The Accad and Koka Report

As a follow-up to the episode on the Ranbaxy Scandal, Accad and Koka are joined by medicinal chemist John Tucker, PhD, and hypertension specialist Swapnil Hiremath, MD. The guests share their perspectives and impressions on the unsettling question of generic drugs.

Generic drugs represent 90% of the pharmaceutical market. Their use has been encouraged through decades of favorable legislation and subsidies, with authorities claiming they are as safe and effective as brand name drugs. Yet generic preparations tainted with impurities are being reported with increasing frequency. What should doctors and the public know about generic drug manufacture? Our guest, Dinesh Thakur, is the chemist who was at the center of the most important scandal to rock the global pharmaceutical industry in decades.

A health policy of choice—not of constraints—is what we need, says our guest David Balat. He is currently the Director of the Right on Healthcare initiative with Texas Public Policy Foundation. He has a broad base of experience throughout the healthcare spectrum with special expertise in healthcare finance. He is a former Congressional candidate in Texas’ 2nd Congressional District and a seasoned hospital executive with more than 20 years of healthcare industry leadership and executive management experience. David is focused on education and advocacy in an effort to simplify coverage that is too expensive, complicated, and untrustworthy. He is an ardent advocate of Physicians and believes the restoration of the Physician/Patient relationship is critical to fixing our dysfunctional system. He often volunteers of his time to help families navigate their bills and how to understand their benefits.

As a medical discipline, psychiatry has often been the target of severe criticism, particularly in the last fifty to sixty years. Is the criticism valid or not? What is the outlook for the science of mental illness and the practice of psychiatry? Our guest today defends his chosen medical specialty. George Dawson, MD, DFAPA, is a Staff Psychiatrist at the Hazelden Betty Ford Foundation and an Adjunct Professor at the Hazelden Betty Ford Graduate School of Addiction Studies. His clinical interests have been in acute care, geriatric psychiatry, neuropsychiatry, and addiction psychiatry. He currently practices addiction psychiatry, providing psychiatric consultation on patient care to the professional staff, and lectures on the neurobiology, epidemiology, and the clinical aspects of addiction psychiatry. Dr. Dawson completed his training in psychiatry at the University of Wisconsin where he was a research fellow. Scholarly interests include biological psychiatry, consciousness studies, and the medical, philosophical, and political aspects of psychiatry. In his spare time, he writes a blog (RealPsychiatry) about some of these topics

Will the randomized control trial bring more clarity and certainty to economic science? Is “evidence-based economics” something to be hailed as a welcome innovation or should it be appraised with a more sober attitude? To examine this topic and discuss the relative place of randomized trials in economics and medicine we have as our guest Peter G. Klein, W. W. Caruth Chair and Professor of Entrepreneurship at Baylor University’s Hankamer School of Business. Professor Klein is also the Carl Menger Research Fellow at the Mises Institute. He obtained his PhD in Economics from the University of California Berkeley, and his BA from the University of North Carolina Chapel Hill. His field of interest is in the area of the economics of entrepreneurship and business organization. He taught previously at the University of California, Berkeley, the University of Georgia, the Copenhagen Business School, and the University of Missouri, and served as a Senior Economist with the Council of Economic Advisers. He is the author of five books and numerous peer-reviewed articles.

Do hospital-based physicians benefit from being out-of-network? Are policy wonks who attack “surprise billing” fully aware of the relevant factors? In this second episode on this topic, Dr. Koka leads a conversation with our guest, Dr. Amy Cho, an emergency physician from Minnesota. Dr. Cho graduated from the University of Michigan with a joint MD/MBA and completed her residency in Emergency Medicine at Advocate Christ Medical Center in Chicago. Prior to medical school, she worked as a management consultant with Bain & Co., and as a product manager with Convio, a venture-funded software company.

Has cardiovascular genetics come of age? Are “polygenic risk scores” ready to inform us in clinically meaningful ways? In the final analysis, who or what are epidemiological data informing? Our guest is A. Cecile Janssens, PhD, Professor of Translational Epidemiology at the Rollins school of Public Health at Emory university in Atlanta, Georgia. Professor Janssens’ research concerns the translation of genomics research to applications in clinical and public health practice and focuses on the genetic prediction of common diseases such as diabetes, cardiovascular disease and cancer. She also studies how the predictive ability and utility of genetic testing can best be measured.

Are out-of-network physicians deliberately trying to price-gouge patients in need of emergency care? Will “surprise billing legislation” solve the problems of narrow networks in a socially responsible manner? In this episode, Dr. Koka leads a conversation with our guest, Dr. Daniel E. Choi, on the topic of surprise billing legislation. Dr. Choi obtained his MD degree from Northwestern University Feinberg School of Medicine in Chicago, completed his residency training at Rutgers State Univeristy of New Jersey, and completed a combined neurosurgical and orthopedic fellowship in spine surgery at Harvard Medical School.

Can a graduate of the Harvard Kennedy School hold on to free market principles? Evidently so! We talk health policy and economics with our guest Richard Menger, MD, MPA, a neurosurgeon serving as Chief of Complex Spine Surgery at the University of South Alabama. Dr. Menger completed medical school with honors at Georgetown University School of Medicine where he was elected to the Alpha Omega Alpha Honor Society and received the Barbara Bregman PhD Award. He then trained at Louisiana State University Shreveport and at Columbia University for a fellowship in scoliosis treatment. At the Harvard Kennedy School of Government he completed a Master in Public Administration and was awarded the Hale Champion Public Service Fellowship. Dr. Menger has authored numerous scientific papers in academic journals and is the lead editor of the textbook The Business, Policy, and Economics of Neurosurgery. His op-ed/policy work has been published in the Wall Street Journal, Forbes, Navy Times, The Hill and others. He has a joint appointment as Assistant Professor of Political Science at the University of South Alabama.

Big Pharma is abandoning its R&D efforts for antibiotics. What are the regulatory, scientific, and economic factors responsible for this potentially dangerous trend? Our guest on this episode is Dr. David Shlaes. Dr. Shlaes is an infectious diseases specialist who trained was formerly professor of medicine at Case Western medical school in Cleveland, Ohio. He left academia in 1996 to become Vice President for infectious diseases at Wyeth Pharmaceuticals. He has been very prominent in the field of antibiotics research and development. In 1998 he was on the cover of Business Week in recognition of his contributions. In 2005 he established a consulting company and has been active in advising companies and policy makers. He has since retired but remains involved in the field. as an editor for the journal Antimicrobial Agents and Chemotherapy and as a blogger on his site called Antibiotics, The Perfect Storm, which is the title of a book that he wrote a few years ago.

How do businesses purchase healthcare services for their employees? What are the factors that bear on their purchasing decisions? These important questions are rarely part of the policy conversation. Our guest on this episode is Jay Kempton, President and CEO of the Kempton Group, helping employers obtain and administer health care benefits for their employees. He relates his professional journey, shares his insights as a third-party administrator, and tells us about his recent efforts to turn employers away from the wasteful and corrupt health insurance benefit model. Mr. Kempton is one of the founding members of the Free Market Medical Association, a board member of the Society of Professional Benefit Administrators, and a member of the Health Care Administrators Association. He obtained a Bachelor of Science degree in Business Administration from Oklahoma State University and holds Life, Health, AD&D, and Property and Casualty Insurance licenses in multiple states.

According to our guest, American health care is stuck in a fortress mentality that stifles innovation, constrains medical advances, and yields low quality care. That fortress was erected more than one hundred years ago but, in many ways, is being circumvented by creative actors who are seizing opportunities to make changes outside of the political process. Bob Graboyes is Senior Research Fellow at the Mercatus Center at George Mason University. He holds a PhD in Economics from Columbia University, and has held a number of academic positions in higher education in Virginia. He is the author of “Fortress and Frontier in American Health Care,” a booklet which offers many examples of individuals adopting a risk-tolerant frontier attitude to compete with insiders and pave the way to the future without having to rely on political reform. Prior to focusing his career on healthcare, Bob Graboyes was regional economist and director of education at the Federal Reserve Bank of Richmond.

The Affordable Care Act was allegedly passed thanks to “the stupidity of the American voter.” The economist who made that claim—and who is also considered to be one of the architects of the law—has recently published a working paper that examines whether better-informed patients make better healthcare decisions. He and his colleagues conclude in the negative. To help us gain a better perspective on that paper, we’ve invited Dr. Keith Smith back to the show. Dr. Smith is the co-founder of the Surgery Center of Oklahoma, a pioneering institution in free market medicine. As such, he has direct knowledge of the behavior of healthcare consumers, and offers us his insights into the chasm that exists between the way healthcare policy makers conceive of medical practice and how ordinary patients actually seek the best possible healthcare value for themselves.

President Trump’s July 10, 2019, "Executive Order on Advancing American Kidney Health" may represent a major turning point in regard to how patients with chronic kidney disease are treated. We have the pleasure of having as our guest Dr. Joel Topf. Dr. Topf is a nephrologist in private practice and a popular blogger and leader in medical social media. He is an adviser to the American Society of Nephrology and was present at the signing of the executive order. He joins Anish Koka to share his insights on the good and bad of the executive order, and on the state and future of kidney disease in the United States.

Hospital executives with a conscience may have a tough time navigating the corrupting waters of our healthcare system. Mr. John Chamberlain is a self-described "recovering" hospital CEO with over thirty-five years of experience as a hospital and physician practice executive. In this interview with Anish Koka, he relates how his attempts to do right by the patient became increasingly arduous. Mr. Chamberlain eventually saw the light of free market medicine and currently serves as Chairman of Citizen Health, an organization dedicated to "rebuilding healthcare for the next generation."

President Trump’s June 24, 2019, Executive Order on health care transparency contains a key provision regarding direct primary care. Koka and Accad welcome back on the show Dr. Lee Gross, a family physician in North Port, Florida, and a pioneer and a leader in the DPC movement.  Dr. Gross and colleagues were instrumental in getting the White House to clarify a prior ambiguity regarding how direct primary care membership fees ought to be considered from a tax standpoint. Dr. Gross discusses this effort and the implications for the growth of the direct care movement. Dr. Gross is a health care consultant to physician practices, medical organizations, insurance groups, hospitals, and private businesses. He founded and serves as President of the Docs 4 Patient Care Foundation, and he is chairman of a new lobbying organization called DPC Action.

What can we learn from the experience of a 90-year-old patient who is told point-blank, “You’ll be dead in a year!”—and who survives to tell the story? This is a first of its kind in the annals of the Accad and Koka Report. The episode starts with a 15-minute interview conducted by Dr. Koka with a patient of his about her journey through the healthcare system. After the interview, Accad and Koka have an in-depth conversation—prompted by the patient’s testimony—about what to take into consideration when making decisions for elderly patients who contemplate expensive and risky procedures.

It is commonly believed that healthcare is a sector plagued by “market failure.” A heavy dose of government intervention is therefore necessary to optimize the needs of society. A paper most commonly cited in support of that view is one published in 1963 by Nobel Prize winner Kenneth Arrow, one of the giants of economic theory in the twentieth century, and titled “Uncertainty and the Welfare Economics of Medical Care.” But how does economic theory arrive at the concept of market failure and how do economists conceive of health care when they apply their theoretical models to medical practice? To help sort this out, we have as our guest Robert P. Murphy, economist, teacher, and author of many books. Dr. Murphy obtained his PhD from NYU and is Senior Fellow at the Mises Institute. He is co-host with Tom Woods of the popular podcast Contra Krugman, and he is also host of The Bob Murphy Show, “a podcast promoting free markets, free minds, and grateful souls.” The episode is in two parts. In the first part, we reviewed the theoretical framework that forms the background to Arrow’s paper. In this second part, we delve into the paper itself, discuss how economists conceive (or misconceive) of medical care, and what the implications have been for the US healthcare system as a whole.

It is commonly believed that healthcare is a sector plagued by “market failure.” A heavy dose of government intervention is therefore necessary to optimize the needs of society. A paper most commonly cited in support of that view is one published in 1963 by Nobel Prize winner Kenneth Arrow, one of the giants of economic theory in the twentieth century, and titled “Uncertainty and the Welfare Economics of Medical Care.” But how does economic theory arrive at the concept of market failure and how do economists conceive of health care when they apply their theoretical models to medical practice? To help sort this out, we have as our guest Robert P. Murphy, economist, teacher, and author of many books. Dr. Murphy obtained his PhD from NYU and is Senior Fellow at the Mises Institute. He is co-host with Tom Woods of the popular podcast Contra Krugman, and he is also host of The Bob Murphy Show, “a podcast promoting free markets, free minds, and grateful souls.” The episode is in two parts. In this first part, we review the theoretical framework that forms the background to Arrow’s paper. In the upcoming second part, we will delve into the paper itself, discuss how economists conceive (or misconceive) of medical care and what the implications have been for the US healthcare system as a whole.

The Commonwealth of Massachusetts’ lawsuit against Purdue Pharmaceuticals exemplifies a common narrative that lays a large part of the blame for the opioid epidemic at the feet of the manufacturer of prescription opioids for manipulating physicians into prescribing the drugs more liberally. Is there merit to that story? To examine that question, we have as our guest Jacob James Rich, a policy analyst at Reason Foundation. Mr. Rich holds master’s degrees in economics and mathematics from Eastern Michigan University. Prior to joining Reason, he conducted research for the Cato Institute focused on opioids and the drug war.

Is the healthcare mess so hopeless that physicians should either leave it or wait for it to collapse? Are there legislative steps that doctors can take to tangibly improve the practice of medicine? And, if so, how should physicians act within the problematic framework of “organized medicine” to bring about such changes? Our guest is Dr. Marcelo Hochman (twitter), who is sharing with us some hopeful successes in introducing important legislation by working in conjunction with his local and state medical societies. The three issues he has focused on are 1) a repeal of certificate-of-need laws, 2) a ruling against “non-compete clauses” in physician contracts, and 3) a tax deduction for charitable work provided by physicians. All three issues appeal to the notion that expanding the settings in which physicians can be free to practice will benefit both doctors and society. Dr. Hochman is an independent solo pediatric facial plastic surgeon who practices in Charleston, South Carolina. He has specialized in the treatment of congenital vascular anomalies. He is a recipient of the Order of the Palmetto, South Carolina’s highest civilian award, and of other national and local professional and community honors. He currently serves as the President of the Charleston County Medical Society, as Chair of the Coalition to Repeal CON (Certificate of Need), and as Director of The Hemangioma Treatment Foundation.

Is the body a machine? Are doctors mere technicians who simply “fix” biological defects in their patients? In a very real sense, that’s how modern societies conceive of medical practice, so much so that healthcare is now frequently experienced as an industrial process: doctors and nurses churning patients through an assembly line. And that process is taking a huge economic, physical, and mental toll on everyone. The mechanical model on which modern medicine is based has obviously brought technological wonders to the practice of medicine—and it should be celebrated for these extraordinary achievements. But have we become so wedded to the machine metaphor that we ignore more fundamental aspects of human reality? Can another way of conceiving of health and life be brought to bear on the practice of medicine positively, without discarding the achievements of the scientific age? Our guest is Dr. Victoria Sweet, author of the best-sellers God’s Hotel and Slow Medicine, two of the most important books on medicine in recent times. Those books were inspired by Dr. Sweet’s rediscovery of the medical texts of Hildegard of Bingen, a 12th-century mystic and nun whose practical approach to medicine may well contain the very principles that can help cure 21st-century health care from its seemingly irremediable predicament.

Quality ratings of hospitals and physicians: help or hindrance? Surely, the general public demands and is entitled to an assessment of hospital quality based on sound methodology. And ratings coming from the private sector are far more likely to be unbiased and to adjust to an ever changing healthcare landscape than those coming from the government and public policy sector. But is there a downside to scrutinizing the healthcare enterprise? We have a fascinating conversation with one of the most knowledgeable persons on the topic. Ben Harder is Chief of Health Analysis at US News and World Report and oversees the team of analysts and statisticians who produce the most recognized ranking of hospitals in the country. Ben holds a Bachelor of Science in Biological Anthropology from Harvard University and began his career in health and science journalism before taking the job of quality czar at US News and World Report.

Two distinguished guests join us to debate the issue of vaccine mandates. Dorit Reiss (twitter) is Professor of Law at UC Hastings College of the Law in San Francisco, California. She holds an undergraduate degree in Law and Political Science from the Faculty of Law at Hebrew University in Jerusalem and a PhD in Jurisprudence and Social Policy from the University of California, Berkeley. She is a legal authority on the question of vaccines and vaccine mandates. She has published numerous articles on this topic in a variety of law review journals and her expertise is recognized around the world. Jonathan Howard (twitter) is Assistant Professor in the Departments of Neurology and Psychiatry at New York University Langone. He is Director of the Neurology Service at Bellevue Hospital and Director of Clerkship Director for the Clinical Neurological Sciences at NYU. Dorit and Jonathan have co-authored a book chapter entitled “The Anti-Vaccine Movement: A Litany of Fallacy and Errors,” in Pseudoscience: A Conspiracy Against Science.

A short episode commenting on a recent piece in Medscape, one of the most influential bioethicists of the last forty years. See "No, Patients Are NOT Consumers, and MDs Are NOT Providers" by Arthur L. Caplan.

If health is an elusive concept, how much harder it must be to articulate what a healthy community should be. But that should not stop us from grappling with foundational ideas and from sketching a forward-looking vision for a better society. Our guest on this episode is Pritpal Tamber (twitter), a physician who has devoted his career to better understanding what it means to live in a healthy community. Dr. Tamber is the former Physician Editor of TEDMED, TED’s dedicated health event, a former editor at the British Medical Journal, and the former Medical Director of Map of Medicine, a company that tried to improve the flow of patients through health care on the basis of clinical evidence. Through his work with TEDMED, and informed by his insights into clinical evidence and system change, Dr. Tamber is convinced that the glamorous, tech-led world of health innovation is unlikely to have much impact on the patients with the worst health—those lower down the socioeconomic gradient. Since 2013, he has spent time with numerous community projects—principally in the US and the UK, but also in The Netherlands, New Zealand, and Mexico—to explore and understand the realities of the work. Through his work he has described 12 recurring principles that offer a practice-based structure for how the health sector can work with communities. Collectively, these principles describe an inclusive and participatory process, effectively illustrating that people are sick because they have little influence over their lives. Social epidemiologists have called this "having a sense of control", and it is something that requires agency—the ability to make purposeful choices.

Does the vaccine debate have to be polarized according to “Pro-Vaxx” or “Anti-Vaxx” camps? Is it possible to have a reasonable discussion about harms and benefits of vaccines? Are public health concerns about unvaccinated children sufficient to trump individual liberty? Exploring the question with us is Dr. Niran Al-Aqba (twitter), a board-certified pediatrician in private practice in Washington State, an area hit by the recent outbreak of measles. Dr. Al-Aqba is a prolific writer who speaks widely and openly on a variety of issues, including policy, ethics, and medical practice. She is a regular contributor to the Kitsap Sun, to The Deductible blog, and to a variety of other outlets, including her own blog, MommyDoc. She is a mother of four children who’s been voted best doctor in Kitsap County on multiple occasions. She also serves on the clinical staff and admission committee at the University of Washington School of Medicine.

Is there a conservative path to universal healthcare? Our guest certainly believes so. Avik Roy (twitter) is one of the most influential conservative voices in healthcare. A graduate from MIT and Yale Medical School, Avik spent many years with the investment firm Bain Capital. In 2009, in response to the debates leading up to Obamacare, Avik started a blog to share his insights. Those were soon noticed by the media and the policy world, and he quickly became the go-to policy wonk on healthcare among conservatives. In 2012, Roy joined the campaign of Mitt Romney as policy adviser and later went on to advise Texas Governor Rick Perry, as well as Senator Marco Rubio. In 2016, he founded FREOPP, the Foundation for Research on Equal Opportunity, a conservative public policy think tank based in Austin, Texas. He continues to edit his blog, The Apothecary, now hosted by Forbes where he serves as Senior Opinion editor.

Should a pass-fail exam designed to determine a student’s competence to practice medicine be scored numerically and used for residency selection? Every year, thousands of students sink an increasingly large number of hours and dollars to prepare for "Step 1" of the US Medical Licensing Examination, a task which seems to be disproportionate to the relevance the test bears to the practice of medicine. Our guest on this show is Bryan Carmody, MD, (on twitter) a pediatric nephrologist who practices at the Children’s Hospital of the King’s Daughter in Norfolk, VA, and teaches medical students at the Eastern Virginia Medical School. Bryan himself has recently spent countless hours studying and blogging about the machinations that constitute licensing examination in the United States.

Despite its many scientific and therapeutic advances, the field of psychiatry remains lacking in coherence or cohesiveness as compared to other areas of medicine. Part of the issue undoubtedly has to do with the intractable mind-body problem, but part of it may also be due to the effort of standardization of diagnosis set in motion by the Diagnostic and Statistical Manual. Is there a way to move forward? Our guest is optimistic. Paul McHugh, MD, is one of the most important figures in academic psychiatry of the last thirty years. He is University Distinguished Professor of Psychiatry at Johns Hopkins University School of Medicine where he was department chairman from 1975 until 2001. He is the author or co-author of several academic books and texts of psychiatry.

Mention the phrase “industry-sponsored clinical trial” and many eyes will immediately roll back. But is the reaction justified? Are academic leaders who participate in Phase 3 trials simply figureheads hired to rubber-stamp protocols designed by Pharma and spin the results in a positive way? Our guest on this show has strong opinions on this question. Dr. Milton Packer is an internationally recognized clinician, teacher, and scientist in the field of heart failure research. He has served as Chief of Cardiology at Columbia University in New York City and, subsequently, as Chair of the Department of Clinical Science at the Southwestern Medical School in Dallas. He is currently the Distinguished Scholar in Cardiovascular Science at Baylor University Medical Center. Dr. Packer has received many teaching awards, mentored dozens of young clinical investigators, completed innumerable successful research projects, and served as a leader in many professional organizations. He is now also well known and admired for his regular column on MedPage Today, “Revolution and Revelation” in which he mixes wisdom and polemics to the delight of his many readers.

A massive push to increase the number of nurse practitioners and physician assistants and to extend their scope of practice is under way. The stated goal is to address a real or perceived shortage of primary care physicians. This effort worries many doctors who are concerned that patients are getting short-changed in the process. But is this concern justified or is it simply motivated by protectionist interests? Our guest is Dr. Rebekah Bernard (twitter), a successful family physician from Fort Myers, Florida. She is board member of Physicians for Patient Protection, an organization calling for more transparency regarding the difference in training between physicians and non-physician providers, and advocating for legislative action to avoid misrepresentation of the capabilities and knowledge-base of nurse practitioners.

Effective pharmacological treatment for opioid dependence was introduced more than 15 years ago, yet the opioid epidemic continues to ravage our country and there are still important barriers that prevent patients from receiving the care that they need. The expansion of health insurance does not seem to mitigate this problem and, in fact, health insurance may be a hindrance for proper care. What if the solution is to simply let doctors help patients directly and personally? Our guest today gives us an extraordinary testimony of what can be accomplished when physicians are free to care for patients privately, without the stigma associated with addiction and rehabilitation clinics. Dr. Molly Rutherford (twitter) graduated from Eastern Virginia Medical School in 2003 and completed a Family Medicine Residency in Portsmouth, Virginia, in 2006. She and her family moved to Kentucky after residency so that she could practice rural medicine. In 2008, she obtained her DATA 2000 waiver to treat opioid dependence with buprenorphine, and she became Board Certified in Addiction Medicine in 2012. After a series of frustrations with employment and the dysfunctional health care system, she started her practice with the goal of providing comprehensive, individualized care to her patients at an affordable price, without the interference of third-party payers. Dr. Rutherford is past president of the Kentucky Chapter of ASAM and current president of the Kentucky Academy of Family Physicians. Dr. Rutherford is also a member of the US Health and Human Services Pain Management Best Practices Inter-agency Task Force. She lives with her husband, a homicide detective with Louisville Metro Police Department, and their 2 sons in LaGrange, Kentucky.

The lure of physician employment seems irresistible and, on the surface, the arguments to justify it are also compelling. But are physicians selling themselves short? Are they really better off if they become employees of the hospital? Do they become more efficient? Are they putting themselves in ethical quandaries? And what is the way forward when the forces at play seem so overwhelming? Our guest is Dr. Arvind Cavale (twitter), an entrepreneurial endocrinologist from Pennsylvania who is bucking the trend with great success, showing that small private practice can remain nimble, adopt technology, and deliver high quality care efficiently. He shares with us his experience and tips for political advocacy.

Bright clinicians who are also trained as rigorous scientists can put healthcare policy under scrutiny and show that the wisdom of the wonks frequently falls short. Our guest on this episode is Dr. Rishi Wadhera (twitter), a prolific cardiology fellow currently in training at Brigham and Women’s Hospital in Boston and part of a team of health policy investigators at the Smith Center for Outcomes Research in Cardiology. Dr. Wadhera obtained his medical degree from the Mayo Clinic, a Master’s in Public Health from the University of Cambridge, and a Master’s in Public Policy from the Harvard Kennedy School of Government. He joins us to discuss two of his most recent papers which have made a big splash in the media.

Will it take data vigilantes to restore some order in the House of Science? With the replication crisis showing no sign of letting up, some committed scientists have taken it upon themselves to find ways to sniff out cases of egregious fraud. As it turns out, identifying scientific misbehavior is surprisingly easy! Our guest is a full-time research scientist, author/consultant at Northeastern University in Boston in a Computational Behavioral Science lab. James Heathers (twitter) completed his undergraduate work in Psychology and Industrial relations from the University of Sydney and obtained his doctorate degree on the topic of methodological improvements in heart rate variability at the same institution in 2015. He and a couple of his colleagues have captured the limelight after exposing problems in the work of a world-famous nutrition researcher, which led to the retraction of 5 papers. These “data thugs” have since designed a couple of tools that can identify suspicious data through a simple analysis of descriptive statistics.

There was a time when communities took care of the medical needs of their members without the intervention of governments and without the corrupting influence of health insurance. Can we ever go back to a system of mutual aid at a time when healthcare costs have grown astronomical? Our guest today shows us that the idea of cost sharing is not only viable but is a lived reality for thousands of families across the United States. Dale Bellis began his work in healthcare in 1988 as an administrator with the first cost-sharing ministry ever begun in modern times. He was instrumental in passing legislation in 11 states exempting cost sharing ministries from insurance regulations. He also introduced technology and administrative techniques to streamline person to person cost-sharing. In 2012, he founded Liberty Healthshare, which provides an opportunity to live free from insurance and government-mandated healthcare to a large and growing number of American families that share fundamental values and a strong belief in personal responsibility.

In the mind of the public, American physicians are represented by one prominent organization, namely, the American Medical Association. Yet, only a minority of American physicians currently belong to the AMA, which has long grown comfortable with political and government intrusions into healthcare. Who should represent physicians when doctors may hold very divergent views on matters of politics, economics, ethics, and even science? Should there be one voice or a plurality of voices? Our guest today is the executive director of the Association of American Physicians and Surgeons (AAPS), an organization that sprung up in the 1940s as an alternative to the AMA and to staunchly defend private medicine free of government interference or coercion. Dr. Jane Orient (twitter) obtained her medical degree from Columbia University and is in a solo internal medicine practice in Tucson, AZ. She is a prolific writer, having penned hundreds of op-eds in national and local media outlets. She is the author of numerous books, notably Your Doctor is Not In: Healthy Skepticism About National Health Care and Sutton’s Law, a novel about where the money is in medicine. She is also the editor of the famous textbook Sapira’s Art and Science of Bedside Diagnosis, now in its 4th edition.

Radiology holds a special place in the medical ecosystem. Radiologists are “the doctors’ doctors” and the treatment of a patient rarely proceeds without a radiologist furnishing an opinion. But the field of radiology also faces challenges: the crusade against “wasted imaging,” the rise of artificial intelligence, the dependence of radiology on hospital systems, and the de facto barrier that separates radiologists from patients. What does the future hold for radiology and what could one wish for it? Returning to the show is Dr. Saurabh Jha (twitter), Associate Professor of Radiology at University of Pennsylvania Perelman School of Medicine. He shares his perspective with his characteristic wit and humor.

Some drugs cost more than diamonds, though their health benefit seems marginal. Others cost less than a package of M&Ms, though they are demonstrably life-saving. Some drug prices have spiked to three-fold, four-fold, or even ten-fold from what they were just a few years ago. Drug pricing seems to be an irrational and incomprehensible aspect of our economy. To help us gain clarity on the matter, we have as out guest Amitabh Chandra (twitter), the Malcolm Wiener Professor of Public Policy at the Harvard Kennedy School of Government and the Henry and Allison McCance Professor of Business Administration and the Harvard Business School. He is among the best decorated healthcare economists alive, having received the highest awards in the field. He is an elected member of the National Academy of Medicine, a member of the Congressional Budget Office panel of health advisors, and a research associate at the National Bureau of Economic Research. Professor Chandra has published seminal papers in the most highly ranked journals of economics and medicine. His research has been featured in The New York Times, The Washington Post, CNN, Newsweek, and on National Public Radio and has testified to the US Senate on matters of healthcare policy.

For decades, the academic cardiology community has focused its attention on pharmacological interventions to prevent heart disease. Our guest is an accomplished clinician-scientist who tells us his personal story that led him from the lab bench to becoming interested in dietary interventions and in the ketogenic diet in particular. Dr. Ethan Weiss (twitter) is Associate Professor of Medicine at the University of California San Francisco. He has a stellar academic pedigree, having received his MD degree from Johns Hopkins Medical School, where he also trained as part of his internship and residency. He completed his fellowship in cardiology at UCSF and has had an illustrious career as a basic science investigator at UCSF, studying the relationship between heart disease and metabolism. He is also the co-founder of a start up company, Keyto, to help people measure their blood ketone levels in real time as part of a diet management program.

Doctors have been suspected, accused, or convicted of fraud since time immemorial. But, in the era of third-party payment for health care, such charges have taken on an entirely new form, particularly when the third party in question is the federal Medicare program. How does the government proceed to establish that Medicare fraud has taken place? How does it distinguish fraud from poor judgment or incompetence? And what does that mean for the practicing physician who submits thousands of claims a year to Medicare? To help shed light on the legal procedures, tactics, and tricks that can send a physician to a federal jail, our guests are Kyle Clark and Andrew George, defense attorneys who specialize in white collar crime and healthcare fraud.  Clark and George work for the global legal firm Baker Botts, LLP, and they recently authored an op-ed in the Wall Street Journal on this subject entitled “A Second Opinion Becomes a Guilty Verdict”.

For a few decades in the mid-twentieth century, the American Medical School represented the pinnacle of academia and its faculty were mightily engaged in the “triple threat” of research, teaching, and patient care. Today, however, the medical ivory tower is subordinated to hospital systems, overburdened with the menial task of “generating revenue,” and is but a pale image of its former self. On this episode, our guest helps us trace the history of the American medical school from its humble 19th century beginnings to its present day turmoils. Dr. Milton Packer is an internationally recognized clinician, teacher, and scientist in the field of heart failure research. He has served as Chief of Cardiology at Columbia University in New York City and, subsequently, as Chair of the Department of Clinical Science at the Southwestern Medical School in Dallas. He is currently the Distinguished Scholar in Cardiovascular Science at Baylor University Medical Center. Dr. Packer has received many teaching awards, mentored dozens of young clinical investigators, completed innumerable successful research projects, and served as a leader in many professional organizations. He is now also well known and admired for his regular column on MedPage Today, “Revolution and Revelation”, in which he mixes wisdom and polemics to the delight of his many readers.

How do we know that a treatment works or not? Billions of healthcare dollars are at stake in the answer to that question. For decades, that answer has largely hinged on theories from a field of human inquiry that combines the precision of mathematics with the accuracy of astrology. We are talking of course, about statistics and statistical inference. To help us understand better this mystical science, we have as our guest Dr. Michael Acree who has spent his entire career working for the University of California San Francisco as a data scientist and a teacher of statistical science, helping countless researchers make sense of the data they had obtained. Michael is now retired and is completing a book on the history and philosophy of statistical inference. He joins us to tell us the whole truth about what is sometimes referred to as the science of mendacity!

We have become highly sensitized to the question of conflict of interest in healthcare—and rightly so. But the dominant narrative seems to be one-sided: doctors and scientists getting personally paid by industry sponsors and letting those payments color their judgment, consciously or unconsciously. Personal financial conflict of interest is certainly an important and pervasive problem, but there are many aspects of COI that get less attention and may be equally harmful to society at large. To discuss this topic, our own Anish Koka engages Michel Accad in a lively discussion that tries to probe the topic in depth, even when such probing reveals uncomfortable truths.

It doesn't take great insight to assert that healthcare waste is rampant. There is an obvious epidemic of testing and treatments that make no difference in patients' lives or could possible even harm. But what is the cause of the epidemic and what should be done about it? In the last decade, a popular narrative has emerged, claiming that the waste has obvious causes and remedies. That narrative, however, overlooks the complexities of the problem and the trade-offs and potential harms of the remedies proposed. Our guest to discuss the “Less-Is-More” movement is Lisa Rosenbaum, MD, one of the best medical writers of our generation. Dr. Rosenbaum is a national correspondent for the New England Journal of Medicine, a cardiologist at the Brigham and Women’s Hospital, and an Assistant Professor of Medicine at Harvard Medical School.

The healthcare system continues to inflict “moral injury” on physicians, causing burnout, depression, or apathy. And, built as it is on a mountain of debt, the edifice may also not provide any long term security for those who choose to remain on board. Yet the prospect of jumping ship may seem daunting to many. Our guest today shares with us her personal story of how she did abandon the titanic and forged for herself a successful path to professional sanity. Kathleen M. Brown, MD, obtained her medical degree from the Eastern Virginia School of Medicine and practiced dermatology and internal medicine for several years in Maryland. In 1997, she and her family moved to the coast of Oregon to join a multi-specialty group of which she was a partner in the group until mid-2011. This group was a good fit but the administrative and financial burdens of the system were increasingly taking a toll on her enjoyment of medicine. After passage of the Affordable Care Act in 2010, she saw that continuing to stay within an insurance-contracted system would make her style of medical practice impossible. In July, 2011, with help from her husband, Jack, she opened a direct pay Dermatology practice with a transparent fee schedule. Within a month of opening she had a full schedule and a restored sense of professional satisfaction.

We spend billions of dollars a year on healthcare yet no one can give a satisfactory definition of health. Is our inability to articulate what health is precisely the reason for our insanely dysfunctional healthcare systems? Our guest today will give us his very personal reflections on that question. Pat Caslin is a business strategist from Dublin, Ireland, who’s had a successful career nationally and internationally, working for a variety of financial and business development institutions. Eleven years ago he was diagnosed with relapsing-remitting multiple sclerosis. Five years ago the disease became progressive and he lost his ability to walk. Instead of letting the illness take over his life, Pat went through a profound change of perspective regarding his health and what it means to be healthy. As a result, he has been sharing his insights, both in writing and in speaking engagements, with students, with physicians, with patients, and with the public at large. He was recently selected to give a TEDx talk in Dún Laoghaire, Ireland.

Doctors are embroiled in a healthcare system they appear to have no control over. It therefore seems plausible that if they got involved in healthcare policy, they might be in a position to “steer the ship” or at least have a say in how the ship is steered. We discuss the pros and cons of healthcare policy in general—and of a doctor’s involvement in such policy—with Aamir Hussein (twitter), a fourth year medical student at the University of Chicago Pritzker School of Medicine. A native of Farmington, Connecticut, Mr. Hussain also holds a master’s degree in public policy from the University of Chicago Harris School of Public Policy and a BA from Georgetown University in Government. He writes frequently about interfaith dialogue, Islam, and the intersections between healthcare and spirituality and has given lectures around the United States on these topics. He has been interviewed by The New York Times, Al Jazeera, and PBS, and his writings have been featured in medical journals and several online outlets including Religion News Service and The Huffington Post.

Doctors are increasingly asked to follow decision rules, guidelines, and “evidence-based” algorithms. Is that the right approach to take care of patients? Are cognitive errors over-emphasized in healthcare? Our guest on this episode is Gary Klein, one of the most important figures in cognitive psychology in the world. His pioneering work in the field of naturalistic decision-making has become a major challenge to the established schools of thought on how experts make good decisions. He is a leader of a growing research community focused on understanding how human beings acquire and apply knowledge to complex situations under uncertainty. He has developed novel explanatory models and training methods for decision-making that are widely recognized as ground-breaking. He is the author of numerous books, including the best-sellers Streetlights and Shadows: Searching for the Keys in Adaptive Decision-Making and Seeing What Others Don’t: The Remarkable Ways We Gain Insight. He is notorious for having gained the respect and admiration of his intellectual opponent, Nobel Prize winner Daniel Kahneman, with whom he co-authored a widely read paper contrasting their somewhat divergent views.