 This is our third event of this academic year. We're not sure if we're going to be able to squeeze a fourth one in. We're going to try. But if you're interested in that, the easiest way to find out, and indeed the easiest way to find out anything about the forum, is to go to our website, which is Health Policy Forum. That's all one word. HealthPolicyForum.stanford.edu. That'll also give you a chance if you want to view any past events that they're all archived on the site. So our structure today will be a conversation for about an hour, and then we will open it up for about a half hour for your comments, reactions, and the like, and we'll have roving mics to make that work. As is usual with our conversations, our interviewer will be the estimable Paul Costello. Paul is the head of media and communications at the medical school, and he had before that a long and distinguished career in journalism and media relations. Our guest today is a true Renaissance woman. You will know if you've read her biography, Pam Bellick of New York Times. She has really covered an extraordinary range of topics in her career. I initially became aware of her work in a series called The Vanishing Mind about dementia. And what was so impressive about it is some journalists get the emotional aspects right, some get the science right. She got them both right. I thought, this is someone I'm going to keep reading, and I have kept doing that. The range of topics she's covered is incredible. Cattle wrestling, embryo adoption, and should seriously mental ill people be allowed to smoke in psychiatric hospitals. Most recently, what is it like to be a doctor on the island of Nantucket, something I've always wondered about and now I'm going to learn about. So please join me in welcoming her to Stanford University. Thanks, Keith. Nice introduction. How many of you have read the book, Island Practice? Okay, they're outside, so you can pick it up to read it. We're going to talk a bit about the book, Island Practice, and why Pam found this idiosyncratic physician surgeon on the island of Nantucket so fascinating and such a compelling figure. And then we'll talk generally about her writing for the New York Times and her coverage of health and science and a wide range of issues that she's covered. But first of all, why Tim LaPore? You know, of all the people you could have chosen to do a book on, why did you find him so compelling? Right, well, just to give you a little background on how I met Dr. Leppery, so this was before my incarnation as a health and science writer, I was the New York Times New England bureau chief based in Boston, and I was asked to basically do a profile of someone in my region who had not been written about before, wasn't famous, but was doing something interesting in an interesting place. Those were the marching orders. And so I was sort of considering a variety of people. There was a guy who was running a nude bowling league in Maine. I thought that had possibilities, but then, you know, the times... You couldn't do the pictures at the time. Well, the Times wanted to do video, and it just wasn't going to work. There was a guy who was running a secession movement in Vermont. He wanted Vermont to be its own country. I think the idea was that they were going to survive on Ben and Jerry's Chunky Monkey alone. It sounded appetizing, but then I sort of happened across really just one little mention. Some people do read the medical school alumni newsletters. I guess I do, and this was the toughest medical school alumni newsletter that happened upon my desk. And there was one little line that said, our alum, Tim Leppery, is the only surgeon on Nantucket. I thought, okay, I didn't know Nantucket at all. I thought I'd call him up. And he was just so engaging on the phone. And I became very interested in this question of what is it like to be a doctor, kind of the main doctor in a community where you're on an island and your resources are limited and your travel is limited. And I went out and spent a few days and did a piece of The New York Times and immediately got calls from book people who said that they saw the potential for a book. And so I started looking more into this. And I feel like I was sort of fascinated about it in kind of concentric circles. The central question, that initial question, what's it like to be juggling all of those things and facing all those pressures in a community like that? As a solo surgeon. As a solo surgeon and really sort of the go-to doctor. I mean, he is the medical examiner. He is the football team doctor. He's the medical director of the hospital. He will fix up your animals. He will give you some rather unorthodox psychological counseling. He's the tick disease expert. You know, you name it. And so that became very fascinating. But also in a sort of the person himself became very interesting because he has all these contradictions within him. This is a doctor who, by definition, his job is to save lives. And he's a gun fanatic. He's an NRA member. He collects 200 guns. He keeps them stored in his basement guarded by tear gas, which one day went off in the face of the fire chief who heard a hiss and was opening the door. His exam rooms are named Smith and Wesson. His bathroom in his office, my favorite, is called Pea Shooter. You know, so there was sort of those kinds of contradictions. This kind of brash, almost cowboy-like style that can be very alienating to people, but at the same time incredible devotion to his patients and actually underneath that kind of bravado, a very careful clinician. And then I was also kind of interested in the larger issue of what does this say about healthcare in America. This community turns out to be a lot more complicated and diverse than one might think. Let me ask you about that. Most people know Nantucket as being the enclave of the wealthy and the playground of the wealthy. But it's like Martha's Vineyard in Nantucket. Off-season, it's a very different environment. What's the environment like? It is remarkably diverse. So Nantucket has, I believe, still the highest median home value in the country. And it supports this wealthy summer population, and yes, they are there, and Dr. Leppert treats them. But the implications of that for the people who live their year-round, about 10,000 or so, is that it's an incredibly expensive place to live. And so they are basically sort of struggling to hold themselves together in the off-season, which lasts about six months. They're putting jobs together. It gets very desolate and very bleak. There's sort of like a three-mile radius that you can navigate around in the winter months. And it's a very, very different. It's not all sunshine and flowers. And at the same time, it attracts an amazing diversity of people. There are immigrants from Cambodia and Bulgaria and El Salvador, South Africa. They're all and immigrants of a sense from the mainland, which Nantucketers often call America. And so you have folks who are there to kind of reinvent themselves, to they like the idea of being kind of offshore, maybe offbeat, a little bit, you know, out to sea figuratively as well as literally. And all of these elements kind of converge in this 14-mile square island. And so you have this really combustible and interesting environment. So it's strangely, I mean, you would not think it, but the diversity sounds like it's strangely a microcosm of America. Oh, yes. I found it to be very much a microcosm in economically, ethnically, and in terms of healthcare as well. The range of diseases and conditions is extraordinary because people bring their own remedies from various countries. They bring their own infections. They bring, you know, strange diseases from everywhere. And it's all there. And so you've got a small hospital, 19 beds, one operating room, six units of blood, no recovery staff, you know, essentially one surgeon dealing with all of this stuff. So you chose two stories. One was Leopardy's story of a surgeon on an island and everything that he was faced with. But what does it tell us about healthcare in America? Does it tell us anything about healthcare in America? Yeah, I think it tells us a lot. And it's interesting as well because Leopardy's hospital, Nantucket Cottage Hospital was during this period where I was reporting the book, basically taken over by Partners Healthcare, which is the big hospital chain which runs Mass General and other hospitals in the Boston area. And so you have this kind of phenomenon that's going on everywhere in the country of the sort of corporate, you know, corporatization of healthcare. And you have this incredibly individualistic doctor who in some ways is a bit extreme, but I think also represents a lot about why people want to go into practice medicine. And I think there are lots of doctors who reflect aspects of the care that he provides, whether they're in the inner city or in rural areas or in the suburbs. You know, they want to be able to have individualized relationships with their patients. They bridle under the restrictions of insurance. They don't want to give, you know, cookie cutter, you know, 15-minute appointments. And they're trying to figure out a way also to kind of make a living with all of these restrictions. And he's, you know, an unusual character, but he is emblematic of that struggle. Talk about the clash between partners and, because it's really interesting that they tolerate each other because they have to tolerate each other. That here's this sole practitioner who's a necessary critical part. And if you walked away from his practice, one hardly knows what would happen. Talk about the clash between, because it is sort of an American clash today between, as you said, big hospital systems and physicians. Right. So he would refer to them as the suits. And now, remember, Dr. Leppery is the medical director of the hospital. And as such, he gets to say certain things to the hospital brass. And once a year, he gets to give this PowerPoint presentation to the Board of Trustees, which he completely delights in. And he makes it very irreverent and somewhat insulting, you know. And they just kind of have to sit there and take it. He wanted to bring his dog in to use the ultrasound on the dog. And he did it in this sort of, you know, broad daylight way that just, you know. In your face. In your face way. And, you know, he might be coming back from hunting and have his gun with him and pack that into the hospital. And, you know, he feels that he doesn't, if you sit down and talk to him, he doesn't completely reject everything about having this merger. Although he does say that, you know, it's sort of like a marriage between a Greyhound and a Chihuahua. You know, he, but he understands that there is some efficiencies there gained and there's some, you know, economies of scale and there's some expertise that they get from a close relationship with these hospitals. But he wants to be able to choose his own experts. If he wants to send somebody to, you know, Newton Wellesley Hospital or another hospital that isn't run by partners, he wants to be able to do that without having it be dictated for him. He has relationships with doctors all over the region. And partners basically bridles at him but sort of says, there's nothing much we can do, you know, we need him. And they know that he's a good doctor. And that's sort of the thing that always sort of comes down to it, is that he does well by the patients. Did you feel watching him as close up as you did? Would you go to him? Would you feel comfortable going to him as a patient? Did you think that he was a tremendous physician, surgeon? I've only been asked that question one other time so far and it's interesting. Medically I would have no issue going to him at all. I feel like I know him so well personally that I'm not so sure that I would but I do have a lot of respect for him also as a person. And one thing that you would know that he would always be there for you, no matter what time of day, no matter how little the question, no matter how kind of non-medical the question would be. You know, he had a patient who I write about in the book who had this very involved case of narcolepsy with cataplexy and he helped her diagnose it. He put his reputation on the line prescribing xyram which is the one medication that's approved to treat this but it's very dangerous. It's basically a date rape drug. It was illegal for a long time. It's highly controlled. You have to be part of a federal database to do it. It's very expensive. He somehow got insurance to cover it and he has basically been, you know, not only her doctor but her counselor and recently she emailed him one evening a picture of a spider that was in her apartment and was freaking her out and she didn't know what the... She sometimes hallucinates. She wasn't sure whether she was actually seeing the spider and what kind of spider and, you know, Dr. Leppery's wife was saying, you know, why are you spending time with this patient with her spider? That's not your role. But he was fascinated and he looked it up and figured out it wasn't poisonous and that's all just part of a day's work. One of the things that I don't know how many of you know this but Nantucket is the epicenter. One of the epicenters, if not the epicenter for tick-borne illnesses. I wondered if you could tell us about tick-borne illnesses, what we know about them and what Leppery has learned about tick-borne illnesses from being in Nantucket. Yeah, he's basically become a national expert on tick diseases and one of the things that I found interesting there's all sorts of colorful stuff but, you know, Nantucket didn't... it's sort of accidental that it became this tick epicenter. Or even a home for deer. Or even a home. Well, so part of the tick life cycle is dependent on deer and so Nantucket used to have no deer at all and then in 1922, I think, a deer was seen swimming in the water in the Atlantic Ocean and a fishing sloop picked up this buck and brought it to Nantucket and the islanders went crazy and they had sort of a parade and then, you know, they were worried that the buck was going to be lonely so they enlisted the help of... These are nice people on Nantucket. They are very nice. They enlisted the help of Breckenridge Long who was a diplomat who helped form the League of Nations and also had a summer home in Nantucket and he negotiated, I think it took about four years, the importing of two does from Michigan and they brought the does and they had another parade and the does and the buck got together and the rest is history and where are these deer going to go? Most of them are not swimmers. So they have heavily populated this island which is fueling the propagation of ticks because of the ecology of the island there has been a lot of multiple sort of co-infected ticks so we've heard of Lyme disease but there are two diseases one of which actually Leopardy helped identify that are really more dangerous Babesiosis and ehrlichiosis and a lot of the ticks on Nantucket have multiple infections so if you get Babesiosis your spleen could rupture, you can die and there is an outsize number of cases on that so he has a little sort of research arm that he does with tick diseases and during deer hunting season he will basically camp out in the deer check-in station which is the sewage treatment plant and when people bring in the deer he will pop out and he always carries a vial in his pocket and he goes through and picks the ticks off the deer and pops them in the vial and then he faxes them to the mainland where he has a partner at Tufts Veterinary School and they analyze them for tick diseases and actually just I think last month he was a co-author on the study published in the New England Journal a fourth disease that was identified in part on Nantucket You've had a... you travel the country a lot as a science health reporter for the times how would you describe this moment in this country in health care? That's a big question I think it's a very... it's a very pivotal moment in a lot of ways obviously that will end up happening with the insurance system I think a lot of that will depend on how states implement Obamacare but that as we can see from Massachusetts which I covered that was sort of the example the health care reform there was the blueprint for Obamacare The state health care reform which was Romney's baby there it's gotten a lot of people covered but interestingly not on Nantucket there's still about 18% of adults on Nantucket who do not have coverage because they just don't have employers or job situations that allow them to get coverage so it doesn't work for everybody but even with the coverage you have this huge issue that really has not been addressed which is the cost of health care and that I don't particularly see how that's going to end up being answered in the current proposals and as long as that isn't answered there's going to continue to be pressures on the system like what we're seeing What do physicians tell you as you travel around the country what's on their mind mostly is it the pressure of time is it the pressure of practice of time with individual patients Yes, I think that's a lot of it it's depending on what flavor of medicine they're in it could be there are not enough so they're overwhelmed primary care physicians are having a hard time but it's also time that has to be spent with bureaucratic and administrative duties dealing with insurance companies dealing with lawyers everything that takes them away from the patient care is not really why they went into medicine When you sit down with someone as you did for the book or any of your articles how do you help get the story what's the process for you as a journalist to go through and saying I really need something compelling built here how do you bring them out how do you work with them how do you engage your subjects Well, I guess my approach I really try to have a very straightforward approach to the people that I interview I let them know what it is I'm interested in and I'm genuinely interested in what they have to say I don't approach people with a preconceived notion or judgment about some particular aspect of who they are and I will often encourage them to ask me questions if they want to know what's the story going to look like or do you have to use this particular fact sometimes people are concerned about one detail of their family life say or their work life which may not be at all relevant to the story that we're working on and once you can sit down and have a conversation with them you can allay their concerns and I think also just trying to understand what their motivation might be for sharing their story one of the questions that I get asked frequently about Island Practice is that there are a lot of patients who are quoted by name sharing very personal information some of it very painful information and I think that everybody has a different motivation some people find it cathartic or helpful to have somebody listen to them some people feel that by sharing their story they may be helping other people and you know some people I think in this book were interested in were willing to talk about their own painful experiences because they wanted to be able to show how effective Dr. Leppery was in helping them and that was worth it to them and so just getting in touch with their motivation Does it help or hurt that you're with the New York Times? Does it depend upon where you are around the country? It definitely depends it definitely depends on the story I've been writing over the last year a number of women's reproductive health stories dealing with the abortion issue and it does not always help with people on the anti-abortion side and they you know tend to equate us with east coast liberal editorial page wouldn't be to their liking so that takes a lot of work but I really do make an effort to say look I know what you might be associating with my publication but here let me tell you what it is I want to do and I recently did a story on crisis pregnancy centers which are the centers that are set up to discourage women from having abortions and I spent quite a long time trying to find one that would allow me to visit many slam doors and several harangues about the New York Times but I was able to find one because basically explained to the woman who was running it that this was an opportunity for them to demystify what happens in these centers and if they're proud of the work that they do and they are then this is an opportunity for them to let people know what it is that they do what do they do that was a fascinating story because as I find with almost every healthcare story but especially stories that run up against political issues where the rubber meets the road where you are looking at what is actually going on it's always much more complicated when people on either side of the political spectrum would have you believe these issues like abortion get hijacked by the political folks and when you look on the ground it's much more complicated so when you go to a crisis pregnancy center they are offering women who are pregnant who often don't know what to do yeah they are talking them out of having an abortion but often what they're doing is offering them emotional support sometimes financial support sometimes housing they are incredibly strategic in the way that they are fighting against Planned Parenthood they'll put up the one that I visited which was in Waco, Texas was putting up signs opposite the Planned Parenthood that would say there's a law in Texas that says you have to have an ultrasound within 24 hours before you have an abortion and that the abortion provider has to perform it and it costs about $105 and so they would put up a sign opposite Planned Parenthood that said change your mind will refund your ultrasound money and just a phone number and they would get people that way I thought that it was very instructive because on the one hand there are people getting real help here but also it's instructive to somebody who is a supporter of Planned Parenthood why they might be losing some of the hearts and minds in that battle because they are not really reaching out to the hearts when I went to the Planned Parenthood there and I said you know in a very efficient clinic and they're providing good medical care and I said do you give them any emotional support and they said we are not our patient's emotional counselor we're their medical provider and I was thinking well if you were you might let me ask you about a story you wrote a fascinating piece a couple of years ago about the prevalence of Alzheimer's disease within an extended family of 5,000 people in a Andean mountain village in Columbia how did you first come about finding this family and what are US researchers learning about prevention from this group of people yeah so I my editor said to me go to the Andes and solve a problem and I said what kind of subject would interest you if you're interested is there a line of reporting for this next year that you might be interested in so I said well you know how about Alzheimer's and now I'm you know relatively new to the science department and there are people with a tremendous amount of expertise and that is very helpful it can what I provide I think and why they do bring new people on is that I tend to be maybe more easily surprised by certain things and I don't feel like I've read it all before I've written that story before so she said well you know I'm not really sure that there's going to be that much new to say about Alzheimer's because all of these treatments that have been tried they don't really work but poke around so I poked and I'm a persistent poker and I sort of noticed a reference after talking to a whole bunch of people it was like on the bottom of an email to this family in Columbia and I talked to one person and another person and another person and it turned out that this is the largest family in the world to suffer from genetic Alzheimer's generation after generation after generation and part of it is because as you said it's a very isolated community it's a tremendous amount of intermarriage so the family currently there are about 5,000 people probably about a third of them have a single genetic mutation that causes them to get Alzheimer's in their 40s it's devastating obviously so I was able to go down there with a photographer to spend some time talking to some of these families we went to some fairly dicey areas and but we were able to talk to them and I've learned that there were scientists who were studying these families and that they were looking at them for a very compelling potentially groundbreaking reason because one of the reasons why we haven't been able to figure out what works for Alzheimer's is that all these drugs that we're testing have been on people who already have the disease and the thinking is maybe those are not the wrong drugs maybe it's just way too late the brain is so ravaged that we're just fighting a losing battle but how do you test beforehand when we really don't know what is going to cause Alzheimer's to a degree where you can actually set up a clinical trial and say well this family we do because we know that if you have the mutation you're going to get it and we know roughly when What percentage of this family comes down with the disease? We think it's about a third so it's incredibly high so we wrote a big story about that and we're told partly as a result of that that this project was one of the first grants of the new National Alzheimer's plan and they have just now begun testing they're testing an anti-amyloid drug on members of this family probably about up to 15 years before they might get the Whose testing? This is the scientists it's a collaboration between the Banner Alzheimer's Institute in Phoenix and Colombian researchers there's a very related neurologist Francisco Lupera in Medellin who has been following these families for 30 years What are you learning about Alzheimer's as you we were talking earlier today with one of our research scientists about telomeres and telomeres at one point you may want to describe them one point seen is perhaps a window a biomarker into Alzheimer's and you were saying that there's some doubts about that but when you look at generally at the science the illness of Alzheimer's what are you finding is there great growth great stories great advances potential breakthroughs? It turns out that it's a really exciting time and that story that we did the Columbia story after I did that story my editor said we should start really looking at this and then we've a colleague of mine Gina Claude and I have been over the last couple of years writing occasional stories of the vanishing mind under the umbrella of the vanishing mind and what we're finding is that I think there's sort of two main streams where there's sort of exciting things going on one is this issue of prevention, the possibility of prevention which is what the folks in Colombia are doing in other groups around the world who are looking at possible ways to prevent and obviously if that or delay the onset of symptoms and obviously if that can be done that's very exciting the other thing that's happening now is that detection is becoming much, much more accurate so we can we can identify Alzheimer's pathology 10, 20 years before onset of symptoms and that raises currently some questions of do you want to know if there's no effective way to treat it so we're sort of looking at those things but also it's setting kind of new targets for researchers so maybe they're looking at trying to identify biomarkers that could be actually attacked in the same way that for example high cholesterol is now a biomarker for heart disease and you can treat the high cholesterol to try to prevent the heart disease and that's the way it's going in Alzheimer's and we just had a story I think last week about the FDA considering accelerating drug approval so that you wouldn't have to have proof that a drug would ameliorate clinical symptoms of the disease but if it addressed the biomarker that might be enough. What are the interesting things you wrote about a few years ago were five studies that were presented at the Alzheimer's Association International Conference that tied the decline in thinking skills like memory planning almost in parallel with the ability to walk fluidly. What are they finding the tie-in between movement and cognitive skills? That's the kind of thing that those are the kinds of stories that you look at say a field like Alzheimer's and there's so much happening and there's so many studies and how do we pick which ones to write about and we're looking for research that has some results that are significant but we're also looking for things that are surprising or counterintuitive and that was one that I thought was very interesting at first blush you'd think why would it be that if you're a slow walker or your walk is defining why would that have anything to do with your cognitive ability but then if you sort of unpack it a little bit you can see that there are parallels. Motor skills are driven by the brain just as cognitive skills are and there are some of the things that are involved in walking planning what's called executive function we do it we do it automatically the brain's doing a lot of stuff to get us to walk and so it makes sense that if you see a decline in your gait speed or your coordination that's sort of more advanced or more pronounced than an age-related decline ought to be that you might also see some cognitive declines. When we were talking earlier today you were saying that you were at the Commonwealth Club last night and one of the questions was do you find your work frustrating? Sitting here listening to you your work is fascinating. You as a journalist must be looking through this window and thinking I'm at the most exciting age to be covering health care biomedical breakthroughs innovations. Is that how you feel? I just love the work that I do you know it's I didn't really know how to answer that question because I don't find it frustrating at all I just find it to be this incredible privilege that I get to talk to interesting people and enter people's communities and lives and tell their stories and it's just this wonderful combination of being able to learn about stuff and then actually use the creative process of writing it and communicating it and ideally making a difference for the people who read it and maybe for the people whose stories are being told so it's very exciting and when you're talking about health care there aren't too many more important subjects that affects everybody in one way or another. You spent time in a California prison not as an inmate I might add to the story about first-degree murderers who were working with other first-degree murderers assisting them with Alzheimer's the first-degree murderers had Alzheimer's one population the other first-degree murderers were caretakers how did you find out such an interesting story how did you find out about how did the warden I guess put this into place that again I sort of try to and I came across a small paper that was presented I think in Canada about that program and I said really that's kind of interesting and then you verify that it's actually going on that was generated by the Alzheimer's Association chapter in this was in San Luis Obispo it's the California Men's Colony and they had were working with the person who at the time I think was the chief psychologist at the prison and you know what's going on in prisons you know the population generally outside of prisons is aging rapidly we all know that right the baby boom generation well in prisons particularly in your stay here where you have these you know life sentences you've got a aging population and they're getting dementia and a lot of them have extra risk factors for dementia because they may have had head injuries they have you know fairly low education you know a lot of them have mental illness that or depression that may kind of parallel or exacerbate dementia and the system can't afford to take care of them because it's very expensive to hire caregivers so they came up with the solution where they train other inmates to basically be the caregivers for these inmates with dementia bathing them you know helping them dress taking them to doctor's appointments calming them down you know reassuring them when they think that one of them used to wait by the gate still does I think every morning convinced that his mother is going to be there to pick him up well his mother's dead you know a long time ago and these the inmates are the ones who bring him back and tell him you know they say well she'll be coming later you know so it was just fascinating one of the things that you also told me earlier that when we were talking about the stories that really impact you personally there are 6 million children in the U.S. right now who have been diagnosed with severe mental illness and you've written about the reality of what parents caretakers deal with every day in with a seriously mentally ill child tell us about Haley Aspor Aspor yeah what's her story? well so this was years ago I we decided to do an in-depth kind of portrait of a family struggling with a child with mental illness and again the sort of criteria for that when people talk about you know why fully identifying people with sensitive issues we wanted to be able to focus on a family who would be openly telling their story because we felt that that brings a certain credibility to the issue and this is an issue obviously that has so much stigma to it and so I spent over several months a lot of time with the Abbas Forre family Haley was I think 11 then had multiple psychiatric diagnoses it wasn't even really clear what she had it was just just in so much torment and the family was trying very hard to figure out what the best treatment was for her and how to take care of her and I basically sort of told the story from the point of view of each family member including her older sister who had become at one point suicidal because she was just feeling so stressed out by the family having to focus so much on Haley and that story it just got so much amazing reaction from readers people who were so grateful to the times and to the family for coming forward and sort of letting people see you know a window into what it is actually like and not being embarrassed about it you know the father was having almost you know hallucinations and nightmares because he just felt so helpless and the mother was trying to hold things together and navigate this Byzantine system of the schools and the hospitals and you know it was just an incredible story and I actually heard from them not too long ago and she's doing much better so there is some light you know it's a tough situation but she is doing better what are the services available to these children severely mentally ill children today it's a very chopped up system yeah well there's a shortage of child psychiatrists there's I think there's discussion debate within the psychiatric community about what type of therapy what type of medication is best which diagnoses are real diagnoses and which are and which are are not it's it's a very fraught area that you know there's a lot more reporting I think in our part but it's tough to do you looked very closely at the morning after pill and you read hundreds of pages of FDA documents transcripts, scientific studies and you talked to people involved in the original approval what was the story, what were you trying to find out about the morning after pill? right so we were trying this was a story that ran last year around so what was happening is that the morning after pill was being debated in the presidential election and sort of in the atmosphere and there were claims that were being made by folks on the anti-abortion side that the pill prevents the fertilized egg from implanting in the uterus and that's important because in the view of anti-abortion advocates that would be tantamount to being an abortion pill because for them life begins at fertilization and so anything that acts after that to disrupt the process is considered an abortion fashion. That's not the way that the conventional you know medical community looks at it, they consider pregnancy to begin after implantation but this has become a very big issue and this is not something that anti-abortion advocates just kind of made up but it's actually on the label of plan B and Ella it says it probably works by blocking ovulation in other words preventing fertilization but there's a chance that it could prevent implantation and we were trying to figure out is there actually science to back that up? Where did that come from? Does it actually do that? So I read pages and pages initially the FDA would not talk to me about this at all which was interesting and then I kept finding out reading studies and talking to experts that in fact there had never been any science to support the idea that implantation was being disrupted it was basically sort of grandfathered in from other types of birth control pills but there had never been studies done that had shown that these pills did that and there were new studies on the most common morning after pill which is plan B and it's generics that gave strong support to the idea that implantation is not affected so eventually I got the FDA I kept sending them questions and I got this email back from a spokeswoman from the agency who said that she had had this conversation with the high officials who dealt with this issue and that their conclusion was well she's not stupid which I considered high praise and then they came back with what I'm told is a really extraordinary statement for the FDA which they basically said on the record yeah the science doesn't show the science shows that that plan B does not implantation so essentially How did they get on the label? How did the FDA come to the conclusion to put it on the label of the first place? Yeah it's well I think there are sort of two reasons it's a longer discussion than we probably have time for but one is that conventional birth control pills do appear to affect implantation and so this was just something that was sort of part of the process now interestingly the company that manufactures plan B three times at approval and at two reviews since then requested even at the time of approval that it not be put on the label saying that there was no science to back it up but the scientists who were doing this didn't really consider it a big issue because remember for them they didn't see it in the context of the abortion debate they just said you know if there's a chance why not put it on there and if it does what does it matter it doesn't it's still preventing what we consider pregnancy and then it became kind of mired in the abortion debate and then I think it became too politically difficult to remove it and so interestingly you know since my story ran I mean we basically have the FDA on the record saying that their label is incorrect but they have not they have not changed it yet but several of the medical websites including the NIH website and the Mayo Clinic website as a result of our story have taken that language out of there and there was even an anti-abortion columnist who wrote this column saying that because of our story he was now convinced that these were not abortion pills and that they actually might be good for the anti-abortion side because if they prevented unintended pregnancies they would reduce the number of abortions so we're going to take your questions in a second but I want to close with a story that's not about health and medicine about science because it's nonetheless a very interesting story tell us about Holly who is Holly this was a story she wrote six months ago no it was just a couple of months ago it was recently yeah Holly is a cat a tortoise shell cat who got separated from her family on a trip that they were taking to Daytona beach and somehow made it the 200 miles back to their to their hometown in Florida and I was asked to do a story on the science behind that how could a cat find her way back home so the cat was on the holiday with the family the cat was at the Daytona speedway at a mobile home rally with the family and for some reason got a little spooked and ran and later shows up at a neighbor's house in West Palm Beach and who didn't know this family but they lived in the same town straggling in lost half of her weight bag putting down bags in the airline sure her claws were shredded her pads were worn down she had lost about seven pounds and this woman you know feeds her for a week until she gets her to come into the house and wants to keep her and she's naming her cosette after the orphan in Les Mis and she takes her to the vet to get her checked out and and the vet says you know you ought to check and see if there's a microchip in her an ID and there was and it turned out that it belonged to this family who lived just a mile away so that story that story was most emailed for about a month it got a huge huge response and I was just telling you that an agent called me and was interested in having a book about it but I I don't quite see it and I think you need to talk to the cat and you know I did get among the many emails I got I got an email from a communicator who said that she would be willing to talk to the cat so stay tuned Pam thank you for being here today and joining us we're going to take questions from the audience and I've always found the New York Times to be extremely interesting as a matter of fact I spent too much of my day reading it and obviously your talk shows that your subjects are all made interesting everything that's been discussed has had an interesting aspect the Affordable Care Act has never been fully understood by many of the population in a remarkable way would there be a way that you could make the Affordable Care Act interesting so that more people could understand it well I don't know if this is fortunate or not I guess the question would be also as a journalist do you feel responsible for clarifying as you well know the Affordable Care Act has been so politicized what is it what is it not the Obama administration did a terrible job explaining it they walked away from it death panels became the cry do you feel as a journalist responsible for clarifying the record on health science issues I actually don't do a lot of health policy types of stories of being in the science department medical stories so I I think I've only written one story about the Affordable Care Act and that's mostly covered out of our Washington Bureau and I think they have done a good job in trying to explain it it's tough to explain in an engaging way and I think we continue as a paper to try to find ways with policies like that to show how real people will be or could be affected and that's the way that I look at everything that I write which is that it's a political issue I want to get beyond the politics and I want to look at what the science says and what the impact could or is going to be on real people who are experiencing you know the whatever it is and that's what I see our mission as we are to we're translators in some way and and our job is to try to show people what's really going on I'd like to get back if I could to Dr. Leppery and to ask you as to whether Dr. Leppery may actually be at the epicenter of the national healthcare dilemma I teach health policy here at Stanford but for eight years I was a Dr. Leppery in the Santa Cruz mountains about an hour south of here as the only doctor for about 5,000 people with I had a doobie brother as a patient as well as farm workers and Dr. Leppery can do no wrong because on then talk it by definition if he wants to do it it's the right thing to do but Dr. Leppery has a tough time in Kaiser Permanente where I went to practice after I was in the mountains because in Kaiser Permanente you have to think of the whole system and keep the system going and practice appropriate medicine and cost effective medicine and just because you want to do it doesn't always make it right with the cost run ups in the overuse of imaging and the inappropriate use of medications and doctors saying well you know it's partners health who's trying to reduce the quality of care it's really an issue of partnership and doesn't he kind of embody this the independent physician who can't partner with the rest of the system to make the system work you know I think he is partnering with the system in as long you know he he's trying to he's trying to do it in his way you know he doesn't completely flout the system he does recognize that there are advantages for what he wants to do and and he has had cases where you know he's been able to make things happen faster because of the association with Mass General and with partners and he knows that I think it's just that you know for example they have a physicians organization Mass General Physicians Organization all the other doctors on the island have signed up with it and they measure they have a measure of physicians time spent with patients that they call relative value units you can imagine what Dr. Leppery wants to do those relative value units and he has not signed up with the physicians organization and you know he doesn't want to have his schedule ruled by that and he doesn't want to have the 18 minute visits you know I don't think of it so much as it's right because he says it's right I think it's he's not quite you know even though he does have signs in his office that say you know Tim Leppery czar of pain or something like that he isn't a czar there he is working within the system but he's just he wants to pick and choose the way he does it but he also can choose it because he's isolated on an island and it's a soul practitioner well and also because he is fulfilling crucial functions that it's going to be very difficult to find somebody else to do because if you are surgeon you know frankly there's not enough actual surgery on an island like that in a community like that to keep a surgeon working full time and so if you're going to be a surgeon there you're going to have to also do other things you're going to have to be a family practitioner or you know do C-sections or something else and it's going to be hard to find young doctors, new doctors coming up who who want to do both of those things with the demands that you know on your time that it takes for him so he's very valuable there hi the question of how you get the subjects to open up one thing that you didn't mention is how much time you spend on the stories and so a recent article that you wrote you interviewed one of my patients and spent the entire day with him you know flew out from New York to San Francisco and spent the entire day at his home going to where he used to work and so forth and it's interesting because the article was about lots of people and so he ended up being a fairly small part so I can only imagine that everybody else that was quoted in the article you spent similar amounts of time with and it meant a lot to the patient that somebody cared that much and so I think that you didn't give credit for that but I was very impressed with how much time you spent with the patient and it gets a little bit to the question of Dr. Leppery and so forth is how much time is valuable and that as physicians we spend so much time now justifying RVUs talking to insurance companies and it reduces more and more the amount of time spent with patients so we just had an RVU workshop where I found out that if I described what I had done but didn't label it that I would get no credit for any of that so I could have you know an entire paragraph describing everything but if it wasn't labeled with a specific modality that I would you know not me personally but the hospital would not get any credit for what happened and so more and more things like that seem to be running what happens in medicine and so the actual time spent face-to-face with the patient is reduced and eaten away at and I think that's what Dr. Leppery is I don't know how much time he spends in a day arguing with insurance companies you know to be able to do all these things that he's doing to know his patients that well yeah well he does hire a lot of people he doesn't you know he has trouble saying no to people and but to your point though thank you very much for saying that but I could also tell in working with you on that story that your physician who also obviously doesn't want to live in the world of RVUs I mean you knew everything about your patient from his long history and long struggle his job situation you know his the story was about smoking and mental illness and his sort of tumultuous struggle with smoking his parents and that is the kind of thing that I think you know most good doctors want to be able to do because you're treating the whole person you know what happens in their life outside your office is can be very very relevant to what you are treating them for in your office and and you know I think when you ask you know what are doctors frustrated by it's that very thing it's the things it's the walls that go up that prevent you from making those connections that can be valuable to your actual treatment of the patient this island practice has been purchased by Imagine Films and Imagine and it's being made into a television series what's the status of that? yeah so imagine television is Ron Howard's production company and they in conjunction with 20th Century Fox as a studio they've bought the book they have chosen and been working with this wonderful screenwriter named Amy Holden Jones who is actually a film writer who has written movies like Mystic Pizza and In Decent Proposal and The Beethoven Movies and she's produced a draft a pilot script which is now being apparently enthusiastically circulated and we'll see what happens it's going to be a fictionalized version of of island practice Tim Leppri is just turned 68 he's bald, he's punchy the main character in the TV series will be probably about 25 years younger and I bet a dash or two more good looking and there will be some other changes but the sensibility of the book is there a lot of the characters are actually there the names are changed but it's been really an exciting thing to see so far we'll see what happens but it's been a lot of fun so far I had a question here one story that science writers love and editors tend to love is the brilliant iconoclast the person in medicine who has the idea that's rejected by the mainstream and can't get any oxygen and some of those people are brilliant iconoclasts and some of them are crazy and giving them oxygen and the press can be a dangerous thing actually there have been examples of that for example in HIV how do you decide when you're interviewing somebody like that who is truly the brilliant iconoclast who needs that oxygen and who is the person to whom it would be dangerous to give that platform that's a really interesting question I've been getting emails from a guy who is campaigning for the Nobel Prize in physics and invoking some putative research that he did with Yoko Ono and Paul McCartney and that guy is not getting any oxygen I think it goes back to investing the time in the case of Dr. Leppery for example I would hear stories that he's this brilliant diagnostician and whenever I hear that I'm always skeptical of people saying that because you think well they're just watching too much house but so I started looking into these cases and talking to the patients and trying to figure out and it turned out that I feel quite confident saying that he is actually an incredibly astute diagnostician and there are reasons for it he reads like crazy all sorts of ancillary information and he sees such a variety of cases that when the woman brought her baby in screaming he was able to recognize that the baby had toternicate syndrome which turns out to be something that's actually not that uncommon but a lot of physicians don't know how to recognize it a hair often from the mother's head gets wrapped around the toe cuts off circulation if it's not treated the baby can lose the toe, get gangrene and he knew what it was he knew that a guy who appeared to have skin cancer actually had tularemia which only occurs about 200 cases a year in the United States but he had that information the case after case after case I satisfied myself through reporting that there was there was some there there and that's why I felt like it was worth talking about that in the book here, last question I'm curious about the kind of training or background that you had that qualifies you essentially to be a writer of technical or medical information and if there's an editorial process that you're writing has to be subjected to to make sure that it's technically or medically accurate I'm just curious about that process okay so I have very little formal background that qualifies me to write about medicine I went to Princeton I studied international relations I and a whole bunch of other things but and I studied Chinese and I went to Asia and for much of my career I've been a generalist but always interested in health and medical issues and have always along the way in my various stations and stops written about these issues and then I had a night fellowship a few years ago at Harvard and MIT where I studied health and science and after that the Times asked me if I wanted to cover this this area some of my colleagues in the science department have more formal scientific training and they bring that expertise which is terrific and I guess what I bring is more sort of the ability to connect you know I'm able to navigate the complexity of these issues and I'm interested in them and I'm interested in getting to the bottom of the science I can read papers understand them and ask questions but I also have the ability to sort of connect that with how it might actually affect people and to talk to people about that so that seems to be the thing that they have put me in the position of doing we have terrific editors some of them as I said before have a lot of history with a number of these issues and they are very good at asking the important questions does this study really stand up does it move the ball in terms of does it advance the field how significant is it we look at things how large is the sample size how well controlled is the study where did it appear was it peer reviewed we have various thresholds that we look at and then we'll call on experts frequently what I do and I'm reporting about a scientific study is that I'll go back to either that scientist or others in the field and say you know we're going to be writing about this but we're not going to be naming every single drug or physiological interaction the way that you have in the New England Journal of Medicine if I explain it this way audience is that accurate am I we're very conscious of the idea that that we're communicating to the public but we don't want to reduce the science or over simplify it because part of our public is the scientific community as well thanks Pam the proceeding program is copyrighted by the Board of Trustees of the Leland Stanford Junior University please visit us at med.stanford.edu