 This is Think Tech Hawaii. Community Matters here. Good morning. This is Craig Thomas, your host on Much More on Medicine, part of Think Tech Hawaii's live stream series, and assisted by Cindy and Rich, our engineers, and joining me today is Ray Fidel. He's many things. Today he's here in the role of a concerned citizen. And we're going to do something a little different today, which is we're going to talk about some current medical topics, including, I believe, one, hold off the TV, probably as recently as last night, and look also some 2018 medical literature. And I'm delighted you're here. I'm delighted to be here, Craig. Good. You know, we all have bodies. We all make choices medically or have choices made for us, as the case may be. And far as I can tell in the end, none of us are going to leave this alive. So we're part of the great experiment, and it's honestly pretty uncontrolled because, especially in this country, nobody's keeping track. I misspoke. A politically correct way of saying that would be there is no national data repository for our health interventions, treatments, outcomes, that kind of thing. And that would be fantastic if there were. We should start with some good news. So Hawaii is second in the nation in the rate of percentage of the populace. I should say it's all of us, covered by health insurance. That's fantastic. We have a little bit less than 5% uninsured. And that's stunning. Why is it? Why is it? It's honestly, Hawaii has always been very good in this category because of the health insurance reform of the 70s. It was actually, in my opinion, improved by the ACA, the Affordable Care Act. And this is sort of exemplified by who's number one, which is Massachusetts. Massachusetts also had a comprehensive insurance plan before the ACA was initiated. But that was the model for the ACA. So it works. And as a consequence, Hawaii and Massachusetts are leaders in many categories of health among all the states. And the states didn't expand Medicaid, adopted the ACA kind of grudgingly. They tend to be at the back. And I think the highest uninsured rate is Texas. Is there a correlation between the percentage of people covered by insurance and the quality, you know, the medical quality of their lives, health in general as a quotient? So that's a really interesting question. And we are actually having the opportunity to do this sort of experiment because you can always compare before ACA and after. You can also compare Medicaid adoption or not. And you can even, in some states, and Oregon comes to mind, see different strategies in specific populations based on geographics because if you have insufficient money to expand old mammography services every other year to all. And this is not just the U.S. This experiment has been done in Scandinavia, for example. You can then see what the outcomes are. And interestingly, mammography, assumed to be beneficial, may not decrease overall death. It decreases a little bit, death due to breast cancer, but it comes at a cost. Procedures get done, people get treatment, even radiation, surgery, chemotherapy on cancers that would not kill them. Sort of in the interest, just as an aside, of gender equality, pretty much the same is true of prostate screening and treatments. You might decrease the death rate due to prostate cancer slightly, one or two out of a thousand, but overall mortality doesn't change because the people you're treating weren't going to die from it. It's not so simple. You can hurt them. No, it's not simple. And I think that's actually one of the lessons of the day. It's not simple. There's some obvious things that we're just learning now. There are clearly some very basic things we don't know. That's exciting. And honestly, we live in interesting times in medicine. We're finding now getting good databases. We're getting the dawn of artificial intelligence, which hopefully will, I think it's going to revolutionize imaging, for example, computers. But not all of medicine. When did I see a piece that said, do not rely, a doctor wrote this piece, do not rely on artificial intelligence to make diagnoses. Well, intelligence is good. Hopefully the human can bring some. Yeah, you don't want to rely on it. In fact, so far it's not been very successful. I think that the early successes are in analysis of images, which makes sense because they're digital. They're tricky and it's learnable. That's where the early waveforms, EKGs, for example, what kind of illness do you have and what should we do next? That's much harder. And in fact, what was it called? It was called the computer that did well at Jeopardy Watson. It was called IBM Watson. Yeah, IBM Watson, a great name. It's not doing very well in medicine right now. Still, I think that in the future, I think it will in time. I don't know about Watson, but when I started medical school, which was in the 70s, I thought computers are going to have me out of a job in no time because the belief then was we can set up an equation. Okay, so you're a male. You have right lower quadrant pain for X hours. Your lab tests are such and such. Your probability of appendicitis is 97.2%. Trouble is no one's ever able to figure out what that all means. It didn't work. Yeah, it didn't work. But it's so interesting because the point about keeping records, keeping demographics like they do in Europe using what you learn in demographics about choices made and results obtained, we don't have that so much in this country. And you'd think with all our technology and with the fact that the federal government has so much leverage over how doctors provide information that the federal government could say, look, we want it just like it is in Europe. We want you to report on outcomes. We want you to help us in a national database of outcomes and we'll use that to advise the profession. Yeah. Oh, I think it'd be fantastic. And there's progress. However, we have a pretty fragmented healthcare system. So in some ways we're great. If you need a cutting-edge treatment that works, that would be a first concern, but a cutting-edge treatment that works, there's nowhere better to be in the world. There's some other places there is good to be, but there's nowhere better. If you need access to basic health screening and healthcare, we're not so good. And where we do really badly is what's called coordination of care. And that means if I see you in the emergency department, did I know that you got treated yesterday up the street and these are your meds and your imaging from last month showed this? No, I usually don't know that, unless it was done at my hospital. And that's pretty normal in the U.S. We've got to do better. We've got to do better. And excitingly, there's something called EDIE, which stands for Emergency Department Information Exchange that's coming to Hawaii, that is going to help that in the emergency departments. I don't think it's going to make a big difference outside of the departments for a while, but that's huge. At least I'll know where you were, what got done, and what I should do next. A little chip in my hand somewhere. Just subcutaneous. And it has my whole medical record on there, and I walk around with it. It would work. And you know, the veterinarians are ahead of us in this. So may I may suggest, I actually like our vet very much. And I'll make an appointment for you, get you chipped. I don't think the pet ones are medical records. They're more identification. When I get lost, right? But no, honestly, that could be done. Or even we have appropriately guarded access to medical information. You don't want your medical record on the front page. Neither do I. Yours or mine, for that matter. On the other hand, everything has a cost. And if you sequester the information so securely, it can never be hacked. It'll never be accessed. And then you might as well not have it. It's a balance. It's a balance. And honestly, given that it's potentially life-saving, I'm willing to chance it on. Me too. Can we talk about trust for a minute? Of course. We talked about choices. Patients make choices. And they make the choices with the doctor and upon the doctor's advice. And a part of that is trusting the doctor, trusting the hospital. If I'm worried, for example, about MIRSA, I may not be too happy to go to a hospital that's had a lot of cases of MIRSA. At the same time, I want to trust my doctor on a field that what he advises me is something I can and must and should do do the right thing. There was a piece on Hawaii Public Radio a day or two ago about African American doctors. There's an initiative to have more of them. And the study was so interesting. The study was that African American patients are more likely to listen and follow the advice of an African American doctor rather than a non-African American doctor. Do you know why that is? No, I don't. I do. Well, I can't tell you I know why it is, but I can tell you that's probably a good strategy. The embarrassingly in medicine, there is evidence that the gender and the race of the doctor treating you, depending on who you are, particularly, impacts what gets done, what gets done, how affected the communication is. And this is, I think, an example of all of us have internal biases we're not even aware of. Implicit bias. Implicit bias is the word. And do I wish it wasn't so? Oh, I do, honestly. As an enriched doctor, I treat whoever comes in the door. Some of them look like me, not too many, but some of them look like me, but obviously some are very different from me. And on the side of the patient, the patient has to look deeply in the eyes of the doctor just to see how the doctor moves. He has to actually think about what kind of an individual the doctor is and define his level of trust based on the human experience. It's true. And so our job is, every specialty is different. In my job, odds are very high. We've never counted each other before. And somehow I have to get you to share with me important private stuff you may not have told anybody else. Or even if you have, it's private. You're in an exquisite situation, though, because the patient in an emergency room said he's very vulnerable, or she. And he doesn't want to resist. He doesn't want to do game-playing with you. He needs you to life. And so he is going to do pretty much, I would say, all the time what you have to offer. Well, the question isn't so much what I have to offer, although now we're talking about shared decision-making and things, which is a very interesting topic. But the real question, the real issue is, some things, you know, you've got to nail through your forearm. I can probably make the diagnosis. But if you have, I don't know, a fever and a few other things, a weird rash and stuff like that, the more we can connect early. And you can share with me things that you're concerned about may seem inconsequential. The better chance I have of figuring it out and helping you. Right. And once I understand that, I'm going to be willing to share everything with you for what you call it shared decision-making. Right. And we can talk a little about shared decision-making, which is sounds fantastic, just like many other words in medicine, evidence-based medicine, sounds fantastic. It is. Shared decision-making is too, they're not easy. I'll tell you, I'll pick those up after the break and that has been fun so far. I look forward to more. This is Think Tech Hawaii, raising public awareness. I'm Ethan Allen, host on Think Tech Hawaii of Pacific Partnerships in Education. Every other Tuesday afternoon at 3 p.m., I hope you'll join us as we explore the value, the accomplishments and the challenges of education here in the Pacific Islands. I love this discussion. Welcome back. I'm with Jay Fidel, a curious citizen and owner of a body, like all of us, therefore interested in medicine. Yeah, sometimes I wonder about being the owner of the body. Sounds more like the body owns me. In the end, they always do. It does what it wants. Yeah, no, it's really true. In fact, the interaction of mind and body is a topic for a different, well, not entirely, mostly for a different subject, but we were talking about evidence, shared decisions and how complicated that is. And, well, raise the question. Okay, I need to make decisions. I recognize, and our body feels this way, but I recognize that I'm the guy in the world who cares most about my body, just the way it works. It seems like that's healthy. So I have to make decisions. And if I choose not to make them, if I choose not to inform myself, I will probably pay a price. So a random approach doesn't really work very well on medicine. So I have to be aware of the doctor. I have to be aware of at least what's available in the press on the new medical research. I have to follow advice, which is a matter of trust. And I have to deal with the information that comes to me. For example, sitting in front of the television on any given evening on cable or otherwise on every channel I can think of, there's the wars. I call them the warfarin wars, warfarin versus zirelto versus two or three others. And they're all blood thinners, and they reduce the risk of stroke if you have factors that might otherwise give you a stroke or a heart attack. This will help you. I say, gee, you know, that sounds really interesting. But which one do I look at the flash he had? They're romantic sometimes. The doctors are very good looking. They're very well produced. And they are repeated over and over and over again. And I'm trying to think, you know, why are they sending me this information? Am I going to make this decision? Do I go to my doctor and say, Craig, you know, I know you wanted me to use baby aspirin, but forget that. I need warfarin, right? Well, the ad actually is for the new high price spread against warfarin. So I might have you on warfarin and you want to be in Xeralto or whatever. So, you know, first of all, we think those ads are normal. They're anything but worldwide. Mostly that's not allowed. And you might say, well, this is good. Empowers knowledge and all that stuff. I don't think it's good. And yes, the goal is for you to come to me to change your prescription. Now, by the way, we're all human. I have my own pressures. I get detailed by drug graphs. We ban them from the hospitals. And that's a good thing. They still take pizzas to a lot of doctor's offices and there's evidence that it works, which is very... Food and prescription. You know what's so interesting about it? Doctors are so cheap. Just a couple pizzas and you can impact prescribed and practiced. That's ridiculous. Anyway, back to your thing. None of us should be making decisions based on advertising. Surely we do. We shouldn't be. Why is it permitted? It just seems so inappropriate, so offensive really to tell me and I'm really ignorant about this which drug I should use. And then, of course, the sequence is often, they're going to tell you how beautiful the drug is in beautiful people, romantic scene, idyllic, idyllic. And then at the same time, they're repeating all the warnings. You can take this drug and it can save you from a stroke, but it can also kill you from some horrible, horrible disease. Well, it's true. And here's a list of all the deadly, fatal kinds of things. But we have the best drug. And then, you wait a few minutes and you get a lawyer. And he's on it. Anyone who has taken Zeralto or their loved one who is now... Call me. Call me. That's right. What? So this is a fascinating topic. And I'll stick with you shouldn't use advertising. I shouldn't, you shouldn't, who decide the best course of action almost ever, including particularly in medicine. The next thing is benefit is always assumed. Harm is delegated. So if I put you on Zeralto, all of the advantages, you don't get your blood drawn to get checked and it'd be easier to stay in range, etc. That's all nice. The fact that some of those new anticoagulates have a higher risk factor for cardiac disease, and it's a risk down there, but it's not mentioned. Overall, I do think in that particular arena, we're mostly talking market share. Overall, I think warfarin is going to be used less and less. Perfectly fine, but difficult to use drug. And probably the other three or four new ones, hopefully the right one will surf, it will swim to the top. That's what this fight is about. Is it important, you know, is it important in the process of deploying new technology? I mean, there is new technology. These drugs are new technology. They are. They can improve my prospects. On the other hand, is it necessary to advertise in order to roll them out and make them available and make the public accept them? No, I don't believe so. Or at least the rest of the world certainly doesn't use that practice. And you asked before, why is this allowed? You didn't ask many other questions like, why are drug prices so high? Why is it not competitive? Why is lack of inferiority, the bar to putting in something new? Well, that's a pretty low bar. It should be, like, better. And the answer is the same for all those questions. Big Pharma is very powerful and supports many people in our government. And the rules are good for them and they're less good for us. So that kind of technology, which costs billions to get it all approved and trials and all that and then roll it out and advertise it and whatever you've got to do to make it acceptable to the public. That's different, isn't it, than medical research. Research that's funded by the National Institutes of Health, any number of charitable organizations that fund medical research. Well, and the drug companies. Ah, yes. Thank you, yes. And so, yes, pure medical research is funded differently. But more and more, it's actually being funded by the drug companies. And the problem with that is clearly you're under tremendous pressure. Even whoever's funding it, you want to have a positive result. Okay, well, we all work to get positive results. Turns out we work a little too hard. Honestly, there are some crooked researchers, but also it's just, it's hard to do right. The real question is, can you replicate the result? Or can someone else? That's the real question. And what's in your heart when you're rolling out a drug like an opioid, which gives a high and makes somebody feel good for a little while and gives them some sort of relief. Relief is good. Relief from pain is good. Yes. But then you habituate them and you know it and you keep doing it. I mean, that's real trouble. Talk about credibility. Well, the opioid story is probably worth a whole session. But in short, a well-organized, pharma-driven research and PR campaign was performed. Research can definitely be inappropriate. There's inappropriate research. Many examples. Inappropriate. Inappropriate. The tobacco research years ago, oh yeah, was wrong. The sugar research much more recently was wrong. The opioid research about the danger of addiction after acute pain was wrong. There was a big market. If you've been to the ER or your doctor's office and you have a painful condition, I'm going to score 1 to 10. How much is your pain? Actually, it's 0 to 10. And you pick a number. Well, this was part of a campaign with the rollout of OxyContin. And it's universal. Any ER is going to ask you that question. There was a 15 or 20-year push to do that. It's completely subjective. Well, of course it's subjective and it's not measurable. It's not measurable. OxyContin, I give you a high number. Yeah, go for 12. Top is 10. But no, there's actually a great little study I just saw that one of the predictors of people who are seeking farmcloth, you know, there's a whole bunch of predictors. The best predictor is picking a number greater than 10. You weren't offered a number greater than 10, but you took it anyway. No, the opioid epidemic is a case in point of the corrupting power of money in big pharma on everyone. And there are some doctors who are just criminal in this. But all of us were influenced. Pain's a vital sign. You're scored on satisfaction. Your patients don't want to hurt. I'm all in with that. Potential for harm is not usually at the front of those decisions. Then it needs to be balanced. This is why shared decision-making is tough. Yes, I can make your pain better. I can't take it away, but you won't care about it very much. I'll also make you constipated for sure. And there's some chance you'll get hooked. That's terrible. Not very high, but it's not zero either. And you'll be habituated. Yeah, well, that's right. Even, well, they go together, but habituated, of course, sort of means you develop tolerance. So not only, in the end, you're in the worst of all worlds. You have to take the pill to keep from going into withdrawal. So it doesn't even mean like you're doing that well. You just stand out of withdrawal. So it's a mess. And in the bigger picture, it's why shared decision-making is tough. How do you weigh it? What's important to each individual? What do we know? And what don't we know? We don't know some really basic things, or at least we haven't recognized some really basic things. The public still doesn't know, really. I suppose in the red states where they kind of live on this stuff and there's really millions and millions of bills are being floated out there to the community in lieu of real medicine, I think, you know? It's easier than solving a problem. It's easier than solving a problem. But, you know, does the public really understand about opioids? Does the public say, no, don't suggest that to me, doctor. I don't want any part of that. There is some work, yeah. It's starting to happen. So, and of course, there's also a significant subset who come to see us for just that reason. So, because they want them. So, it's not solved. Interestingly, opioids in Hawaii aren't that big a deal. They're real. It's an issue. And there are some providers who honestly go into jail. They really have, because they prescribe too many. The drugs here that matter the most are alcohol and methamphetamine. And, of course, smoking, which smoking doesn't bother me as much, because if you decide to smoke, hey, you're going to be bad for you. You'll be bad to people sitting near you. But overall, it doesn't affect most others. Alcohol, you can run over me. You're going down the road. I don't like that. There's been some interesting literature research about the other health impacts of alcohol, which are much greater than anyone wanted to recognize. To your own self. To your own self. Long term. Long term. To destroy your organs, that sort of thing. It does, yeah. And it's long been sort of touted. Here's probably an example of some industry-associated research that, oh, it's good for your heart. You'll, a little wine is good. Isn't that, isn't it been debunked lately? Yes. All alcohol is bad for you? The, yes. I think that's a fair summary. And whatever possible beneficial effects there are, they're very small if they exist at all and they're vastly outweighed by all the deleterious ones. And it's dose-related. It's interesting, too, that the individual person, the patient, a curious member of the community, has to watch for the changing of the ideas, the changing of the medical ideas. So before, you know, two glasses of red wine a day, that was good for you. Perfect, yeah. Even for small children. Mendes France. Remember him? Yeah. Premier of France. Yes. And now, you know, it's different. So you have to watch out. And the whole thing about prostate screening, should you have it? Shouldn't you have it? I mean, it changes. Well, it does. And as we learn more, things evolve. But I guess my advice would be, be skeptical of any source of information that has a bottom line associated with what they're telling you. So if, in the recent scandal, the alcohol research was, the spirits industry was subsidizing the research. Oh, no. They blew up the study. Oh, yeah. It should have. Oh, just like the tobacco thing. It's like, yes, or the sugar thing. So, and the screening, don't forget there's the medical industrial complex. There's big money in screening. And it's not just the testing. It's what comes after. Which overall, you're optimistic. Overall, you're optimistic because you read the journals, you get the journals every day or every hour, all those journals, and they have very interesting, important advances in medical science. So overall, I'm excited. I think we're at the threshold of new opportunities with data and other kinds of interventions. And hopefully we'll have a way of sharing information so people can make informed decisions, which is how we all get healthier. Tell us about some of the remarkable results in medical research these days. Well, you know, I think we're going to have to do another whole talk about this. Sorry. No, we had it. No. Well, the, well, I'll tell you what, we'll touch on a couple and then we'll have to go for next time. Okay. We're just learning about the microbiome. We are more bacteria and viruses than we are cells. This is an astonishing thought. We're appreciating sometimes at very basic levels things like importance of sleep or cardiovascular fitness or lean body mass versus overall weight. All these things matter. And so we're part of the great experiment. And to me that's exciting because it's a chance to be healthier and happier. And so, Jay, we'll have to do this again. I hope so. I want that. I'll look forward to it. Thanks for joining us. This is much more on medicine with host Jay Fidel, part of the Kauai's live stream series. Thanks for having us. Thank you, Craig. Thank you. And thanks for joining us.