 Yeah, the business of medicine in the United States today with Dr. Joshua Jacobs who joins us from Hawaii now, home. No, Ron, home is Hawaii, but he's in what, Washington state? No. Yes, okay. Because he's everywhere, actually. Welcome to the show, Joshua. Nice to see your smile and face. Appreciate it. Good to see you too. It's nice to be here. So let's talk, let's sort of, you know, ramp up on this because there's a lot to discuss, and it's a good thing we reserved only six hours for it. So okay, so you're working, you're a graduate of a medical school, you're working as an MD for Oceanette here downtown. That's the last time you were actually doing stuff professionally in Hawaii. So that's, we should therefore track your steps after that. Tell me where you went, what you did, and yeah, we only have half an hour. All right, well, let me give you the one or two-minute version. So yeah, I was on faculty at JABSOM at UH for about 10 years after completing my residency in family medicine. Worked for Juana Medical, which was a spin-off from Oceanette. And after we got FDA clearance for the products, took my family and moved to Japan. We were there for two years, and I was doing research in public health and consulting with the Japanese government on patient safety initiatives and teaching over there, teaching resident doctors how to be doctors, and teaching their doctors how to teach doctors. I was then brought over to Singapore where that government had decided to transition from a British model of medical education to an American model, which means from a more passive, lecture-based observorship to a more active, hands-on model. And so I was very involved in that work, which is very rewarding and exciting and embedded us in the culture there. You might have been there at the same time Dwayne Gugler was there. He was a fellow that Cadman brought over from the National Institutes. Didn't work out in his infectious research, tropical infectious disease research. He worked at JABSOM, so he ambled off to create his own laboratory courtesy of the Singapore government at the National University of Singapore in tropical medicine. And he had a fabulous career. Did you ever know him? I did meet him once. He worked at the Duke NUS collaboration, I believe. So I worked at the other part of National University of Singapore, so the schools were somewhat in competition, which is what the Singapore government wanted to spur innovation. Nice guy, as I recall, doing great work. Yes. Okay, sorry I interrupted. Go ahead. No, it actually brings me to this infectious disease thread, just to bring it to COVID right away, because that's on everybody's mind. I was back in Singapore in 2020, in January, seeing old colleagues and giving a talk at one of their conferences. And during that time, they pointed out, here's our new infectious disease building built to $300 million building. That's where we're keeping the patients from Wuhan. And I scratched my head and said, oh, that's interesting. What does that mean? And flew back after the meeting in January 2020, landed in Washington state. And not three days later, there was the first confirmed case of COVID in the United States, which happened to be in Washington state, which happened to be at one of our clinical campuses in Everett. Shortly thereafter, I was back in Hawaii at another talk as part of JABSOM, talking about standing up the new medical school. That was in February of 2020. And shortly thereafter, the first cases in Hawaii were declared. And then the whole pandemic got really started in earnest in March. So my wife likes to point to me as the super spreader. By the way, I had nothing to do with it. Wives will do that to you every time. Yeah. She keeps me in check. So yeah, we were in Singapore for three years, had a great experience, and then was recruited over to Washington DC. The Association of American Medical Colleges, or the W.A.M.C., as they like to be known, is one of the parent organizations that accredits all the medical schools in the U.S. and Canada, among other things. They inflict the M.C.A.T. exam on applicants as well as a lot of other things. So I worked for them for about three or four years doing very interesting projects around helping doctors track their competency. And while there was working at the uniform services for health sciences as teaching our young emerging doctors and nurses in the military, and then working at George Washington University, seeing patients in their urgent care. And then I caught wind of this opportunity here in Washington state to help start a new medical school. Washington State University, which has been around for a hundred plus years, it's the land grant university of the state like UH is the land grant university in Hawaii. And they decided there was a need for a second medical school in the state because University of Washington has had one for a hundred plus years. And so I was brought on the team to help that become a thing. And so after doing that for four years and standing up the medical school, getting it accredited, graduating our first cohort, I got another opportunity to evolve yet again, reinvent myself. And now I work at Optum. Optum Care is a subsidiary of United Health Group. United Health Group is a Fortune three company in the US. They own United Health Care, the insurance arm and Optum, which is the care delivery arm. And so for Optum, I'm getting much more educated on the business of medicine as I can imagine ivory tower of academia. Kind of imagine, you know, another way at this point in the show, you know, I got, I got a little thing here bothers me in my arms. Get my gloves. Yeah, sure. There you go. Gentle medicine. And by the way, I remember you were on our radio show somewhere in the early 2000s. And you had a little thing that you wore. It was like a early cell phone kind of thing, which had the whole Merck manual in it. And you could look up any medical question from this thing you wore on your on your belt. You remember that? Yeah, that's the ectopic brain, the peripheral brain, because I just can't squeeze it all in here. That's called a palm pilot back in the day. Yeah, early days before smartphones. So that's my first area of inquiry with you about the, you know, the status of medicine in these United States. You know, of course, we always need to compare with how we're doing visa via other countries and continents. But, you know, it seems like technology is where it's at. Medical technology, research science on the biochemical level and on the electronic level, record keeping level, what have you, you probably get to see all of that from where you are with Optum. How are we doing, Joshua? There's a lot of excitement and a lot of promise. There has been excitement and promise for a few decades now. If you've ever read the work of Eric Topol, TOPL, he's written extensively on the technology side and the promise of technology in US healthcare. And he correctly points out there is a lot of hype. You know, IBM Watson was heralded as, you know, going to medical school at one point. The Cleveland Clinic was a 30-year medical student there. That was a lot of PR, I think. But the concepts remain sound. The promise and the potential are there. It hasn't yet been realized. And part of that is because of the funding structures and healthcare finance that exists that keep the entrenched systems in place for now. And that said, there's still a lot of great innovative work happening at the periphery. It just hasn't made its way to the center where the primary care clinician is meeting their thousands of patients every day. So we are, we're well poised, I think, in the United States to do innovative work. The FDA is just now starting to look at regulating some of the technology as a medical device, which will make things safer. Right now, there's still a bit of wild west out there in many aspects, both in technology and in lab testing, where proteomics and all the genomics and all the omics are happening. The promise of the liquid biopsy, where I take a vial of blood, run it through a machine, and it tells me the 20 or 30 things wrong with me. That hasn't quite been regulated effectively yet. So there's a lot of promise, and there was the, I can't remember the woman's name, but the person in Silicon Valley who fooled a lot of people into investing a lot of money based on these promises, but is just an empty shell that she had. Maybe you remember. No, but I did know a doctor at Japsum who appeared on our shows a few times, and his thing was that he would take blood and serum from people and analyze it, and then send samples to big pharma, and they would use it for testing, and that was very creative. Next time I saw him, I asked him, are you still doing that? He said, no, I don't send samples anymore. I send electronic analyses with a database of hundreds, thousands of fields that analyze the blood samples and the serum samples, and I send that. It's cleaner. It's easier. I send that to big pharma, and that's what they use on their research. I said, really, this was a remarkable change. And I guess that applies across the board. I don't have to send the actual biological specimens anymore. I have the technology to analyze them, put them in a database, and send them that way. And I imagine that this has a profound effect on medical research, on pharmacology, on medicine. Am I right? Yeah, absolutely. I wonder if it was Peter Bryant Greenwood. Yes, it was. That's exactly who it was. He's a classmate of mine from med school, and very innovative guy. So all that said, all the promise and the potential, I think where our biggest gains from a healthcare perspective remain to be realized is in basic blocking and tackling of chronic disease management. A lot of the stuff we're talking about will help the niche cases, those that are difficult to diagnose or that have very rare diseases with rare treatments or expensive treatments. However, there are things we know are best practices today that we're not doing on a wide scale. And that's what I mean by basic blocking and tackling. If managing type two diabetes or managing consequences of obesity could just be done to the standard that we know already should be done, we'd be much better off. And that's reflected in the public health metrics of our country compared to other developed economies. In the OECD grouping, which is lots of countries in Europe and in Asia that have our equivalent financial resources, their metrics are way better than ours. We're among dead last among that group in many. And yet we spend the most on healthcare. And that's not because we don't have the technologies or the innovative ideas. It's because we have a fractured healthcare system and some malaligned financial incentives for healthcare financing. And so those known best practices on, hey, get your colonoscopy when you're 50, actually now 45. Check your blood glucose to see if you're developing diabetes. Manage your weight. All those, what we would call basic things are not uniformly implemented because they're not, they don't capture the attention of the public, the way that a bright shiny digital object or a new thing with omic at the end might. So I think we have a ways to go and there's plenty of room to grow in what we already know without waiting for the next best thing to be invented. At least part of this has to be social psychology and it's the American notion of exceptionalism that pops up in so many contexts, including history and politics and business and what have you where people believe that the American style, the American juggernaut will achieve no matter what we do. And I suspect, let me see what you think about my concept here of social psychology. Is it people think is, they'll take care of me. They have a way to take care of me. I don't have to take care of myself. This is not my responsibility because they will swoop in and use this wonderful scientific discoveries on me and they'll fix me even if I don't take care of myself. Is this a factor in the American exceptionalism view of medicine? I can only offer my opinion. I agree with you. I personally agree with you. What's the evidence for that? I don't know the social psychology literature well enough to cite it, but it's my personal observations as well that match what we just described. I think without getting too far down the rabbit hole of COVID vaccines and people declining to get vaccinated and yet, on the other hand, clamoring for the monoclonal antibody treatment that they do get sick, there's some evidence that that's how we as a people in the United States behave. I remember some quote at some point that went along the lines of how that paraphrase. I've got a pill. If you take this once a day, you will age more slowly. You will feel better. You'll sleep better. You will have regular bowel movements. You'll look better. You'll be more attractive and all your chronic diseases will get better. And we'll have better sex too. Don't forget that. Yeah, sure. Let's throw that in there. And 10 out of 10 people will say, sure, I'll take that pill. And we say, well, that already exists. It's called exercise. And then they throw up their hands. I don't need to do that. I wanted the pill, darn it. That reminds me. This whole continuum over the past year and a half, to our credit, and I do want to ask you about this, the pharmaceutical industry was able to develop in rapid, rapid time vaccines. But then more recently, within the last, what, month or two, we have the pill by Pfizer. And who else has got the second one? Moderna? Thank you, Merck. And so, you know, there are people out there that says, I knew I should not have taken the vaccine. I knew they'd come up with this kind of morning after pill. And I'm going to do that. And that'll save me. There it is, American exceptionalism. There's always a way they can fix me, even if I abandoned my own health. Right. Yeah. And it's, of course, more nuanced than that, right? So, in that particular example, we know there's this entity called Long COVID, a post-acute, this, the SNHC, PASC is the other term for it. But Long COVID occurs, we're guesstimating between 30 and 80% of people who get COVID. And the only way to not have Long COVID is to not get COVID. And one way we know to not get COVID is to get vaccinated and to practice non-pharmaceutical interventions, the wearing of the mask, the maintaining of social distancing, hand hygiene, all of that. So, yes, we can use the morning after, you know, this new pill or pills. But that's after the fact that you've contracted COVID. And we don't yet know who among us will die of COVID. We have a better idea. Those with chronic conditions are more at risk. Those who are extreme elderly are more at risk. But there are examples of young folks that are otherwise healthy who die from COVID. So, there's something we haven't yet figured out. And so, if I get COVID, either of us, and we're not quick enough to get the pill, we could get into serious trouble. Or if we do get the pill quickly and we make it through to the other side and we resolve our acute illness, well, we're 30 to 80% likely to develop one of these Long COVID symptoms, which can be pretty debilitating. And for all we know, it could be lifelong. What we don't know is the long-term effects of some of these new medications as well. We do know the long-term effect of these vaccines because the technologies that have been used to develop them have been around for decades. But the new pills, one of them has been around for about seven years, the technology, but it hasn't been widely utilized. So, it's a bit of an unknown. So, if we were hesitant to take the vaccine, which is a much more known entity in terms of the technology, we should be doubly concerned or leery of taking these new small molecules. Well, I wanted to talk about the vaccine. My recollection, of course, this is only for Pfizer, but the people who did the technology on that vaccine were from Turkey. And they were in a company in Germany. And in fact, Donald Trump tried to make a deal with them when it first became evident that they were on the right track and that he was unable to do that. He was offering the money to buy their technology or their company would have it. And ultimately, Pfizer stepped into that and did it. So, for those who think that this is American technology, think Turkey, think German. It's not exactly the case. But where do you think American technology, pharmacology plays in all of that? Are we exceptional in terms of developing the vaccine? It really was quick. And it's not only Pfizer, it's a couple others. And my question is, was it as miraculous as it seemed to be? And furthermore, will it be as miraculous in the future when the pandemic turns into endemic and other viruses pop up for one delta reason or another? Are we going to have the same experience? Are we that good? We're trending into areas that are not my expertise, but I'm happy to speculate alongside of you. And I think the answer is yes, we are that good, but it's not us. Who's the us in that sentence? I think it is the collective biomedical innovation effort globally. I mean, these companies are not US companies or German companies. They're global companies. And I think that there's a lot of benefit in viewing ourselves as human beings, that it doesn't matter where you live on this world, we're all the same from a biomedical standpoint. And so innovation and ideas come from all corners. So I'm not sure I'm answering your question, but I do think that Oh, no, I totally agree. And I guess you are. But let me let me go to one other point that I think we need to talk about, and especially from your vantage, in terms of the industry, the health industry, you know, there are there are problems. I mean, you're probably far more aware of how many problems there are than I, but but, you know, one problem is we seem to be losing doctors, at least in Hawaii, maybe other places. And the, you know, the profession may not serve the individual doctor as well as it used to. There are negative features to practicing alone, which is why a lot of doctors like to gather into groups and hospitals. And there are negative features in practicing in groups and hospitals, too, which is why a lot of doctors like to retire these days. And then, of course, it's risky in a pandemic. And then that's another reason why they like to leave. So I guess my question is, how is it in the profession? How is how is COVID changed profession? How are these, you know, evolutions, if you will, around medicine and practicing and education, I suppose, and insurance and, you know, and state regulation, the whole ball of wax. How has that affected the individual practitioner and thus the industry? That's a far-reaching question. And it does, you correctly point out the pandemic has affected every aspect of the profession of medicine from becoming a medical student and your ability to actually get practical experience in a hospital in this environment where we had to send all of our students home at a key period when they were developing these skills. So what does that mean for their future competency? A big question mark. It has changed national exams, licensure exams, had to change based on the reality on the ground. And then through to residency training, same challenges. And then when you're new into practice and you're faced with not only getting up to speed on the business of medicine that you're transitioning into, but the rapidly changing business of medicine where telehealth gained much higher prominence and importance. And a lot of the restrictions that pertain to HIPAA and privacy were temporarily set aside to use these less secure platforms because, you know, what is it? What's the mother of invention? Necessity. Necessity. Desperation is in there too. Yes. And so, and then this is impacted workloads and it's impacted reimbursements. And so a lot of the individual practitioner, depending if they're primary care practitioner or specialist, is impacted differently, differentially. You know, the specialist, a lot of discretionary, well, what we're called discretionary surgeries and procedures were put on hold. Now how discretionary were they is up for further discussion. And I don't think we have time for that. But those folks came near to going out of business. They had no income. And then the primary care folks were just overwhelmed with the hospitals in particular with COVID infections and people becoming desperately ill and overwhelming the hospital systems. And a lot of the folks that have to take care of people at the bedside, nurses, respiratory therapists, pharmacists, all those folks were not as available as in normal times because either they were exposed and had to quarantine or they were sick or they were unavailable. So the burden got heavier right at the time that the workforce got less available, which led to burnout in not only physicians but everyone involved. Wow. The other thing I wanted to talk to you about is the business. Okay. And that does include disparities in income and thus in many areas of the country, disparities in the availability of healthcare, insurance issues, pharmaceutical issues where drugs are real expensive and so far Medicare doesn't have the leverage to negotiate with the pharmaceutical industry about what it costs. All these things are huge public issues, but they're not being resolved. And I wonder what you see as the ones that count most in terms of satisfying the quality, the caducean need to serve the public, to serve patients, to serve the population as against capitalism in general. And the way it's all come out here in the last few years in terms of making a buck and dealing with the insurance issues and the governmental regulation and so forth, seems to me that there's a need for a whole review of how we do medicine, how the medical business industry operates in this emerging new country of ours. Wow. There's a lot we could talk about there. I'm going to try to focus on three things. One is awareness. I think that the emerging awareness that seems to be sticking, which is wonderful, around the disparities is hugely important. And it's not enough, but without awareness you can't do the next steps which is fixing or trying to fix the problem. So I'm very hardened and encouraged that we're uncovering what has been there all along and shining a light on it. It hasn't been fixed yet in many areas, in most areas, but at least now there are sustained efforts to get after it. So that's one encouraging thing as dark as it is to see all this horrible thing, all this horribleness that has been happening for so long. It's a bright spot that we're now looking at it. Number two would be the emergence of value-based care and that's the business of medicine, the fee for service where I get paid for every patient I see who comes through the door and so I'm perversely incentivized to keep them slightly sick so I see them more often because I get more money that way versus value-based care where I'm assigned a group of patients, let's say 2,000 patients for primary care, and I get paid for basically keeping them well. So I get paid a certain amount based on their disease burden and I'll get paid that next year too and so if I keep them healthy and they don't end up in the hospital, they don't need to be seen by me again and again and again, they stay at home and in the community, then that's a win for the patient and that's a win for me financially because I'm not spending money seeing them. So that's a better alignment. Now systems like the VA have been doing this forever, Kaiser does this very well and the organization I work for now is doing this OptumCare. Now the third and last point I'll make around this is there's a risk around the customer service aspect you mentioned, you know, serving the public. So the Center for Medicaid and Medicare Services, CMS, pays for value-based care based on a formula and parts of that formula include quality measures and the quality measures include both, well, process measures. Did I check that person's blood pressure? Did I check that person's blood sugar and outcome measures? Did I get the sugar where it needs to be? Did I get the blood pressure where it needs to be for that patient? And then the third and more heavily weighted is how does that patient feel about the care I'm providing? And that's the one that's both to I'd sort because it's great that the voice of the patient is super loud. However, if a patient is demanding ivermectin or that you start injecting bleach into me because I heard that's a good thing to get rid of COVID and I say no and I get rated poorly on my annual survey because it's only once a year that they fill out a survey versus all those times I'm making sure their blood sugar is where it needs to be. All those process and outcome measures are worth one quarter, one fourth of what the patient says about me in terms of my reimbursement. So I'm now incentivized to do what the patient says rather than what's best for the patient. That's wrong. Hopefully they're the same thing. We have to fix that. Well, perhaps. So I mean, we talked about where we're winding up here almost out of time but about the fact that, you know, patients and people in general have to take responsibility for their own health. They have to learn about medicine and they can. I mean, you can go on the internet. You may be inaccurate compared to what your your primary will tell you. But you can go on the internet and learn a lot before you ever go down the doctor's office. And, you know, the notion of looking at it globally I think is very important in making a comparison. And maybe that's a little intimidating because you find out that last year in the United States our life expectancy decreased by a couple of years. That's very troubling. And maybe other countries do better. Other countries do worse. But I think we have to see that in the global context because as you say it's global. I guess my question is how should we see public health? How should we see engaging with relating to the medical establishment now in terms of helping us, in terms of our own participation with it? That's kind of a partnership perhaps. It's different than it was. It's not like the doctors sitting on a throne and handing down edicts to you. That doesn't really work as well anymore. How do we deal with that as a population of citizens who require, by virtue of the species, who require medical care? Yeah. Well, at the risk of suggesting that money'd be diverted from my my own profession, I would say investment in public health is probably the best spent dollars for the public. I think investment in medical care. Medical care is mostly, there's some primary care and there's a lot of tertiary care in the hospital. And that's less than 1% of our lives are spent there. 99% are spent out in the community. And social determinants of health are what's going to keep us healthy and going. Seeing my doctor isn't going to keep me well, but having access to healthy foods, not being in a food desert, having access to safe places to walk and exercise, bike lanes, that's going to keep me healthy. So I think investment in infrastructure and public health programs and infrastructure is where we'll get our biggest bang for the buck, but that's not where the powerful lobbies lie. I will let it go right there, won't we? Well, I'm reminded of Hill Street Blues, Joshua, where the cops in the station house, you know, would get briefed in the morning and they would go out on the streets and the sergeant would say to them, you know, it was a version of have a good day, but it was like have a good life out there, stay alive, do well out there, you know, and so forth. And at one point in my medical contact, I had a doctor who would say to me, every time I saw him, he would say, okay, we're finished with our little meeting now, go and lead a good life. It's just like Hill Street Blues. And I think at the end of the day, it's a quality of life question, isn't it? We want to leave a lead a life free of pain or free of, you know, degrading health. We want to lead a life that's clear and productive and so forth. And that's what medicine enables us to do. And your thoughts about that, because, you know, medicine more and more has the capability of doing that. And therefore, my life is better if I'm healthier, simple. Yeah, I agree. I think if you take care of your life, then when the inevitable or I take care of mine, when the inevitable happens, because we're human and we will break down, that's when medicine has the role and these innovations of improving quality of life, not necessarily extending life beyond where a reasonable quality of life exists, unless that's your goal. And that's perfectly legitimate in today's society to say, I want to live on a machine even if I don't think or breathe on my own until the machine breaks down. But I think most of us would prefer not to be on that machine. And I think that's the role of medicine is to help us in those circumstances where we can't help ourselves. Yeah. Well, I'm so glad you're thinking about these things and you're in a situation where you can do something about these things. It's a critical, you know, it's part of the economy. It's a critical part of the, what did I call it, the social psychology, the social experience for the country. Then if there's one thing we all have in common, it's that we need medical care and we ought to attend to it. And we ought to call for the expense necessary to maintain public health. It's a healthy country. It's a better country. There you go. Jay, it's great to see you. Great to talk to you. Great to see you, Joshua. Joshua Jacobs in private and in our relationship together, I call him doctor. I thought it was your highness, but okay, a doctor will do. Thank you, Joshua. You take care.