The Ricochet Podcast - Ask Dr. Savage

Episode Date: May 1, 2020

Dr. George Savage is the Chief Medical Officer / Co-Founder at Proteus Digital Health, Inc (full disclosure: he’s also a member of Ricochet’s Board of Directors) and has been closely watching both government’s management of the Corona crisis, the evolution of the testing protocols, and the search for a treatment and ultimately, a vaccine. In this conversation with Rob Long, Dr. Source

Hello, and welcome to another edition of Ask Dr. Savage. In the middle of this, I don't know why we had to wait for a contagion, George, to do this. Why don't we have to do that? Well, that's it. You know, doctors never want to talk to you about how great everything is. That's right. Or rather, patients don't want to talk to doctors. But anyway, you get it.

Yeah, that's right. I just want to hear that I'm going to be fine. So we are here with a Ricochet Council friend, board member, investor, and dear friend, George Savage, who has sort of guided us as a company to where we are now. And that's not your fault, George, by the way. meeting, every single board meeting we have begins with a recitation of a litany of complaints, physical and physical ailments that each one of us has. And then we turn to George and say, what do you think of that? So we're sharing the free medical advice he's been giving to us privately in now in a public forum. George, how you doing? So you, you let's just, just bring everybody up to speed. You had it. You were, you, you, you were not, you were, you, you were, uh, worried about infection.

You took the test. You didn't have it. Was that right? Or would you get a, did you get a false negative? How do you feel? Yeah, well, I feel great. Um, yeah, some weeks back I had, uh, very unusual symptoms, chest tightness, dry cough, no fever.

Um, and then after a week it went away, but the symptoms felt different than anything I'd ever had before. So I went and got a PCR test on the first day that Stanford Healthcare was offering them, and I came back negative. I have not had an antibody test. I still wonder whether I'm one of the asymptomatic ones. You just don't know. I've heard a lot of anecdotal reports from colleagues and friends of high fevers and symptoms that were unexplained dating all the way back to January, where they also have similar worries about whether or not they may have had it. Right. And so do you expect to get an antibody test sometime soon or, or not? I mean,

well, if I could, if the opportunity presented itself, I certainly would, but I don't want to, you know, try to shove my way to the front of the line or something. I think more important than my own personal test is general surveillance in a more organized fashion, which I know people are all trying in different areas to get a real handle on this uh so so let's just quickly you know i i know we're all sort of like i don't know what we're od'd on this now as it were but let's just get the state of play now so here's you tell me what you think i was told you got to stay in mitigation strategy is important it keeps people from dying in the emergency room and dying in hospital

parking lots it keeps you know the people who have other emergencies from entering a hospital that is overwhelmed and unable to serve them because we don't know how many people this is going to send to the hospital it turns out we lucked out a little bit right don't don't you think i think so yeah i do think it was uh what it was, if you had to put it at a combination of luck and or the good sense of the American people to sort of do reasonably what was asked of them, is it 50-50? Were you luckier? Do you think that all of the social distancing really worked? I mean, where would you place it if you had to on a sliding scale? Well, first of all, we are operating with not nearly enough data. We have a lot more than we used to have. So the answer is not really certain, but I think social distancing has certainly played some role,

but less of a role than I think people thought at first. The disease appears to be much more prevalent than had been thought earlier. I saw a report that in New York City, something like 25% of patients who were tested in one survey were positive for COVID-19 antibodies, which means that this is widespread. And if you look at the experience of states that shut down late or not so much, like Texas and Florida versus California, with the exception of New York, they're all doing more or less the same. Sweden, which hasn't really locked down at all, isn't doing substantially worse than Norway. You can argue at the margin on that.

But so I'm just not sure that social distancing at the level we're employing has delivered everything we hoped. Right. But it delivered whatever it delivered. It wasn't as bad as we expected. Is that fair? That's right. That's right. It's fair to say that the idea of initially 15 days to stop the spread or slow the spread, flattening the curve, avoiding overwhelming the health care system, that's all worked. Whether we needed to do that or not, who cares looking back it's worked we haven't overwhelmed the health care system so we need to reverse course and and try to find ways to get out of this as quickly as we can and um uh you know of course we have some governors dragging their feet on this and others um uh in the forefront we'll see. Right. So Georgia forefront,

Gavin Newsom, not so much, not so much. Yeah. I mean, I was chatting with some colleagues the other day and we were wondering about the political advisability of trying to prevent cooped up, crazed families who've been stuck with their small children all week on a

hot weekend in Southern California from going to the beach where they can easily stay separated from people. And, you know, good luck with that hot and sunny and all that stuff. So I want to get to that and I want to get to the future in a minute, but let's just, just go through the test.

There's the PCR test, which tests if you've got, if you've got the virus with you now, that's right. Genetic material. It measures that it is from the virus yeah that's right and then there's a second the antibody test test for two different things i'm by the way i'm reading off notes here just so i can you know i'm not like i'm sorry igm and igg yes antibodies

possible antibodies and um if you test uh a positive or any of the antibodies, it means that you are recently infected and that your body has degenerated antibodies to the virus. But it doesn't mean necessarily, we don't know yet, if it means that you're immune. That's right. This is one of those things where we're still waiting for the data to find out what degree of immunity is conferred by a past infection and whether those antibodies are sufficient for short-term immunity, whether it persists a long time. Some viruses work different ways. German measles, you have antibodies, good. You're good to go for pretty much your lifetime. Other things, patients who have HIV have active HIV infection. Their

body has antibodies to it. They just can't kick it. And you have medications to manage that. And so viruses behave in different ways. Coronavirus is kind of weird. It ranges from the common cold that we're all aware of. That's a coronavirus in many cases. Two things like SARS or what we're seeing now, SARS-2. So I guess what I'm trying to say is like, is there a way to catch just a little bit of it? I mean, is all virus all the same? I'm thinking of our friend Richard Epstein, who wrote a piece and got in a big trouble for it and then was sort of lambasted in The New Yorker for it. Because he kept saying, he kept using lay terms lay language that i kind of knew what he meant but if you know if you know anything about the subject you thought

was just idiotic he kept saying the germ whether the powerful germ versus a less powerful germ and i think what he meant was viral load does that have any what does that mean in the case of Corona? Like you can, can you get like a, I only got a little, like, uh, somebody who had COVID-19, uh, sneezed on a, a subway, uh, pole. And 30 minutes later, I grabbed that subway pole and I got a little bit of it on my hand. And then I brushed my eye and I got a little, I mean, is that, is that actually, is it all or nothing? The amount of inoculum can be related to the- Inoculum, that's the word. Yeah, the amount that you get at the start

can impact for some diseases, the clinical course that you wind up having. And there've been animal experiments where you find the lethal dose of a certain bacterium. In other words, if you just have a little bit, it's obviously starting to reproduce from a much more tenuous position in the body. There's less of it to start with fewer cells infected at first, that gives your immune system more time to whack the virus before the virus and it's doubling time winds up getting out of control

and whacking you. And so that that certainly can be a factor. Another factor can be that the virus continues to mutate. Now, how mutable this virus is is still an open question, but we know that viruses change over time as they go through multiple generations, and there may be more than one strain circulating. Some may be more or less deadly. And in fact, in most deadly pandemics, viruses tend to regress to the mean over

time which is to say a coronavirus that's really severe over time you would expect it to as it mutates to be more likely to get less severe rather than more because it's already way out there uh at the edge of severity and is it also that it kills like a cold you know yeah i mean the virus if it has a will doesn't want to kill you no it wants to make lots more viruses right it wants to live live free just like the rest of us there you go free range virus is what it was yeah although viruses of course are the weirdest thing in medicine uh or one of the weirdest things because they're not actually alive um they're just bits of dna and some protective proteins around them so they become alive when they hijack your

cells machinery and force it to turn out more viruses it's like the original alien movie and right well but it and like the original alien movie i mean or slightly different from the original alien movie this see i mean it's it's likely just to go with me here i'm not going to go to the spy novel version of it i'm just go to the normal human being version of it that we have facilities both in certainly in asia definitely in china and also here that study these viruses and the idea is to study as many as you can and to keep a library of them and a library of the vaccines and get get all the knowledge you can of these viruses so that the next covid 27 or COVID-27 or COVID-20, we hope not COVID-21, we can keep that at bay. And it seems highly possible that since these labs are staffed and administered entirely by human beings who are just the worst when it comes to

following procedures, right? Right. There's going to be an accident. There's going to be an accident. There's going to be a mistake. And when the alarm bells were sounded in the United States, our response was to stop testing, stop researching these viruses. What do you think the likelihood, first of all, what do you think the likelihood is that this is exactly how this,

this is the COVID virus was somewhere in that Wuhan lab. And it's somehow because people in China, and I'm not making an argument about China, that's a separate argument. People all over the country, all over the world are capable of great incompetence and it somehow got out. Yeah, well, I think that has to be the prime hypothesis to reject in terms of how this happened. Otherwise, the level of coincidences strings together into something very unlikely. Let me start with a couple of things. First of all, generally, when viruses make a jump from animals to humans. Zoonotic?

Yeah, zoonotic transmission. When they first do that, they're pretty inefficient at it. And that's how world health authorities get an early read that, uh-oh, we better watch out for this because something is now infecting farmers from, say, pigs or birds or what have you. And we're having little outbreaks of a disease that's not fully adapted to humans, but seems to be starting to infect humans. If it tunes itself up through more generations and mutations to get really good at humans, watch out. Rarely do you have something out of the blue like this, I can't think of anything else, where it doesn't infect humans at all, and suddenly it is tuned for humans like you wouldn't believe.

We know that the Wuhan BSL-4 laboratory, that's the highest level of security, you know, think of the Andromeda strain kind of place, you know, with all the controls and what have you. They were researching bat coronaviruses. The impetus for this was the original SARS outbreak. I think it was back in 2003. And they want to research these viruses, make sure they can come up with vaccines. All makes sense. They've gone to Yunnan province, a thousand miles away to get these horseshoe bats and get all the viruses, study them. We also know that they were doing gain of function research.

And this is trying to make viruses more effective at infecting humans, more deadly and all this and not, I'm not alleging that this was chemical warfare. But this is what you do as a researcher it's controversial because of what may have happened here um but by making the virus kind of bad you learn more about what makes viruses infect humans and you can develop vaccine strategies in case one actually breaks out so it makes sense we want to learn about these make sure that we can treat it and of course there's probably a sense that China wants to be in the big leagues and, you know, do their own research and show that they can cure viruses and, you know, be a super first world country.

And as you point out, people make mistakes. And so one thing I'd like to have ruled out is that they weren't doing what's called gain of function by passage, which means you run the virus in series through mammals, like through a ferret, and you take the output once he's infected and infect a new mammal and then so on. And this is a way to effectively accelerate what would happen in nature over many years, do it very quickly to get all these mutations and this efficiency of transmission to study it. And then someone made a mistake. Now, that may not have happened, but if it didn't, it would make sense for the Chinese to open the records and really dig into this

because the coincidences of where this happened and how otherwise raise concerns. So I guess I'm trying to grope for analogies here. One of the analogies I was groping for is Three Mile Island or Chernobyl. I guess Chernobyl is maybe because it had more of a larger, more global impact. nuclear power and nuclear power technology in its tracks, despite the fact that we desperately need it. And it's the most rational way for us to power the growth of the globe, um, in the future. And it would solve all sorts of problems, including, including global warming. Should that be a problem that you, you know, keeps you up at night? Um, what do you think the outcome is here? I mean, I mean, studying contagion seems like a really smart thing to do. And certainly studying these kinds of viruses seems like a really smart thing to do. What happens if we stop doing it? Well, great, great question. I think that

studying viruses is really important. I think the real debate I would have is over gain-of-function research, this idea of intentionally making the viruses stronger so that you can study them or try to get ahead of nature. That's really dangerous. And perhaps we can do it appropriately, but we really need to have a detailed scientific debate of the risks and benefits of that kind of work, particularly in light of what may have happened here today, where, you know, by trying to get better at treating viruses, we may have created a virus that is going to kill a lot of people and also destroy a lot of economic health and vitality for years to come. Right. So, I mean, I guess just to go back to how we treated it, the next virus comes along, it's going to be hard to say to people, oh no, we need to shut down again. I'm looking for the learning curve here. What have we learned about, if anything, about how we dealt with this virus, how we studied it, how we adjusted our behavior for it, that we can apply to the next one that comes along? Assuming the next one is some version of this, right?

I mean, I think it's fair to say, right, that if we've had three in a row of this kind of thing from um uh sars to i guess swine flu is a version and or maybe not and then this that this is going to be kind of what the danger looks like for a while um yeah um well first of all the world has been predicting this particularly as our economies have become more global with more routine travel from all over the world to everywhere else. And there have been books about it, science fiction novels about it. Now here we are with reality. So partly being better prepared, more ICU beds than you might otherwise need to be efficient based on an average year, more ventilators and emergency stockpiles, personal protective equipment, all the things that we're learning here about the emergency response on the economy, having supply chains

that are more resilient rather than the most efficient, where the most efficient may mean I source all my raw materials for pharmaceuticals from, say, China. And of course, if there's a global pandemic, China will want to take care of its own citizens ahead of everyone else. And then where's the rest of the world? That'll cause a lot of strain as well. So that's part of the preparedness. Further investment in vaccine, vaccine technology, antimicrobials generally, and other drugs

that you desperately need, but only when you need it. It strikes me that this is an area of market failure, potentially, that the government could get more involved in. There already is BARDA, the Biomedical Advanced Research and Development Association or organization in HHS, that's doing this with drugs for bacteria, and they have some vaccine work going on. But we really want to think about how we could potentially beef that up. And then finding a way to hold China accountable, because again, we lost precious time, many weeks, if not months, when China was first not sharing information and then sharing incorrect information about no human-to-human transmission. And of course, that informed a lot of the inappropriate response of global health

leaders, because you take the information you get, and you make your decisions based on that. Right. And I think globally, what the first response from when we say that is to say, okay, well, we got to punish China. But first, we have to become, as you put it, more resilient and less efficient about dealing with this. So you can't really punish a trading partner that you desperately need, you can only punish a trading partner that you don't need if you don't get any leverage. So by the time we get the leverage back, will we have forgotten all about this? Well, we might. I don't think so. The human toll is one thing here, but the shock to our culture and our economy, the economic damage is so immense from all of this. And then it's going to be

political damage as well. We're only starting to reckon on that as we're watching governors. Once you close something down and you're the one who did it, how do you reopen it? At some point on a political basis, every death afterwards could be laid at your doorstep. On the other hand, if you keep the economy closed down, you're going to create a lot of other issues, both economic and health related. I was hearing from a colleague just earlier today that clinic visits for routine medical care, say you have cancer or you have hypertension or what have you, are down 70 percent in many areas as people avoid the doctor because they don't want to get COVID-19, which makes sense. But you may save yourself from COVID-19, but if you don't get treated, you may wind up dying of your heart disease or whatever it is. So I guess, all right, so let's talk about patients. Let's talk about patients for a minute, because I tend to think of the entire

population of the United States as one big patient. And the sort of the collective administration you know executives governors presidents senators public health officials as the doctor right giving the patient advice and it seems to me that one thing you can say i think pretty fairly across the board is that um all of the doctor figures here have failed. Massive failure on the part of the people who are supposed to be collecting and disseminating information in a timely way, not just in China, but in the White House and in the state houses

and in the offices of CNN. And yet, all because I believe they think that the American people can't handle the truth. And yet, when you look at the patient as a whole the american people as a whole they're pretty solid about this stuff they kind of like shrugged okay i gotta do this i gotta do that they're doing all the things they're supposed to be doing there's not been a freak out in general i mean there was a brief toilet paper freak out um which i think everybody everybody recognized with both was both absurd, but also not something I want to take my chances on.

In general, people seem to have said, okay, I understand this. I understand the principle of it, which makes sense, right? I mean, every single American who's ever used a computer understands what a viral transfer is. They understand how your computer can get infected by an email, how you don't see it, but it ruins your data. They understand all of that. I know how a video goes viral. I mean, this is the word we use. They understand the concept. And the minute they were told that this thing's happening, you got to use Purell, you got to stay in all that stuff. They did it. They really did it. The people I think for whom this is still surprise are the, you know, especially the governors, right? The people on the front lines of making these regulations. How do you convey to

them? Well, first of all, two questions. One is, is this the normal way a doctor patient relationship goes that the doctor worries about the patient not being able to handle the truth and therefore sugarcoats the truth or changes the truth to get a certain outcome? And two, how do you regain that trust once you've lost it? Yeah, it's a great question. And I think some doctors do act that way, worry about their patients. And I think in this case, both politicians as doctor to the body politic and doctors for individual patients often underestimate their patient. And as you just pointed out, the American people are resilient. They make pretty good decisions.

Frankly, if Gavin Newsom and all the other governors released all the restrictions, except, let's say, public health restrictions on sporting events and mass gatherings, but said, you want to open your business, you open your business. Well, what are the odds that the restaurants will be packed tomorrow? I'd say zero because Americans are smart. They're going to be cautious. They're going to take steps. They might want to see that, well, I'm thinking of coming to have dinner at your establishment. What kind of steps are you taking? What kind of social distancing things are you guys doing over there? And people will have to be convinced and centralizing the decision making leads to some of these ridiculous things we've read about like in michigan where you're only allowed to buy certain items but not others in an open store okay so again am i a dumb patient because i i'm trying to be honest here the minute these things are open i'm i'm not going to make that call i'm going to

go to the restaurant and the bars that i love and i'm going to i don't care how many tables i mean i'm just going to sort of be vigilant and purell on the way in and purell on the way out and not touch my face but i'm gonna i'm gonna sidle up to the bar and to my favorite bartender and i'm gonna i don't care how many people there are i'm gonna order a bunch of drinks and i'm gonna tip him 100 bucks because he's been through a lot. And I'm just going to do that. And I definitely err as a person on the side of the reckless and the thoughtless. But I don't think I'm the only one.

No, you're not. I guess what I'm saying is the danger is here that I'm like, it's like know when i when i when my doctor tells me you got to lose weight which is about every two and a half years okay and i do the thing i'm supposed to do you know like the car business and all that stuff and go to the gym and i give up bread this i recall give up bread yeah i lost a little weight, I recall. Give up bread, yeah. I lost a little weight, you know? And then I'm like, I'm so sick of this. And I go, I mean, I go right back. Like, I'm not changing my behavior at all. And I kind of feel like this is, I mean, I'm just saying, now I'm the patient again. I'm just saying that this is, I can sense that I'm about to do this.

That the minute this thing is lifted, I mean, it's hell's a popping. Right. Well, it's risk benefit. Everyone has an individualized risk benefit approach. And I think for a lot of people that will depend upon where you are, you're in sort of the hotspot there, New York. But if you're somewhere less hot, that would inform your decision. I think a key decision would be based on age and what we call comorbidities, how many other illnesses you have. But people who are very elderly or who are immunocompromised, you say have cancer or serious diabetes or something like that, well, you'd want

to take a lot more care because the statistics do show a much higher risk related to COVID-19 infection. Part of what makes this disease so maddening and mystifying and intellectually interesting at a different level is the very radically different clinical course different people get. Typically young people, no problem at all. Some middle-aged people, a smaller number do very badly. The most do okay. But then the very elderly, most people have a much higher risk of bad things. Right. Okay. So let's just say, let's pretend it's over now and we're moving forward. What would you, what advice would you give the patient moving forward? We, you know,

we're out of quarantine or whatever we're calling this now, the shutdown, we're back at work. Everybody's back to normal. It's a year from now. Every now and then there's a COVID-19 infection, but it's nothing big. Maybe it comes back a little bit in the cold and flu season. What do you tell the patient to do? Well, in what sense? You mean in terms of an individual or are we talking about the country? No, not me in particular. For me in particular, you tell me to stay home and stop hanging out in crowded rooms. But for the country in general, I mean, put it this way.

November 2000 rolls around. Yeah. And I say, hey, George, I'm going to get on the subway and go uptown. Do you recommend I wear a mask? I think it will depend on the data as we see it right now going forward.

I think more important would be washing your hands after you're in and out of the subway. Masks tend to be more important if you're feeling ill from infecting others than in actually preventing your infection. It's turned into locally something of a totem of social unity against the virus to be wearing these flimsy pieces of cloth over our faces. So I don't know that the mask will do all that much. But certainly taking care of your hands, watching out for different surfaces. And again, it will depend on the data, what we're seeing in terms of hotspots, trying to stamp them out, hoping that we get a vaccine or effective treatments that make getting this disease more reliably a non-event rather than something that can occasionally go very, very wrong. So a year from now, we'll seeing uh more purell dispensers in uh the building lobbies more purell dispensers in airports yeah it'll be sort of normal when you're getting on an airplane you

put you purell on the way in purell on the way out yeah i'm clean cleaning you your tray tables it used to be somewhat novel and weird when the seatmate would be cleaning off the belt buckles and all the surfaces and did you do that? No, I didn't. But I admired people who did and thought, wow, I should really start doing that because I catch colds on airplanes a lot. Now, you know, it's sort of, I think, potentially going to be sort of de rigueur, like taking your shoes off as you go through security. I was talking to a friend of mine the other day. We're trying to imagine the New York City subway in the subway of the future would include branded purell dispensers you know like the city bikes around town are like from city bank has sponsored the city bike they're called city bikes so there should be some you know

jp morgan chase purell dispensers uh uh everywhere you look and you can just constantly you know so it's a you do it three four five times a day and maybe take a 10, 15, 20% bite out of cold flu season, which would include this virus. What about a general awareness of health? I mean, part of I was going to say

part of what we learned it isn't what we learned it's what was brought, a lesson that was brought home to us with COVID-19 has been that we are incredibly vulnerable to all sorts of infections, bacterially and otherwise.

And that the guy with the Purell and the wipes with the seatbelt buckle and the tray table was a weirdo six months ago and now seems like he knows the way to be. What else are we not thinking about? What's the thing that we're not aware of, right? What's the thing that we're not paying attention to? Yeah. Well, one thing that's really going to change is where people get medical care. I think more and more, it's going to be routine for people to get medical treatment from home. And that's been the biggest shift that probably won't go back to normal from the last month.

What do you mean by getting at home? Well, where you have televisits with your doctor routinely, where you look at a screen and talk to them, where you have sensors built into your phone, built into your medicines, built into whatever other products that you're using that can give the doctor an objective picture, something like having the physical exam at the doctor's office. Think about it. The most dangerous place to be if you're immunocompromised and worried about COVID-19 or just generally is a place where sick people are likely to give you what they have. And that's in line at the pharmacy, in the waiting room at the doctor's office, at the hospital. And certainly sometimes you need to go to these places, but most visits are routine. And so if you're very elderly and

you're at risk for getting an infection, particularly a deadly infection, why at this era where I can do my entertainment online, I can do my finances online. Everything I do online except healthcare still as of a month and a half ago had to be done in person. And now you're, you're my doctor changing. Yeah. You're my doctor. I call you up. I have, we have, we have a zoom conversation or a FaceTime or something. That's right. Um, how do you take my vitals? Well, that's just it. There'll be sensors. You can put a little bandaid on and these have been around for a long time now, but now they're getting paid for for the first time. That will talk to your phone. That will talk to the cloud.

You could be wearing that before we get on the call. You may have been using it. So what will the bandaid, that's a big patch. And what will the patch tell me? Tell me a heart rate? Yeah, it'll tell you things like your heart rate, your temperature, your activity, your sleep. It'll tell me when you've taken your meds, right? There can be other special tests that we can get.

Like if you are a diabetic, your glucose readings and that kind of thing from your sensors. So when you get together with me on the phone, on TV, we'll be looking at one another, talking about it. And I'll see in a side screen what all your data have looked like since the last visit. And we'll talk about what to do next. Does that exist now? Yeah, it does. It's just been adopted at a very slow rate because we have a healthcare reimbursement system that pretty much got codified back in 1964 with Medicare. And then all the

computer systems got built in the billing codes. And we wound up with this health system that is based on heads in beds and minutes in clinics. That's how people get paid. And telemedicine was reimbursed in the most grudging possible manner, all kinds of hurdles and what have you. Well, those hurdles are day by day now being wiped away by a combination of legislative and executive action as part of these rescue bills. And healthcare telemedicine visits are up thousands of percent in the last six weeks. And once people get used to the convenience of this and they start adding these sensors to the video visits. And little cameras,

right? So you can peek inside. That's right. It's not going to go back to normal. I mean, for one thing, just think of how many people who never use Zoom and would never have thought of not having the meeting in person are now going to be comfortable doing that. And long term, even when travel comes back, it's unlikely, I think, to come back to the degree it did before. Because I think now, for many parties, rather than hopping on a plane and me flying coast to coast to New York to have a meeting, we'd be much more likely to all say, oh yeah, let's, you know, get on teleconference. Right. I mean, that's certainly happened to my business is that actually even, even former, even conference calls, which conference calls, which would have been a conference call six months ago have been upgraded to zoom calls. Right. And a lot of in-prem most

in-person meetings have been downgraded to zoom calls. And a lot of, most in-person meetings have been downgraded to Zoom calls. And Zoom calls, whatever, you know, visual conferencing has actually been, you know, a very fine compromise for both sides. It's made conference calls much better. It's not quite as good as an in-person meeting, but that's, I think, more a question of how we treat it

and how we interact with that tiny little, you camera that's right partly it's been more efficient right because you can't i mean you and i are having conversation right now and you know if i leave or you know if i'm not paying you can see me right so this these things are much much more efficiently um you know they they transpire much more efficiently. So, um, so if you, if that happens, two things I think will happen. One is won't people take more responsibility in general for their day-to-day health, right? So the idea being that I don't have to go to some, um, special place, some temple of health and go through a certain series of patterns to get into the see

the the the the the health wizard yes who wears a you know white coat and looks very uh wizardly and get my 11 minutes with him if that um where in fact all he's doing is reading a list of stats that the nurse compiled my temperature my all that stuff um won't will that make me a better personal advocate for my own health or will that just mean that these poor doctors i got people without a barrier to come visit me um i got people stacked up not in my office but in my virtual office all day I think it's going to be mainly about patient empowerment and patient engagement Again, look at the revolution in finance Since the you know, the stockbroker that you used to meet with in person decades ago

Now the dawn of the internet age went online and how much more savvy people are about their 401ks and their investments and everything else. Healthcare is trending the same way in terms of information. People look up everything on Google and various websites and they come in with printouts for their doctor to talk to. I'm glad I don't have to bug doctors, right? I'm not just driving crazy. Don't come to me with your- Sometimes. It never drove me crazy. I've always enjoyed it because a well-informed patient is great because now you have more in common from a vocabulary standpoint. They've done the research. You can help. It's just a better conversation to be more informed. But the main barrier why healthcare has lagged is now being blown up by this crisis,

and that's been regulation. If you think about it, licensing of physicians is state by state and incumbent state doctors don't want to make it possible for doctors to be all that mobile. So until a couple of weeks ago, you couldn't deliver telemedicine services across state lines. You couldn't bill Medicare for telemedicine services unless the patient left their home, was in a rural area, left their home and went to a rural area, left their home and went to a specific healthcare center to have the televisit. You had all of these bizarre, you had HIPAA rules that basically said that even though what we're talking on now is secure, even though there's a lot of things that are secure, if the company didn't go through some

government process to have it validated as HIPAA compliant, that's the privacy law, then it couldn't be used. Well, why can't I talk to somebody using FaceTime if that's convenient for the patient? It's private, right? So all of those rules are now going away and we're seeing everybody respond. And I think that's going to be a lasting change for the good with healthcare because once patients now are able to do more on their own at home and have more data to show the doctor and do it from a position of comfort and sort of control right um uh they they they're more part of the process and less of a bystander so the only remaining thing i mean it's just talking about so science fiction medicine and although apparently it's not science fiction the remaining thing that remains slightly difficult.

And we know that because the company called Theranos famously went, exploded because it was fraudulent. The only thing really is a blood panel. But I went online just a couple weeks ago when we were talking, and I went, okay, so how many diagnostics does lab corp do uh and how many diagnostics does uh um uh the other one i keep forgetting the other name um quest oh yeah sure and they do about three million a piece a week okay it's a lot that's everything it's blood and urine and drug testing and all sorts of things that's a lot that's a huge capacity

and they have them all over the place. That's a lot. That's a huge capacity. And they have them all over the place. The minute you start noticing them, they're everywhere. And I noticed them in New York City. They're everywhere. I mean, they're walking medical clinics, CityMed and places like that. But there's also, there's a LabCorp, you know, a block and a half from me. Why couldn't I just, you know, divide that, separate those things in my head? I know I'm going to go see,

I'm going to have a telemed conversation with my doctor on Tuesday. So on Friday or Saturday, I go in and get my blood work done. It pops up right there during my conversation. So it's not like we have a conversation, then I go get blood work done. And then we have another conversation later. It all happens at the same time. And it's so much we have a conversation then i go get blood work done and then we have another conversation later it all happens at the same time and it's so much more efficient you get the information you need i'm a patient i'm i've taken a little bit of responsibility for myself being settled around like a like a patient already like a hospital patient i mean it does seem like we already have a free market system that deals with this stuff pretty efficiently doesn't just need a little extra juice a little extra incentive or am i is this a pie in the sky well um certainly greater efficiency in terms of getting your lab tests lined up with your doctor makes sense uh the concern the reason why

you want to have some medical consultation at the front end it's is to determine which tests to get uh because you don't just want to get all the tests, even, even if there were a package deal, because, um, uh, medical tests aren't perfect. We have these things called sensitivity and specificity, false positives, false negatives. Most people have heard those terms bandied about. And so if you think about something just to oversimplify, if, if each test had a 5% error rate, uh, say false positive rate, and I just figure, let's order the 20 tests. The odds are I'm going to have one test that is falsely positive, that is abnormal. And then because I have an abnormal reading, the problem for the physician

and the patient is you wind up having to chase down that abnormal reading, which leads to more expense, more invasive testing, potentially side effects or problems from the more invasive test you go on to. Say you have an abnormal test, maybe this looks like it's cancer. You do a biopsy, you get an infection from the biopsy, and on and on it goes. And actually, it was a false positive to start with. And when you're in practice, you see those kinds of chains happen, sometimes with a terrible outcome, and they stick with you. So you don't want to order everything for your patient. You want to hear what's wrong. You want to examine, you want to think about, okay, I think it could be one of these three

things. That means I need the following four tests and you just get those four tests. Okay. All right. So that was, I probably was probably just imagining that, you know, we're all going to go in like every couple of weeks and get some blood drawn and just check our blood work. That's kind of dangerous. That can lead to what I call medical student syndrome. And when I was a medical student, I had it, we all had it, which is you're reading textbooks and you're reading about incredibly rare exotic diseases. And then of course you go on to be convinced that you have that disease. I got off a bicycle one day with back pain and I was convinced I had a rare kidney tumor in my bike because I didn't exercise enough.

It was springing my back rather. And then I guess just to wrap it up for the, for the patient, doctor patient thing. So just say this happens in the future. I had that little thing, a little giant bandage package on my, you know, I guess the chest thorax, is that what they give me right there? You know, yeah. And you're, and I'm telling you, and you're asking me questions like, well, how are you taking your medication? I go, well, I'm taking it twice a day, doctor. It's like you told me, right? Well, are you, are you staying off of the sugar or whatever? Yeah, absolutely. And you can see

in real time, my lies. Well, you wouldn't do it that way. This isn't a Michael Flynn kind of thing where I have the transcript and I'm going to ask you the question and then I'm going to prosecute you. What I would say is we would look at the printout together and I'd say, what happened last week? I noticed you didn't take your diabetes medicine like four days. What was the problem? And you would explain that you had stomach upset or maybe for some patients, they're just embarrassed to admit they ran out of money and they couldn't afford and they delayed getting their prescription refilled, which is a whole different thing.

You know that you need to check with social work and what have you. But you actually surface the issue rather than the patient trying to appear to be a better person. We all do this. I do it with my my dental hygienist who says uh do you do you floss and of course i say well well sure and and honestly i have it's wednesday and since monday when i looked at my calendar uh i have flossed three times a day but for the last three four months not so much my uh my dentist here in new york she actually said

to me she said the way she's russian very taciturn Russian, she's a dental hygienist. And she said, you know, I actually think that you might really actually floss every now and then. Like her standards were so low. She asked if I floss and I said yes. The evidence of her exploration was like, I actually might not be totally lying all the time. Yeah, that's right. That's right. So I think it's generally that most people are aspirational. You think of yourself as your best self quite often, unless you are depressive. And so you want to be your best self to your doctor or to your nurse or to

your dental hygienist. But when you have objective data, people don't argue about a lab test. So this isn't a case of trying to say, oh, you're lying to me. You don't argue about your white blood cell count. You don't argue with a police officer about the radar gun saying you were going at whatever speed. You just talk about what to do about it. What's going to happen next?

So you haven't been taking your meds right. OK, well, what's the problem? Why is this an issue for you? And let's talk about what to do about it what's going to happen next so um uh you haven't been taking your meds right okay well what's the problem why why is this an issue for you and let's talk about it so okay so i don't i wouldn't keep it too long because i you know you got work to do but i i still have a couple questions um but one is all in this experience to me now maybe again i'm it's confirmation bias right so i'm looking at the of the the state of play in the how the country how the health care system has dealt with this and i'm it seems like like if anything it's dealt with it just about as poorly as every other country in every other system dealt with it which suggests to me that maybe the free market health care system first of all isn't the giant disaster people expect, some people expect it to be, but in many ways, maybe it has been more nimble. Maybe it's

going to be a little bit more able to adjust as you describe it, you know, and to deregulate itself and to sort of transform itself more, more nimbly and probably more aggressively than a top-down state-run system. I think that's fair. I think it is fair. And again, when it comes to digital healthcare and telemedicine and these sort of things, the main barriers it's turning out have been regulatory. And as we relax those, we're seeing a lot of experiments play out. Fortunately, under the Federalist scheme, we've got more experiments playing out about who's opening quicker than other people and what restrictions are happening. And we'll be able

to draw some conclusions from that. I think it's fair to say we have to find ways to get the economy working and get younger, lower risk people back to work as quickly as we can. Otherwise, in economic terms, well, we already have a disaster on our hands and it'll get worse. But even on purely health only concerns, our target fixation with COVID-19 could cause more harm than good. If we think about all the patients who are not getting treated for their cancer, you know, they're not getting chemotherapy. They're not getting their heart disease looked after. And so COVID is a problem and it's a serious problem. And it's happened all of a sudden and it's a very big deal. And I don't want to make light of it, but it's not the only health threat in the world. And so we have to look at it in totality. So a year from now, two years from now, do I think, and I think certainly from an infectious disease

standpoint, just the fact that you talk about how people made mistakes at a Chinese lab, potentially. I know that healthcare professionals who are trained in this stuff make mistakes all the time as well when it comes to personal hygiene. I'm certainly washing my hands a lot more than I ever have in my entire life. And I bet everyone else is. And I think some of those habits will persist. It's a bit like, you know, if you think back to older generations who lived through the depression, they had certain habits about being very frugal and not wasting that just ingrained in them from that experience. And I think a lot of us will be much more careful about personal hygiene and cleanliness. Yeah, I think that's true.

I think it's one of those things that I remember, you know, going to Asia or seeing Asian tourists in the United States and seeing them with their masks and rolling my eyes. They go, oh my Lord, give me a break. And now I think to myself, well, it's not maybe, you know, I don't know if I would pack for a trip, for a longer trip, certainly, or definitely an overseas trip without bringing a mask. Well, and you know, my reaction to that is I was always of the mindset that, you know,

I'm going to work no matter what, because I'm tough. And, you know, part of that's drilled into, ironically enough, in medical school and residency that my first day as a surgical resident, I was told I was expected to be at the hospital every day in the coming year, either working or as a patient. And that was a quote. And so, okay, I was once working in the ER and I was the sickest person I saw that day. And that's nothing to be proud of. What you're learning from this is when I would meet with Asian folks, somebody had the sniffles. And so of course they're wearing a mask. That's actually a sign of respect and concern and the fact that they don't want to infect anyone else. And so I'm going to have a much lower threshold for staying home if I'm

feeling unwell and just firing up my screen and doing work that way where I can't endanger anyone else. And I think that's a good thing for society. I think so too. I think so too. I mean, I don't know. It's my general optimistic attitude about everything. But it doesn't seem to me that a country, like certainly our country, goes through an event like this and doesn't come out stronger and better. Yeah. I mean, that's just sort of how we do it. Yeah, I think so. Just got to learn. It's always messy and it's always a pain. There's always a lot of mistakes um you know and i uh while i i really want this lockdown to end um and i think we could do more more quickly particularly in places like california

to do it i don't think we have fascist overlords i think we have a lot of people uh trying their best under imperfect information to muddle through yeah but it's time to open up the bars i gotta be honest with you absolutely i need a drink it's right i open up the bars. I've got to be honest with you. Absolutely. I need a drink. It's Friday. I need a drink. I need someone else to make it for once. And I need it in a convivial tavern-like atmosphere. Or there's going to be hell to pay. I've got to tell you that right now.

That's right. It's not fun falling asleep over your drink and your laptop. Yeah, I don't find this amusing anymore. Hey, George, thank you for joining us Oh thank you this has been fun Stay well see you soon See ya

Scott I don't know where Scott I nailed it It's like it was 5-0 5-0 minutes right That's what I think I nailed it. It's like it was 50, 50, five, zero. We're five, five,

zero minutes, right? That's what I think. Oh, good. Hi, Darla.