owners of the HMO called me and he said, hey, you got to get my patients out of there quicker, out of the hospital, right? This is the whole model of HMOs is the quicker, the less resources you use, the better, right? And I said, look, you're beating my staff down. Everyone's demoralized by this. I'll tell you what, you name your price and we will use our resources

and treat your patients across our spectrum of resources. And just you tell us what that's worth to you and that'll be it. And he goes, no, I just want a three-day detox. And I said, I'm offering you the world. What are you doing? He goes, no. He goes, look, if they relapse three

times, they'll lose their job. Then they're no longer my concern. It's a doctor saying this to me. A physician said that to me. Then he finished with, I'm an insurance administrator now. I'm not a social agency. I can't tell you whether that's good or bad. Literally, I was speechless. And I knew him back when he was a practicing physician. He was pretty good. I just put the phone down. I thought, I can't believe this. So then time goes on and the insurances take a deeper and deeper and deeper hold on what you can do in the hospital.

And you can, you can't do anything. You know what I mean? I had people that need weeks and months of treatment. I'd be lucky if I got three to five days for them in the hospital. And well, let me just finish because this is where the story, it's ridiculous. But I started, I started inventing all kinds of residential and outpatient. And we really, we struggled, you know, to get resources for our patients. It's that we, it was, the hospital hated it because we never made any money. We were just constantly using

resources to try to build programs. And, and, but it was a good marquee for the hospital that we had a good program and that people were getting well and, you know, I had a great team and we were very happy and had a good, you know, sort of community presence. So they let us survive. But I started complaining.

The insurances were ridiculous. And I was saying, look, a reviewer in Illinois would call me and go, you have no business keeping this patient another day. You know, never seen the patient, knew nothing about the patient and day, never seen the patient, knew nothing about the patient, and would demand I discharge the patient. And the patient would then call the insurance company,

and the insurance company would say, oh, of course, Mr. Smith. If Dr. Pinsky would just tell us what you need, we, of course, would provide that. Well, what they don't tell the patient is what you need is their criteria for ongoing care, and their criteria for ongoing care is harm to self or other, right? And so if I then discharge the patient and the patient kills themselves, the insurance company goes, we don't practice medicine. There's Dr. Pinsky's name right there on the discharge.

The patient died because Dr. Pinsky discharged the patient. If I keep the patient in the hospital, the patient is responsible for $800 a day of financial liability. They're drug addicts. They can't afford this. It ruins them. And so when I complain, I go and I would complain to like the board of the, what's the insurance? I forget now what the insurance state, your insurance board person is. The insurance company then goes, oh, Dr. Pinsky, you're sending lots

of appeals in. We understand you're not happy with how we do service. I'll tell you what, we will decertify you and no longer cover you under our plan. And to that matter, you should tell your hospital administrator, we plan to decertify the entire hospital. So this is the shit they pull. This is the shit they pull. None of this surprises me at all my mom's a psychiatrist she worked in this she worked a lot with substance abuse and stuff in fact she's a big fan of yours from back in the day she's like i owe you in the indian woman i love doctor you're going on dr drew's show my goodness so so this is what you just described drew is okay that was the

hmo model it's a zero it wasnum game. It was the HMO. That became just insurance. All the insurances run to the same kind of DRGs and all that stuff. They all were under the same sort of model, especially in psychiatry. It was funny, because I was doing medicine and psychiatry simultaneously, practicing in both fields as time moved on. And in medicine, it got tighter first. And I always was like, wow, there's a lot. And at the time, I was thinking, oh, there's a lot of excesses in psychiatry.

There were at the time. There were excesses. They were keeping people for long periods of time. They were milling people through all kinds of testing and things they didn't need. And all of a sudden, it went completely the other way, where it got so restrictive in psychiatry, it became ridiculous. So what you described, though, that feeling of, okay, if I keep them longer, they're going to go broke. I'm financially assaulting this patient. If I let them go, they could hurt themselves, in which case I'm indirectly responsible for this because I was pushed out by the insurance company. That creates a tension morally for us that we've called moral injury. It's a kind of a psychic wound that happens every single day for doctors. Over time, then the administrators say,

well, you're burned out, which is a kind of a victim shaming thing, right? What it really is, is burnout is like the dialysis. You're end stage, your kidneys are gone. What caused the disease was chronic moral injury caused by the insurance companies, the administrators, the system, the regulations, the lawyers, everything. And you just want to do the right thing. But every day you have to make these compromise. Well, I got to take care. I have to read my daughter a bedtime story, but if I don't chart in Epic, then I could get sued. And then the administrator will be mad. I'll lose my job. But then the patient could get hurt if I don't check this potassium right now. So all that

creates this injury on a chronic basis. And then it gets back to your initial statement of why were the doctors so slow to respond to the pandemic? I mean, they're injured. Yes. I agree with you. I totally agree with you. This is what it feels like to me, that the injury is complicated. I like calling it a moral injury because it's a moral assault that they've been under, and they're fearful for their livelihood and jobs. And you mentioned it earlier, the way we're trained. We are trained in a militaristic system, right? Is that a fair assessment? And if you're not careful, this is going to sound harsh, and please, I'm using this language to sort of make a point. You can get a little cult-like in your behavior.

You go with the group, you listen to the leaders, and you don't use the thing you were trained to do. And it feels culty. I started thinking about some of the things I used to do as a resident. I go, why did I do that? I go, oh, well, that's what they told me to do. That's what I was just told to do. It's just, that's what you do. And I thought, wow, I don't do that anymore. Interesting. It's because I've thought better of it. But had I stayed in the cult, I would still do it. And what's interesting is that cult will excommunicate you in a second if you step out of line. You're all in or all out. And especially if you...

Oh, just like a cult. It's like a cult. That's the way cults are. That's what's culty about it. Yeah. We have our own language of the cult. It's a military language, too. Oh, strong work. Oh, you're a wall. Oh, he's a sieve. You know, people who let people through the call. It's a military language too. Oh, strong work. Oh, you're a wall. Oh, he's a sieve. People who let people through the air. And that military language actually plays into the idea of moral injury because that's a term borrowed from the military in Vietnam. Oh, really? Interesting. Seeing things and being put in things that were so antithetical to what they believe, but they had to do it. Then they come home and they have no way to process it and it creates moral injury, PTSD, et cetera. But for us, it's part of the culture. And you're absolutely right. I remember I had an attending position at UCSF when I was a medical student

telling me, you know, Damania, you speak and then think. I'd like you to invert that. Or better yet, just think. And it's because I dared to make a joke on rounds as a medical student. I was so out of line. Oh boy. Yeah. I mean, it's, I get a little PTSD just talking about it actually. Well, it's, you know, it's funny. This conversation is, I'm getting a little jittery, just this conversation because it is, it is deeply injurious what we've all been through. And it gets me kind of anxious in a way that a PTSD-type injury makes me feel, like my whole body is sort of vibrating. I feel it too.

Yeah. You know, Drew, it's funny because for the non-medical audience, this is how doctors talk when no one's looking. Right. That's right. That's right. Well, no, we go further down the rabbit hole, right? It gets deep. Yeah. We go further down the rabbit hole, right? We will.

It gets deep. Yeah. We'll start to dark humor, gallows humor. Very dark. Yeah. We're holding back for you guys. Just not scar you. Yeah.

What's that, Susan? My wife. Can you turn her mic on a second? Susan, my wife wants to. No dirty jokes. I worked at hardware stores. No, we don't get. No, no, no.

It's more it's it's dark it's more more death kind of jokes more death and dying stuff that kind of thing yeah and and and expressions of extreme cynicism yeah cynicism it comes off as disain, but it's not disdain. It's like being overwhelmed. And so it's like you just can't. Yeah. Yeah.

Yeah. And I think it comes from a hurt that we have. I mean, it really is. It's a defense mechanism that we build up where we call our patients. This was when I was training. We called our sickest patients who were beyond helping. GOMERS. They would not die, gomers.

And get out of my ER from Sam Shem, who's become a friend actually in later years. He wrote The House of God. Must read, but oh, he's a wonderful human being. And he was suffering that, ended up becoming a psychiatrist and a writer. And it's because we're morally injured in order to protect ourselves from the fact that we can't help people sometimes, we project our feelings of helplessness onto the patient and go, well, that's a gomer. That person can't be hurt, but also can't be helped. And they're no longer human. And it helps us survive, but it's so dehumanizing to us. And then when we get together, we're like, yeah,

immediately the walls come down and we're like, oh my gosh, you know. Yeah. I think I'm thinking about my own behavior and I was able to avoid adopting any gomeric attitudes about things. But I do remember the first time a resident applied the term, it was a surgical resident, general surgical resident. And I was like a 22 year old kid who had a ruptured appendix that i had operated on with it with the resident and he started developing intra-abdominal assesses all over the place and they were doing one pigtail drainage after another on this kid and um and he was like whack-a-mole yeah and he was um not progressing and it was and progressing. And it was the junior surgeon, junior resident said,

this kid's going to be a Gomer. Just don't even, he's going to be a Gomer. I thought, I've been working on this kid since the first operation. I'm invested. What are you talking about? It was very confusing to me. And I thought, not this kid. He's 22.

Gomers are like 80-year-olds that you can't help. You know, it's like, wow. So it affected me. I thought, not this kid. He's 22. Gomer's are like 80-year-olds that you can't help. It's like, wow. So it affected me. And I also remember the first time a neurosurgeon told a family that there was no hope. And I didn't like the way he did it at all. And it stayed with me in a positive way, even though the modeling was negative. It made me adjust differently.

So in a way, I guess you and I were exposed to a lot of that stuff and maybe it had made us better doctors because they, so they don't do that anymore. Is that right? They don't call them gomers. They don't do all that nonsense. Cause I didn't, when I was teaching, when I was teaching, I used none of that stuff. Yeah, no, no, no. We, we, and I was guilty of it when I was in training for sure. In fact, cause I was the class clown of our group. And so I would, you know, I actually made a parody of Kenny Rogers, the gambler, and I called it the Gomer. And it was about a, you know,

elderly demented patient who was just being strung along by their family because no one would have the, ultimately this is what it was about, is about no one had the courage to have an end of life conversation. What were their actual wishes? They all had their emotional investment

in keeping them alive. And sometimes they had a financial investment because it was a Medi-Cal patient, Medicaid patient, and they got paid to be the caregiver. And it would just hurt, you know, as a doctor to go, why are we doing this? We're taking up a bed, torturing this person with interventions, feeding tubes and tracheostomies that they probably didn't want if someone had just had the courage to ask them. So this is a really important topic, right? And I thought COVID brought it front and center myself because I started talking about it as a result of COVID because how should we frame this?

I would just say that when I was working, I used to work in an ICU quite a bit. And when somebody in their mid 80s needed a ventilator, we generally wouldn't do it because it was considered a zero probability of meaningful survival. And so, I mean, we would do it if the patient demanded it and really made it clear ahead of time. And that's what they wanted. We would do it, but generally we would try to avoid that because it was cruel, cruel, what you'd put the people through in order to get a few months of horrible survival on the other side. I mean, really stuff you don't want to go through, trust me. And so the first thing in COVID that caught my attention was putting all these elderly

patients on ventilators. That was bizarre to me. Was that weird to you? No, because when I was training, we would just do that. Like it didn't matter. 90-year-old ventilated. And we hated it. And I think that drove us too to use that gum. All right. Well, here's why I didn't do it.

A lot of reasons I didn't do it. I talked to my patients and their family well ahead of time. And so you got to have this. So this was what COVID brought out for me. It was like, talk to your family members now. Do you ever want to be in a nursing home? Me? No. If I am so far gone that I need institutional support, whether it's medical or neurological, if I need institutional support permanently, no, I don't want to be in a nursing home. And if I have a zero or nearly zero, 10% probability of meaningful survival

after a horrible intervention and I'm old enough to have a dignified death, no, people need to make that clear in writing to their family way ahead of time. And the worst is when as a hospitalist, so I'm an inpatient internal medicine doc, I pick up a team where no one had the thing and then you're inheriting this person

that now can't have the conversation. And so now that I make videos and do music videos and try to educate people, part of my thing, one of our most popular videos is called Ain't the Way to Die. It's a parody of Eminem, Rihanna, Love the Way You Lie.

That original song was about domestic abuse. I turned it into a song about the abuse that happens when we don't have a conversation about what our wishes are and you end up, all the things you said, you're on a ventilator, intubated, can't talk. Forget it. For nothing. No way to respect. For nothing.

For zero. We know. I'm sorry, but we know when it's a meaningful intervention. We're happy to, we're delighted to do it and keep fighting when it's a meaningful intervention, when it's a useless induction of suffering, why do we do it? And by the way, something like 60, 70% of healthcare dollars are spent in the last, what, six months of life? End of life. Yeah. End of life.

Needlessly. Needlessly. As opposed to. I'll say this. Yeah. Totally needlessly. And I'll say this, though, that we're not entirely uncalpable. There are doctors who are so afraid to have the conversation

and they get paid the more interventions they do in our current model. So every extra ICU days, another thousand bucks or whatever. So they're not inclined to have these difficult, heart-wrenching conversations with families. Whereas there was a Dr. Norm Risk at Stanford. He was the head of ICU. He taught me, I watched what he did. He would sit

down with families and say, you know, it's gotten to the point now where we're doing things to your loved one instead of for them. And I think we need to talk about that. And he was lovely at that. And he had every incentive to do stuff to people, but he was a good human being, is a good human being and a good doctor. And that's what we need to strive more towards. Part of this issue was my surgical friends who would announce when they came out of surgery, we got it all. That's it. We got it all for a solid tumor. And I would be like, I'd have to immediately just go, oh my God. So now I have to undo all that. You know what I mean? Because with certain cancers, there's no such thing as you got it all. Yes, you got all of that primary tumor.

The patient's family understand that as cure. No, no. And I have to start immediately. And then I'm the bad guy. And I have to really kind of start the process right away, like post-op. I remember I had one guy with a metastatic prostate cancer and they got it all when they, you know, they took out the prostate. I had to pull a family sign and go, look, that's, that's not what happened. That's not what happened. This

is not, this is going to be a different, this is a, we're still going to be in trouble here. I mean, you see that one with glioblastomas being removed, brain tumors that just, they simply don't get it all ever. Ever. And, and they'll say, oh, we got that they simply don't get at all, ever. Ever. And they'll say, oh, we got it all. And you're like, okay, this is, I understand the neurosurgeon God complex. I get that. You need some of that in order to be a good technician.

But we're the spiritual creatures that have to suffer when they see this kind of a front to human dignity. And so, you know, we need to change that. Another thing that struck me, again, I learned a lot during COVID about my peers. I was trained to do ICU medicine. I did a lot of it for the first 15, 20 years of my practicing. And I could do all the procedures. And when I signed up to be on the New York volunteer team, when they wanted ICU attendings and things, and they're like, can you put an A-line? Yeah. Can you put in a swan? Yeah. Can you put in a, can you intubate? Yeah. I was like, yeah, yeah, yeah. Do all this stuff. And they're like, you're a hospitalist, right? I go, no, no, I'm an internist. And that was, that was news to me

that in general internists weren't being trained to do this anymore. I couldn't believe it. We've sub-specialized a lot of stuff. So now, you know, when I started as a hospitalist, we had open ICU, we would go and take care of ICU patients. Then the intensivists became more of a specialty and they said, no, no, no, it's now a closed ICU. When your patient gets sick and goes to ICU, they go to the intensivist. And after a while, we started to lose those skill sets. Like putting in a swan Gans catheter was now,

which most of the times you don't need anyways, which is another thing you learn. Most of what we do doesn't help and actually causes harm, but we just don't know it yet. That's right. So that's another thing that I think is very careful. I liked it because I had so much data I could mess with. And you know what I mean? I loved having swans because it was like, you got a lot of information here. And that's why I liked about ICU medicine. You were

in control of everything, you know, like as what, what I, you know, you just got control. Yeah. And, and, uh, having control of people's physiology is a very, um, okay. Is a very, um, is a very secure feeling is you feel like, good, you know, I can now, and if things can't get away from me, which by the way, it was the other thing about COVID, things get away from us. That's what we couldn't let happen. That's why I could feel it happening in my own body. I was like, this is getting away from me. And that cannot happen.

That's how you end up in the hospital on a ventilator. Yeah. Yeah. And, you know, and one of the weird caveats to that is we feel in control, but then the question is, does it actually improve outcomes when you measure it? Different question. Different question. I understand that. I understand it doesn't, but I used to, we didn't know that back when I was doing it, frankly, but it just felt really good to be in control of things. I do felt like, it depended on the case, of course. Yeah.

Go ahead. Yeah. But you have the data right there yeah you can titrate the drip yeah yeah blood pressure is right right it's so great oh the urine output's down let's give a little you know we used to call renal dose dopamine oh yeah which is now kind of a myth oh yeah and open up the kidney flow and oh there's more urine and does it really make a difference to them probably not but man we feel good about i don't know i got pretty good at people getting people out getting through sepsis and out of the ICU. It seemed like, and maybe I kidded myself, but when I could understand what the systemic vascular resistance was, I knew what the pulmonary artery pressures were, and I knew what the intraventricular

pressures were on the right side. I had all kinds of stuff I could use in terms of bringing things down and pushing things up and making things easier for the heart to push things forward. That was at least what I thought I was doing. So what the hell? How'd you get into addiction medicine? I mean, that's like, it seems like a 90 degree. Oh, it was complete. It was two careers happened simultaneously.

So let me just quickly explain. I was asked to explain. I'm gonna take a break in just a second too. But an internist is general medicine, everything non-surgical, non-pediatric, everything. And then a hospitalist is somebody who does general medicine only in the hospital, as opposed to an outpatient internist only in the outpatient. And the intensivist doing only, again, internist only doing intensive care medicine, usually a pulmonologist. That's how you get into intensive care medicine through

pulmonary medicine these days, these days. So how I got into it, a complete accident. When I was a resident, I started moonlighting at this psychiatric hospital. It was a lot of old timers walking around the halls. And so I was this new, young, hot, trained internist, and the psychiatrist wanted me to see their patients. So I was seeing lots of psychiatric patients and doing essentially medical clearances because there was a lot of concomitant medical problems. In other words, medical problems contributing to the psychiatric illness, medical problems that they didn't know about that were causing the psychiatric illness, medical problems from the psychiatric treatments, which was very common. And so I got really good at medical management of psychiatric patients. And I was interested really good in medical management of psychiatric patients.

And I was interested in psychiatry and sort of started absorbing what they were doing. I thought I knew psychiatry pretty well, worked there for 30 years. And I still tell you, get a psychiatric consult. They have specialized training. They know stuff we don't know by virtue of their training. I understand a lot of what they do.

I know not to make some of those judgments that the psychiatrist is better equipped to do. Yeah. Yeah. And we did a lot of delirium management on the hospital service and, and, uh, it was a mix of psychology, psychopharmacology and internal medicine all combined. That was my thing very much because a lot of delirium was related to drug use and drug withdrawal and medication misadventures and serotonin syndromes and all kinds of stuff. I saw everything. You can't imagine what I saw. But most of the really significant medical stuff was going on on the drug unit. So all of a sudden, I'm down in the drug unit, and there was a guy there in 1984 that had invented, really invented at that time, protocols for drug withdrawal. I was like, wow, I'm seeing lots of addicts out

on the wards. No one's ever trained me to draw somebody from drugs. It was usually 10 milligrams of Librium and a little bit of, they were just very haphazard. There was no discipline for drug withdrawal. So I got very, very good at that. And then people are asking me to see drug addicts all the time. And then I saw these people go through something

called recovery. And I was like, holy shit, these people were dying and now they're better than they ever knew they could be. What is this? And the whole time before that, I'd be spending a lot of time on the drug unit. I liked the culture. I liked the staff. I liked the patients. And the 12 step were always up on the wall in the treatment room. And I'd be like, what is that goofy shit up there? Come on, I'm doing the real stuff here. I'm taking them off the drugs. And I got schooled a little bit on how this works. And then I was asked to be the assistant director of the program. And then the director six months later quit. And so suddenly

I'm stepping into a directorship and I had to really, really up my game and learn how to do this. And so all the while though, I was practicing medicine, outpatient and inpatient. So you could do that then. So I was doing inpatient, outpatient and inpatient. So you could do that then. So I was doing inpatient, outpatient medicine. And inpatient medicine meant ICU a lot of the time. And so I was doing a lot of ICU medicine for a long time. And that's how it happened. I love doing it.

And then I sort of dialed out the hospital-based practice, shrunk the outpatient medicine, and got rid of all the medical service stuff at the psychiatric hospital and just did the addiction medicine. And so that's what I did for the last 10 years or so. And- That's a great, so is that- What's that? Oh, yeah. I was going to say that beats my whole delirium management, which was a Haldol dart, just right in the neck. I was battling that a lot because Haldol makes a lot of deliriums from drugs worse. So I was, you're

right. I would come in as a consultant and the patients were vibrating above the bed and they're like, it's a guy's an alcohol withdrawal. We gave him 10 milligrams of Haldol. What are we supposed to do? I'm like, oh my God, that is wrong. That's not the right thing to do. Please don't. Let me take over. Let me, let me get this. And so, so when I, when we get back, I want to talk a little bit about, um, back to the fear based issues with physicians and how the opioid epidemic, uh, is a good example of how scared we get and how we change our behavior. I just want to, cause I lived through that too. And I have actually have a lecture series about it cause it was so vivid for me, what went bad in terms of the overprescribing of opiates

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All right, we are back. It's so exciting for me to talk to a peer, so I appreciate you, Dr. Damania, for coming in here. And my wife, producer, has notified me that I'm talking too much. So I'm going to try to get right to A, some calls, and B, get some comment from you about vaccine enthusiasm. But I do want to quickly talk about the opiate thing very, very quickly, which was that essentially I was around when they started finding doctors aside from their malpractice as criminal and civil injuries and putting them in jail for under prescribing of opiates, that creates the, created the huge opiate surge.

And then they started putting them in jail for over prescribing and they shut down immediately. That that's sort of how our profession works. We get scared and we, and we, we change, we either freeze or change directions immediately. And we're seeing that with COVID, is my point.

And it's been tremendously harmful to people who are dependent on those medications, whether they have chronic pain or they're just dependent. And then to suddenly have the supply cut off, you know what that does. And I remember, you know, when I was being trained, we had pharma companies coming in there and telling us, you know, pain is the sixth vital or whatever. And if you don't treat it, you can get sued. And also nobody ever gets addicted if they actually have pain when you give them an opioid is what we were taught. Which is the biggest bullshit of all time. And by the way, it was not just pharma saying that. It was the entire discipline of pain medicine.

And so I was fighting an army. I was fighting an army of people. And they were telling me that I was interested in patient suffering, that I was an old fashioned. And if my heroin addicts in withdrawal were uncomfortable, I would hear from the public health department, the Department of Mental Health, from my administration. I mean, this was ridiculous. But anyway, we'll move off that. That's it. You know, Drew, I bet what they were saying about you as well,

when you're a hammer, all the world's a nail, and Drew does addiction stuff, so of course he thinks these drugs are bad. He doesn't get it. 100%. Yeah, yeah. Believe me. And by the way, having as full and as rich an internal medicine practice and experience as I had, I get cancer pain. I get end of life. Of course we use opiates then, even for drug addicts, if they want it. Some of them chose not to do it. They wanted to take their recovery all the way to

the end. Great. If they didn't want, they wanted pain relief, bring it. You can't do enough to get their pain relief. But this, this all, anyway, I'm going to get off of that. But talk to me about, you wrote an article, did an interview about the optimism around vaccines. Why aren't we expressing more optimism? It's a great question. Yeah.

Yeah, I did a rant from the studio and it got picked up by MedPage about this idea that the CDC, it took them a while and they finally said, hey, guess what?

When you're vaccinated, you can hang out with people who aren't vaccinated that are low risk in your house without a mask. It's like, oh, thanks, professor. Thanks for the kind words. It's like, isn't the whole point of vaccines that you prevent both getting it and transmitting it and that the idea is that we then release

and relax restrictions. And this idea that we've been so conditioned to fear the optimism that, because I think we've got burned a little early on, oh, this thing's going to go away. And I was a little guilty of that too. I thought by summer, things would really dip down to the seasonality and I was wrong about it. And so people now are very burned. They're like, well, no. And I think what's happened to Drew is that, and I said this in my piece, there's a public health, there's a group of people involved in public health that are very big on social media. So they've been empowered by the pandemic to get

famous really in a way that no one else cared what they were doing before. And now suddenly they're the most important thing in the world. And they are what I call their doom bags. So there are people who are just out there slinging doom bait headlines and, oh, well, okay, yeah, the vaccines are ridiculously effective, but we can't say that. We'll say, well, but what about the variants?

And what about asymptomatic transmission? And what about, and so instead of us rejoicing the way we rejoiced when polio vaccine came out, school was canceled so kids could come home and celebrate. Like, oh my gosh, this huge weight. The most amazing science has been done. We're like, well, but the Brazil variant,

some people are getting reinfected, not dying, not being hospitalized. And the vaccine still prevents that at a ridiculously high rate. I love this guy. But we can't talk about that. I love this guy. Well, this is what Susan's been talking about for a while.

She's like going, why aren't they telling us what to do if we've been vaccinated? Why aren't they telling people like me, who have high immune profile, why aren't they telling you what you can't, why are you the same as you were before you were sick? I'm literally, nothing changes for me in spite of the fact that I'm probably immune

even against the variants. Probably, I don't know, maybe not. I'm probably immune even against the variants. Probably. I don't know. Maybe not try not get, try not to get canceled here. Dr. Z. I see what's happening.

Everybody's so scared this morning. My 79 year old housekeeper. She's been with me for 30 years. I got her the vaccine. I drove her down to Dodger stadium twice. She got the vaccine. She shows up with a mask at work every day. She said,

I hear on the news that two years i have to wear the mask two years two years she can't speak english okay but and we're just like and then we had to try to explain to her it's okay you know you know where jordan's had covid drew's had covid i don't have covid it's okay maybe when the workers come in the house you can put the mask on but you don't have COVID. It's okay. Maybe when the workers come in the house, you can put the mask on, but you don't have to wear it all day. She runs around this house like crazy with a mask on. I feel bad. Look, Drew's got immunity.

I've been vaccinated twice. I would come right now to LA and kiss Drew square on the mouth and feel perfectly good about it. As Bert Kreischer said to me, I could spit in his mouth. So. As Bert Kreischer said to me, I could spit in his mouth. And think that, you know, your housekeeper, you think about her and your heart goes out because she is being, I think, a victim of this culture of pessimism and fear that we've now become inculcated with.

It's so weird. What is it? I find it's well, I think we've we've well, I think we've had a narcissistic term. And I watched it happen on the admission sheets at that psychiatric hospital where I worked. The Axis II, which is the personality disorders, used to be all over the place. By early 90s, 92, it was all cluster B, which is the narcissistic disorder, and stayed the same ever since. And I sort of wrote a book about it, and I've seen how it's happened. And most psychologists will tell you what they're dealing with is trauma and the results of narcissism in relationships, not the narcissist themselves because they never show up. It's the people that are affected by the narcissist.

And I feel like we've turned from narcissism to histrionic. Like we shifted where hysteria and fear and really kind of delusional thinking is somehow gratifying. This is the doom bags you're talking about. I mean, what is so gratifying about scaring people? I don't understand that or controlling people or telling people how to live their lives. That's the most unpleasant thing I could think of, but we have seemed to have developed a whole world of people who are either just gratified by that or want to be told what to do or made hysterical, right? It's a thousand percent true.

And I think there's so many doctors out there who are like, this is ridiculous, like what's going on. Like, I mean, they're the silent majority. They're sitting there going, wait, this is crazy. And the truth is, i think what it is is you're seeing a culture of safetyism that jonathan height uh a social psychologist has written about h-a-i-d-t it's this idea that the the uh yeah coddled americans or whatever you call it coddling of the american coddling the american mind yeah an absolute must read if you're a fan of either dr drew or myself because we're promoting

this kind of alt-middle idea that, no, wait, no, you don't cancel people. You allow free speech. You have healthy debate. And actually those other ideas of like, no, speech is violence and words can hurt you are dangerous ideas, actually. The words aren't dangerous. The ideas that speech is dangerous is dangerous. And so with this, this idea of safetyism— Study your history. There have been many, many, many, many examples of history where it has gone from that to much more dangerous policies and things. I mean, history's replete with it. It's replete with it. The idea of safetyism is that if you can save people at all, then you've got to save as many people, everybody that you can.

And that means that we stick our head in the sand, any concern about variants and forget about the bigger picture, which is what harm you're doing. Like you and I grew up in the age where you sit in the back of a station wagon with no seatbelt and you bounce around like an idiot. And it wasn't the best thing in the world, but we did survive it. But then around about the seventies and eighties, there were a series of high profile kidnappings where parents were suddenly on edge. Even though society was getting safer, they were terrified their kids were going to be kidnapped. So now kids don't get to play by themselves. They don't get to talk to strangers at all.

Forget about going with strangers and all that. You don't want to do that anyways. So this culture of fear and safety creep where, okay, well, now the playgrounds need to be padded all around. And, of course, then there's the legal component. If you don't and someone gets hurt, then you're culpable for it. And now parents are arrested for letting their kid go to the supermarket by themselves. And so this kind of same thing is now what we see with, well, now you got to wear 12 masks because 11 is good. 12 is a little bit better. And we're never going to be able to open up until never. It's irrational.

And the other irrational thing, I heard physicians say the following phrase repeatedly, and it was, again, just kind of astonishing to me. One death is too many. One death is too many, then we don't have a pandemic. I mean, if we're going to have no deaths, then it's not a pandemic. A pandemic is excess death. That's what a pandemic is. It's awful. It's terrible. It sucks.

But we have to make risk-reward analysis all day long. Yeah, right? All day long. A young person, 24 and younger, is 36 times more likely to die in a car accident. We don't say don't drive. Right. One death is too many. Well, don't drive over 13 miles an hour.

Because one death is too many. One death is too many. Exactly. And then you have the Connery thing with like the anti-vaxxers who are like, well, one death from vaccines is too many because, you know, it's the same argument as you'd say, well, but a seatbelt could kill you. Right. In theory, it could cut you in half. Right. So no one should wear a seatbelt. It's the same argument as you'd say, well, but a seatbelt could kill you in theory. It could cut you in half. So no one should wear a seatbelt. It's like, okay, guys, let's just find the truth here. It's somewhere more nuanced than what you're saying. I have a question too. I want to get some calls here too. What are we going to do when we get a runny nose after this is over and I catch a cold?

What do you mean? Oh my God, I don't know if I can handle it. They're going to tackle you and put you in a bubble and beat you. Well, we're going to take you. Some people are into that we're gonna take you we're gonna take you out of work or school out of work or school you cannot worry can't go to school you won't be able to travel for the rest of the year a phone call no because you'll you'll contaminate the phone no yeah yeah are you kidding call my and who knows what you my medical lawyer and make sure I can leave the house. There is an interesting sort of corollary to that question, though, which is how much do we want to really completely protect ourselves from infectious agents?

I mean, when could we have gone too far? Yeah, am I going to have any immunity? Right. We don't know where that point is. That's kind of an interesting question. I'm used to getting a snotty nose every three months at least. Right. We don't know where that point is. That's kind of an interesting question. I'm used to getting a snotty nose every three months at least. Right. And you do wonder with the viral interference question, if regular coughs and colds are actually protecting us from more serious viral infections, you know, just by the innate immunity. So, you know, I don't subscribe to people who say, well, masks are making us sick and all that.

But I do think that natural exposures and the hygiene hypothesis with allergies too, are we sterilizing an environment for our youngest kids that are going to generate autoimmune and allergic responses? It's a valid question that should be looked at. All right. This is Jennifer. She is a nurse. I finally want to get to her. I'm going to try to get to your calls now, guys. This is Jennifer. Hi, Jennifer. What's happening? Hi, Dr. Z, a big fan. I'm a supporter. Hi supporter um hi dr drew i have a question nurses oftentimes bridge the gap between patients and family um like what language like any tips of how we can approach with the patient's family you know instead of saying oh mom had a really bad night you know mom may be 75 years old severe COVID and we're fighting, fighting, fighting.

And like you said, Dr. Z, we're torturing these people. Yeah. Jennifer, I would like to see nurses do more. I'm sorry to put this on you. Like you need more to do, but you're there with them all day and you see the family coming in and out and the doctors are avoidant of these questions and feel like they failed if they have to get to them. And I love it when nurses, I've noticed that nurses have lately started to pick up a language, which I'd like to expand, which is, he's really sick. I don't think they quite get what you mean when they say that. What I do is I start to use language about what the recovery could look like if it's really at a certain point where you go, you know, certain things you don't want to recover from. There's certain things that there's just too much, you know, go ahead. And I would add,

I would just say one thing as a nurse, you know, when Drew said you're adding another piece, well, let's take a piece away. How about you chart less? All those nursing notes, most of them are just garbage that's put on you by administrators. Yeah. Yeah. Which is put on them by a lawyer. Ethically. Yeah. Yeah. How can we bridge that gap? And I, you know, I love nursing colleagues and I love working with them.

And I, so I get to hear what you're really thinking all the time and the level of frustration you have with some physicians and the, you know, some of the things like not being honest with the family and continuing to, you know, to pursue torturous kinds of interventions. I wish there was, I don't know, Dr. Damani, if you know now, there's no system for them to go to. They can't apply to an ethics board, really. They can't really do that in real time. I mean, how can we empower nurses to, maybe the ICU director? We need to allow people to practice at the top of their abilities and training and that means that nurses should be doing that high level intuitive stuff that only humans can do and they should take away all the garbage stuff they make them do and give it to a computer or a clerk or somebody else and if they do that then they can appear you know we can have an interdisciplinary

team where nobody's really the boss. Everybody's the top of their own little hallarchy. So they all have their skill set that they bring. And that's the best. That's why I think that's maybe why you liked ICU too, because it's why I liked ICU. It's why I liked addiction medicine because it was all team, all team. You had to be huge, cohesive, cohesive team. Case manager, social worker, everybody. Yeah. So Jennifer, I think what we're advocating is just make sure whoever is in charge of this, you knows how to build teams and get,

get the teams, you know, working more effectively together because a really good team. Go ahead. I was going to say the only intervention I have right now is getting palliative care or palliative care specialist, you know, to consult on,

you know, 75 year on, you know, 75 year old mom who's in hospital with severe COVID and she's fighting the bypass like a wild tree cat, you know, like, yeah, we get it. And I'm trying to get her oxygen up to 85%, you know, because doctor said 88 or better, but how can I, like, I guess I'm just struggling right now with the language on how I can help bridge that gap. I love that you're getting, I love that you're getting, look, the fact that you're able to get palliative care, that you have palliative care

and you can get them in and people are listening to you to bring them in. That's huge right there. So good for you. And you can feel the moral injury. You can feel it through the phone. She's like, I'm having to do this for this woman and I'm powerless to stop it, even though we know what should be done. Yeah. You see how different this is than one death is too many. One death is how anathema one death too many is. It's like, this is a shitty disease. We're doing the best we can, but bad stuff happens. Let's see. Thank you, Jennifer. And thank you for the work you do.

Believe me. Thanks for your support, too. Yeah. Oh, yeah. If you're of Dr. ZDogg. Brian, what do you got there? Hey. Hey.

Hey, guys. Dr. Z, Dr. D, you guys should make your own spinoff show. I just thought of that while I was on hold. But I think you may have actually answered my question about a minute ago when you were speaking about the opioid epidemic. But I used to work in healthcare and I would meet with, you know, probably hundreds of doctors in all different specialties. And one thing I noticed that I'm curious to get your opinion on is behavioral health doctors, psychiatrists, even some neurologists were by far always the most shell-shocked and had almost a PTSD symptom just when you speak to them, even to tell them good news.

And I'm really curious what the COVID pandemic is going to do to those, you know, providers in the future. But I'm curious if something happened, you know, in the 90s or 2000 that, you know, initiated all that anxiety and that stress that for some reason it feels like behavioral medicine experiences more than other specialties. Do you want to answer that? I have my own theory about it because I watched it happen. Yeah, well, you know, you probably know better than me, but I'd say it was in the 90s when we started getting the mechanization, the commodification of medicine, starting with HMOs and taking our autonomy away. And I think that loss of autonomy, I think there's three things that people need at work in order to feel capable and connected and empowered and connected to their purpose. And that's the tools to do their

job, which means technology and stuff like that. The resources, meaning human resources, team, interdisciplinary stuff, and the autonomy, even if it's just perceived autonomy. And those started to be taken away because the tools we were given were garbage EHRs, which made our life worse. Resources were strapped and our autonomy was gone. And the volume went up and the ability to really make a difference went down because you couldn't invest the time and energy necessary to make somebody better. And brain disorders, it's interesting you said neurology also, brain disorders take a long time to heal, a long time. And if you're not investing structure and time and disciplines, multiple disciplines into the effort, it's a waste. It's why you have the

streets full of homeless people. These are open air asylums, everybody. It's because of what you've done to our healthcare system. It's what it is. And then you legalize drugs and legalize stealing to support drugs. And now it's on. Welcome to California. And then that's what we got here. That's what we have. And I know exactly how to fix it because I worked with these patients for 30 years and they can get better and they can thrive. Instead, just in LA County alone, they're dying at four per day. So again, moral injury, Brian, that, that it just, you just get to the point where they give up and that's a very helpless, sad, traumatizing place to be in. And they're living in fear constantly the rest of the time. Fear of liability, fear of the administrators, fear of the department of mental health, fear of making an error on the record, fear, fear, fear, fear, fear. That's not fun. Makes sense, Brian? Not fun at all. I really appreciate the answer and i'm a big fan fan of you guys i hope you guys stay strong and good luck with the youtube algorithm also

and i love it i will tell you it's in the the it'd be you know there's a flip side to what i was just describing about the fear and the liability and the burden and the helplessness, which is that we know this could be so joyous. It's such a joyful thing to do. It's what forces you and I to do other things, right? It's why we do other things. We need to give of this in a way that feels productive. I mean, I've started doing my addiction medicine for free wherever I can because it just doesn't make sense to pay for it anymore because there's not enough for my time. It's just, don't forget, it's for free. Just give it away. Because I have all this knowledge and experience and it's just, you can't do anything with it if you're within the system.

Crazy. And I won't see patients for money anymore. I do it for free as UNLV faculty. And what I would say is you always think back to what are your best days as a doctor and they're just this transcendent, oh, it's like a opening expansion of your consciousness because you feel so connected to a purpose and other human beings. And I think the goal is you strip away everything that isn't necessary to that. And it means looking at your patients in the eye, having the resources to take care of them.

And then all the science behind it then supports what are the right decisions, but they don't turn you into an algorithmic cookbook checklister. Right. You're automatically, when you're using your experience and knowledge, you're in what people call flow.

You're in the flow. Yeah, you're in flow. Automatically you're in flow. And it's a very gratifying place to be. And what Aristotle called eudaimonia, which was essentially using your skill and wisdom to help a person, to be of service to a person is deeply rewarding. And if you know that you can't do it in spite of having the capacity to, it's like literally being like a lifeguard or something and having to watch somebody drown, even though you can swim out to them and you can sort of make them feel a

little better. Give them maybe a little, you know, a floaty and know that it's not going to work, but even though you know, you could save them, that that's, it's an awful feeling.

Yeah. Okay. Let's see what else we got here. What's the matter, Susan? You're laughing about us, Susan. Yeah. Is it What's the matter, Susan? You're laughing about us. Susan? Is it because I'm bald, Susan?

I'm sorry, what did you say? Is it because I'm bald? Because I will not be laughed at because of hair loss. Yeah, it is. My wife has already done that. The world is beautiful, my friend. She's a hate speaker. She speaks hate.

She does. Is there anything about your heritage she can go after too can we do that because she speaks hate yeah absolutely yeah yeah you know my parents are from india just this is interesting uh that's interesting i've got a lot of interesting calls here i'm going to try and talk to we're going to get an actual clinical question here uh brianna or brianna yes hi dr drew hi dr z i'm a big fan hey there hi so i'm 25 i was diagnosed with idiopathic small fiber neuropathy through a skin biopsy um i can't walk longer for more than 10 minutes,

10 minute intervals. And it's really hard for me to go up the stairs. My legs start shaking and giving out. I just wanted to ask, is weakness in the legs related to small fiber neuropathy or is it just like the sensations in the legs and the pain? Do you want to address? Because I have some thoughts.

So, yeah. And this is out of my standard specialty of hospital medicine. So I will have to refer to my colleague, Dr. Drew, on this one. I think if I remember right, this is in the category of dyschwanomas. Am I right about that? How do they characterize this? Hang on a second. Dishwanomas.

Small fiber neuropathy. Yeah. Trideminal dishwanomas, or dishwanomas. That's a tumor. Well, in my experience, when I've seen these polyneuropathies associated with motor dysfunction that are in the small fiber, and you said it was from a skin biopsy or a sural nerve biopsy? It's almost like a punch biopsy. You just did it in the office.

In your arm or your leg? Two parts of my leg, my ankle and then my mid-thigh. Okay, got it. In my experience, when I have seen neuropathies like this, these complex polyneuropathies, oftentimes, did you have like a GI illness before this thing set up, like a diarrhea or anything? No. I mean, sometimes I'll have some stomach problems. Do you remember when it presented, though, when you first, all these neuropathic symptoms came on? Do you remember?

Were you sick? No. Go ahead. It was very gradual, I think, probably starting around age 22. I had to give up hiking, and then I had to give up cycling, and then gradually I had to give up walking. Let me just say, there was some data that suggests some of these at least are related to infectious diarrheas. And I've had a couple of cases. And we treated them pretty aggressively with steroids and immune modulatory agents.

I'm a little confused why you weren't treated for this. This all sounds new to me. Yeah, see. And this was a neurologist you saw? And it makes me frightened to ask this question. Do you have insurance? Were you sort of put out because you didn't have resources? I have LA Care, so I have to go to who I have to go to.

So that's the problem. That's the problem. I would go back and say, look, this thing is affecting my ability to function. Can we do something to reverse this or halt it so it doesn't become permanent and more progressive? There is a lot to be done for these immune polyneuropathies. There's a lot to be done. And I'm a little surprised they haven't done something. Okay? Yeah. Yes. Thank you so much. That really helped. All right. Good. And it's weird. I think it was Campylobacter, if I remember right, Dr. Z, that was one of the agents that was

sort of implicated in this. Again, it's all faint memory for me. Go ahead. You know, those post infectious neuropathies are fascinating because they think it's a autoimmune syndrome triggered by some similarities between the viral antigens and nervous tissue and even Guillain-Barre, which is another, you know, demyelinating, that's a slightly different product. In fact, these often have a very guillain-barre like syndrome they're kind of but they don't ascend as far and they're and they're very specific in terms of their pathology on microscopy they're a little different that's interesting yeah yeah because when she talked about it i thought oh this is like guillain-barre light yep like she she's not on a

ventilator it's not ascending and it's not reversed yet, which is also concerning. Yeah. Yeah, I mean, there is stuff to be done these days. I mean, back in the day you go, well, do you really want to give her a whole bunch of steroids that may continue anyway? And that kind of thing. Now, no, no, no, no, no.

There's a lot to be done. They can nail it down. A lot you can do, yeah, with immune marketing. Yeah, exactly. You know, one thing I wanted to mention, because we were talking about these kind of ideas of burnout and injury, this distinction between empathy and compassion for caregivers. Like listening to her story, you can empathize, which is feeling another's pain as your own,

and take that on you and then react from that place, which is a reactive place, a defensive place. It's a narrow spotlight on just her, not looking at big picture. And that's what they ask us to do, be empathic. But then we take that home with us. It's painful for us because we're feeling another's pain. As opposed to compassion, which is love and concern for another in the face of their suffering that is a little more detached, but also filled with a desire to help. But it could be a bigger picture thing like dealing with addiction. You don't give a heroin addict heroin to immediately relieve their withdrawal symptoms. There's a broader compassion. Have you thought about that?

Oh, I spent a lot of time thinking about this. And I think you can break down what you're pointing out into different specific little syndromes associated with how we as practitioners accept this or experience this. One is contagion, right? There's emotional contagion. That is not good. If you are overcome, if you are literally catching another person's feelings, you are not going to be available to help that person. You're going to be overcome just like that other person. The other thing is mobilization of tender aspects of yourself that you think is the pain in that other person. The other thing is mobilization of tender aspects of yourself that you think is the pain in the other person, which is called codependency, which is a boundary issue. So this is all boundary stuff, right? If there's a boundary, you can't catch it. If there's a

boundary between self and other, you can distinguish your pain from theirs. But if you start thinking to yourself, oh, I have a special understanding of that patient. Oh, they're in so much pain. I've got to make that pain stop. That's your pain. That's not their pain. That's your pain that you need to make stop. They need you to be present and available and effective. They don't necessarily need you to make the pain stop. When you need to make a pain stop, that's because you can't tolerate it. You need to do the best you can to control somebody's discomfort and to be available to them and present. They need you to contain and hold and be fully there. It's like if an ambulance driver shows up and starts crying or gets upset or is overcome by your pain because you broke your leg, that paramedic's not going to be very effective.

And by the same token, if they're completely detached and sort of throw you around a little bit, also not effective. So there is this middle ground we call a frame where you can hold somebody and be very appreciative. The word is appreciate what they're experiencing without being overcome or without contagion. Does that make sense? Yeah, I call it, it's brilliantly put. It's like a witnessing of suffering. You're there to bear witness and contain it. I like that word, you're containing it. Containing it, holding it, holding it and appreciate it. And there's actually another second order kind of conversation. How do you, and this is something you have to practice,

but how do you signal to that patient that you understand what they're, you appreciate what they're going to? It turns out tiny facial muscles, the tiny muscles in our face will give that signal subconsciously. We'll go right past language, right into the emotional centers. So this is that idea of holding the space, like a guide does that, a spiritual guide does that. And what we do with masks though now is we cover up those minute facial gestures that show that I'm there with you. And I think that's disturbing the healing relationship. We call it the placebo effect.

It's really the healing relationship. It's almost a shamanic relationship. You're like a guide. And like you said, you can't break down. Occasionally, I imagine it's warranted and appropriate, but in general, they need you there to hold the space and witness the suffering. And in medicine, I call it also, so when we're talking to our tribe of people, like other doctors, I call it communalization of pain.

Like when we get together and we go, yo, you're not the only one suffering. Hey, me too. Let's talk about that. Me too is very powerful. That's how recovery go, yo, you're not the only one suffering. Hey, me too. Well, me too is very powerful. Me too is very powerful. That's how recovery works, essentially, in addiction. Just somebody going, yep, me too. And really meaning it. Really meaning it.

You got to mean it, though. You can't say, it's a deep me too. It's like, oh, yeah, trust me. I've been there. Me too. You know, that's that communal quality, fellowship quality that people need. And to your point about the mask. So we, we're not giving children the opportunity to develop that skill of reading second order representation, thereby blocking the development of affect regulation and sense of self even because self emerges in others,

right? That's your, see yourself reflected in others. So we don't know the full impact this will have. It's really actually very, very concerning. And it probably is contributing to all of our sense of social isolation. That's why we're so hungry for contact. I think I agree a hundred percent with this. Yeah. And again, we just don't know. I mean, we can't say that we know, but I'm concerned. Concerned. I do believe, I'm concerned in the sense that we don't know, but I do believe there'll be recovery. I do. I really believe it strongly. I'm optimistic about everything. But man, you know, and let's just kind of, I guess we should wrap up by talking about

the, what'd you call them again? The doom, doom, porn, porn panics, the doom bags. Yeah. When you look back at this year, what do you think? And we've covered kind of a lot of specific territory here about our peers and things and about school closures and masks and things. But, I mean, what do you think? What do you, what do you, I guess I'm, let me see if I got all my notes right here. One hand, I want to ask you, you know, what did you learn?

The other hand, I kind of want to ask, I think I want to ask a little more, how do we go forward? I think that's really more what I'm interested in. What do you see going forward? I think the central thing that I've really discerned from this mess is that we have created a society where social media, cable news, these kind of things are, their business model is so wrong in that you got to get clicks through provocation, through division, through sowing misinformation spreads faster than information. And the idea that there are only good and bad people in the world and you just pick a side and you go on social media and you fight. Well, now you have the doom bags on one side and the total deniers on the other side. There's no nuance, no middle ground. Forget even middle ground. There's no

seeking of truth. It's just scoring social points. ground. Forget even middle ground. There's no seeking of truth. It's just scoring social points. And I think that's why we're in the position we're in. Because when the next pandemic comes, the one that's got a case fatality, infection fatality rate of 5% instead of 0.2, the one that affects kids like adults or worse than adults, in which case all of us, forget empathy, compassion, it's all out the door. These are our children. At that point, if we're not in a good position where we've changed how social media works, we've changed how the mainstream media is incentivized to give news, go back to the Walter Cronkite model instead of the clickbait fear porn model. I think then we'll be in a much

better position to, first of all, love each other, connect with each other, go back to respecting intent of people. Like, look, you and I get stuff wrong all the time. We can, well, mostly me. You could say. No, I do too. In medicine, you update your priors and you expand your knowledge base. That's how we move forward. It's how we do things.

That's Bayesian reasoning. And the thing is, we have good intent. We're not trying to hurt people, pull the wool over people's eyes. We mean well. People assume ill intent because they assume there's only good and bad people because they look at Twitter and people are rewarded for behaving like they're only good and bad people. And I think that's the thing that I learned from this pandemic that we can do better and we need to start working on it like stat. And I'm hoping the marketplace takes care of some of this. I mean, stop, stop watching cable news. That's full of panic porn. Then the market will help. Yeah. It will help us, you know, make things better. And I, and I, by the same token, I hope something happens with social media that holds them accountable so that people can't indiscriminately harm people, harm people, frankly. Yeah.

And yeah, Alex de Tocqueville, I've mentioned this many times in Democracy in America in 1829, pointed out that we have the greatest privileges of speech laid out by law, but in actuality the least free speech because of what the town square

is a place where people get yelled down and tackled and unable to express themselves. So here we are. Now we've made that square. It's prophetic on many things about America. Indeed. All right, my friend. Great to spend time with you.

I appreciate you being here. It's been a great conversation. It's great. I just love talking with peers and trying to make sense of what we've been through. It's been a lot about it that I find myself shaking my head. And not the least of which is that, we didn't really talk about lockdowns and all that stuff,

but that the policies of the Chinese Communist Party were adopted as some sort of mainstream infectious disease interventions, when in fact they'd never been contemplated before and just been, it's looked like they were trying to hide something. I don't know if they were or not, but it was so not what we do with infectious diseases. And then that we adopted that and then killed people with mental health issues and driving people into poverty. That's the part that I look back on

this and just go, I just shake my head. We should have, we didn't know. Okay. But we should have gotten out of it quicker as we, as we learn about it. Five years later, we'll look back and say, mistake, mistake, mistake. We did that right. Mistake, mostly mistakes. So hopefully we're ready for the next one because I'm an optimist. History will not be kind. I think you're right, Susan. I think that's true. I think history is not going to be very, very kind.

I hope not anyway, frankly, because that's how we're going to learn from it so because those will be rational people looking at it historically without the hysteria of the moment where the hysteria is gripped by the moment yeah very weird way i was a history major so ah of course there's you know what you're talking about uh thank you caleb thank you scandal we'll talk about deep teapot dome yes uh that's really We'll talk about teapot dome. Yes. It's really funny. But thank you all. Sorry I couldn't get to everybody on the phone line.

And I was watching you guys on the restream. Thanks for those of you that are coming to our defense. We appreciate it. And tomorrow we have the seed guy and we have the travel guy. That'll be tomorrow. Tomorrow. The points guy. Sorry.

Not the travel guy. But they will not compete with Dr. Zubin Damania, who's carried the day. At 1130 a.m. Pacific. Follow him at ZDogg with two Gs, MD, at ZDogg. And then the YouTube channel is the same? Same thing. ZDoggMD everywhere. ZDoggMD.com.

You can find all our stuff and so on. All right. It's been a joy. It's been so much fun. It's been fun. Don't be a stranger. You're amazing. All right. We'll see you guys tomorrow't be a stranger. You're amazing. All right.

We'll see you guys tomorrow. Thank you, guys. Thank you. Ask Dr. Drew is produced by Caleb Nation and Susan Pinsky. This is just a reminder that the discussions here are not a substitute for medical care or medical evaluation. This is purely for educational and entertainment purposes. I'm a licensed physician with over 35 years of experience, but this is not a replacement for your personal physician, nor is it medical care. If you or someone you know is in immediate danger, don't call me. Call 911. If you're feeling

hopeless or suicidal, call the National Suicide Prevention Lifeline at 800-273-8255, anytime, 24-7, for free support and guidance. You can find more of my recommended organizations and helpful resources at drdrew.com slash help.