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We're experimenting with hangouts on air! Leave your comments and questions below and we'll try and get to them in the next episode. Tune in next *UPDATED* 03/20/2015 @9:30a EST (link:

00:00 - We were tweeting the link…you probably want to skip to 1:13
1:13 - Intro
2:04 -Thoughts on provider status for pharmacists
3:01 - Is there any research about what the recommended fluid intake should be?
5:13 - Does microwaving food make it less "safe." Are there any studies showing it is safe?
6:43 - Thoughts on Apple HealthKit
9:05 -Thoughts on Soylent and other similar full time meal replacement products.
11:08 - Are doctors overpaid?
12:46 - Burger King is dropping soda from kids meals in favor of milk. Is this a good thing?
14:40 - Chiropractic care - is there evidence for benefit?
16:46- Is there hope for rural health?
18:35 - IS there a benefit for probiotics when taking antibiotics for prevention or treament of C-diff infection?
20:38 - Why are mental services so hard to get?
22:00 - Why have we not found a reliable way to turn off the pain yet?
23:04 - Closing :)

 Tweeting (0:00)

Off camera: Offically on there now.

Aaron: It's says I'm live on air. Hello! Hello.

Off camera: Is anybody there?

Aaron: I have no idea. Well, who knows? Have you tweeted it out yet, cause then I'll, I will retweet it and then I will start talking for real. I suppose people could be watching right now.

Off camera: That's true.

Aaron: The magic of the internet. Oh, oh! Oh, no, that's not it.

Off camera: Did it work?

[Garbled talking off camera]

Aaron: You can see me? That's exciting. You can see me in so many ways, here and here and--

Off camera: Yeah

Aaron: You haven't actually tweeted it yet, have you? Oh, oh, there it is. Alright, I'm retweeting it, and then I'm going to assume it's real. I've retweeted it. It's very exciting.

 Intro (1:13)

Alright, we're assuming so many people are watching at this point. Welcome to Healthcare Triage Live! We're going to be trying to answer some of your questions live. All the four, five, six people watching at the moment. Um, we're going to be-- we have some questions which we have received before, in the past, and we have a list of those and we'll go through those. Other questions, please put in the comments right now. Any questions that you put in the comments or anything you spam in the comments is almost guaranteed to be read live on the internet, because I have nothing else in front of me to talk about.

So, um, we're joined by Mark and Stan. And, this is an experiment. We've not tried this before. It's brand new technology in the office. There's a box here which magically, I think, does this. As opposed to-- you know, with the cameras and everything else. Um, and I think I've dawdled enough to give you all a chance to start watching. I'm going to try answering some questions. So, let me find that. Here we go!

 Provider Status for Pharmacists (2:04)

The first question we'd received was "thoughts on provider status for pharmacists?" Well, that's from PharmNerdMatt, and it's not actually grammatically correct, but I'm going to answer it anyway.

Um, if you're asking me if pharmacists should be allowed to practice without a doctor's supervision, um, I imagine there's probably some things they could do just fine. I mean, for the use of over-the-counter medications or even for probably prescriptions for very simple things, I imagine it would be ok.

But, for the use of anything which requires a physical exam or something which might be outside the scope of a pharmacist, then I'm not sure if provider status can be given. I mean, you know, you imagine that even something like the diagnosis of strep throat could theoretically require some level of mid-level practitioner to do it first to make the diagnosis at which point a pharmacists could write the prescription. But, uh, I think that, you know, probably they would need some extra training before then.

 Recommended Fluid Intake (3:01)

We have a question from NiVeck1234. "Is there any research about what the recommended fluid intake should be?" And, that's an excellent question.

So, one of the first myths we ever talked about in our book in our original paper on medical myths was the idea that you need eight glasses of water a day. And for that came out of a recommendation published in like the '40s and '50s by like a nutrition council in the United States. And, to go back and you look at it, it says that they think human beings need about 64 ounces of fluid a day, and there wasn't a lot of good science behind that, it was minimal.

But, they had at least some idea of what they were talking about, but there's a comma. And then it says, but the average person is going to get that through their normal diet, because of course there's water in juice, there's water in tea, there's water in coffee, there's water in beer. And, if you consume those things, you're going to get water. If you eat vegetables or fruits you're going to get water. There's water in almost everything we eat, and normal people who eat a well-balanced diet get more than enough fluid. And, probably get the 64 ounces that they're required a day.

There is no magic number of pure water that you need a day. In fact, the human body doesn't know where that H2O molecule came from once it's inside your body, whether it's, you know, a glass of pure water or whether it came inside fruit or any other type of beverage.

Now, of course, you know, a small woman living in a humid tropical zone does not need the same amount of hydration a day as, you know, an obese man living in the desert. So, there are going to be variations, and there is no sort of good recommendation for, you know, what each type of person needs when.

But, you know, evolutionarily, you are incredibly well-designed to regulate your hydration, and, you know, when you're thirsty, contrary to what you might have read, that doesn't mean you're dehydrated. It's the very beginnings of edge--[techinical difficulties]-- of your body might need to drink something. So, if you're thirsty, by all means have a drink. Um, but, if you're not, there's no need to force extra fluid into your body. You're not doing anything other than, you know, creating extra urine.

 Microwaving Food (5:13)

OK, we've got BobLongmire1, who asks me, "Does microwaving food make it less safe? Are there any studies showing it's safe?"

And, the answer to that is-- Well, the answer to the first question is no, microwaving absolutely does not make food less safe. In fact, there's not a load of good evidence, lot of good evidence that says that microwaving food even makes it less unhealthy.

Microwaving is non-ionizing radiation. It's not the kind of radiation that messes with your DNA or can cause damage to your body. It basically heats up water molecules in food. That's what it's doing. It's more akin to radio waves than it is to they type of radiation you think about in x-rays. And, that's what it's doing, it's heating up the water molecules in food and making it hotter. It's not necessarily breaking anything down or changing chemical composition. Certainly not making it any less safe,let alone even less nutritious. So, um, I wouldn't worry about it at all.

And, you know, microwaves, even if they do leak a little bit of "radiation," as I said before, it's non-ionizing radiation. It's not the kind you'd worry about that would give you cancer or do anything bad.

 Apple HealthKit (6:43)

Mark, Off-scene: Uh, Steven Fole wants to know about Apple's research kit and how it will affect health [garbled]?

Aaron: Apple-- oh! That's a great question. So, I think... I think we even have a Healthcare Triage video on that. So, if you didn't hear, Mark was saying that, um-- what was his name?

Mark: Steven Fole

Aaron: Steven Fole was asking, you know, whether Apple's new HealthKit and their new announcements will change the way that we do research or do anything else. Did we just lose everything?

Off-screen: [garbled]

Aaron: We're off.

[Talking off-screen]

Aaron: Ok. Oh! There we are, we're back! Excellent. Woo! Welcome back to Healthcare Triage. So, the question was whether Apple's new announcements about HealthKit, or their new research will change anything.

So, first of all, we actually have a, uh, a Healthcare Triage video on this where I talked about their announcements way back when, when they talked about the Healthkit when it was first announced, and why I'm very skeptical that it will lead to any significant changes in healthcare. Mostly because, um, we focus to much in HIT on the technology, and not enough on people.

And, there's a lot of theory and a lot of evidence that show the change in the technology is not nearly as important as change in behavior. And, changing people's behavior is so much harder than technology. Just giving people information, just recording it, is not enough to improve health.

So from that end, I'm skeptical. For the collection of data for research-- Look, I love Apple. You know, I'm ordering my Apple Watch the second it comes out. I own a ridiculous number of computers. We've got a Mac right here. Um, I own multiple iPads. Here's my iPhone.

I still don't think this is going to change the way that we do research, because we've had the ability to collect data through web technology in the internet, and even using phones, for years. Um, in fact, I've helped write software and do stuff to do that work.

The problem is always is compliance, and it's how do we get people to actually enter the information we need and consistently do it. That is so much harder than the technology links to collect it. And, the idea that somehow just, all of the sudden, providing a new bell or whistle to collect the data is going to overcome that problem is somewhat naive.

Moreover, a lot of times the patients that we want to collect the data from, the patients that we need the most in trials, are not the people who are frequent users of iPhones or the ones who are massive users of information technology. When we're looking at the very sick, the very poor, the elderly, these are not Apple's core demographic.

And, so why, while I'm hopeful and I'd love to see all of this work, and if Apple wants to send us free technology so that I can test it out, feel free, I'd love to get it, but I just don't think that without a lot of solid work behind it, that that is going to move the bar very much.

 Soylent (9:05)

Off-screen: Let me give you this.

Aaron: Ok. Oh, it's a bag of Soylent.

Off-screen: James asks [garbled]

Aaron: I can't believe there's an actual question on Soylent. This has been an on--

Off-screen: Yeah, I thought I'd bring it up.

Aaron: This has been an ongoing debate in the Healthcare, or the DFTBA offices here, among the people that make Healthcare Triage. Um, so if I'm not betraying Mark here, he's been actually eating this stuff. This is Soylent, which I imagine is a play off of Soylent Green, which is made out of people. Um, but, it's suppose to be a replacement for eating. So, if you eat this whole bag of Soylent in the course of a day, basically it's, like, it's a powdered to make three glasses of liquid fluid consumption a day, and you're suppose to add oil.

It theoretically gives you all a body needs. Um, you get all the carbohydrates, all the fats, all the protein that you might need in a nice handy bag. It costs like 10 bucks a day.

How do I feel about this? I don't think it's dangerous. I think it's probably adequate towards, you know, getting the nutrition that you need; however, I don't believe this is living. Um, I don't understand why people have so much trouble eating food, which is delicious. And, if, you know, can do this, I guess it, if you truly hate eating so much that you'd like it reduced to its bare minimum necessities of putting, you know, powder in a glass and stirring it up with water so that you don't die from malnutrition, Soylent maybe for you. If, however, you like the taste and camaraderie of a well-prepared and tasty meal- I don't understand anyone who eats Soylent, um, and I don't, I don't get it. But, it's a, I don't think it's dangerous at all, and I think, probably, eating--

Now, Mark has brought up a good point to me in the past that if we could distribute bags of this stuff for a very low amount of money to areas that are very low resourced and people are starving, then it's a good solution to get people the calories and nutrients they need that they might otherwise not be getting. I endorse that. That makes total sense to me. But, these bags cost like 10 bucks each, so that's not the solution that necessarily we're looking for, the way it's being marketed right now. And, so I think it needs a little bit of work on its business model if that's what they're going for.

 Are Doctors Overpaid? (11:08)

Alright. Our next question comes from, comes from Austin Frakt, the guy I write my blog with. He asks, "are doctors overpaid?"

So, um, not as overpaid as economists are, obviously. So, am I overpaid? Of course I'm not overpaid. Are other doctors overpaid? That's a complicated question. How do we define overpaid, especially in the United States of America? If we want to say compared to the rest of what people do, doctors do make up a greater percentage of the top 1% of earners than any other profession. So, we make a fairly large amount of money. Doctors also make more compared to citizens in this country than almost any other country we compare ourselves to. So, the ratio of what a doctor makes in almost any other country in the developed world versus regular citizens is actually, you know, their salaries are closer together than doctors are to regular, other citizens in the United States, as well.

There's a big difference, however, between sub-specialists and generalists. Sub=specialists make significantly more than do generalists. So, there's an argument to be made that perhaps their salaries could come down. Some doctors in the United States, especially like family physicians and maybe pediatricians, could actually stand to make a bit more compared to other countries. So, if everything was made fair, there might be a little bit of progression toward the mean.

But, I know Austin's asking this just so I can say that I'm overpaid. I will not do that.

 Dropping Soda from Kid's Meals (12:46)

[Off-camera talking]

Aaron: Wow, so, what was his name?

Off-camera: Kyle Moore

Aaron: Kyle Moore asks if it's a good thing that Burger King has now replaced soda with milk in their kids meals. 

Well, if you watch this show at all, you know my hatred for the milk emperor. So, god, this is a tough-y. Ok, so, if we're replacing like sugar soda with milk, that is probably, milk is probably better. I'm going to say that because at least it's more protein based, it's a little more satiating, it's not added sugars. That might be a bit more healthy than pure sugar, especially in a large soda where you're going to get a ton of calories. So, probably. 

However, if it's diet soda versus milk, I don't know. I don't know if kids even need the added extra calories they're getting from, you know, milk, which is still not zero. It can be, you know, three 8-ounce glasses of milk a day can be 250 calories, even with non-fat milk. Diet soda is zero calories, and, as we've done on another episode of Healthcare Triage, the dangers of artificial sweeteners are vastly overblown. There's no good evidence that that's real at all.

So, I don't know that I would rather see, you know, kids be drinking milk rather than diet soda. That's a fair toss up. Now, I know a lot of people get angry at me for that or would disagree me for that, but I don't know. Having said that, you know, of course, eating Happy Meals or meals from Burger King entirely is of questionable nutrient content compared to sort of a home-prepared meal. So, I'd rather say have a meal prepared at home, perhaps not as high in fat, perhaps more laden with, you know, protein, perhaps a little more vegetables and fruit than you'd likely see in Burger King meal in general. So, perhaps this is just the wrong question. Not that I fault you for asking that question. 

 Chiropractic Care (14:40)

Alright, we've got next...

[Off-camera talking]

Yes, I think. Yeah, yeah, yeah, yeah. Am I missing...?

[Off-camera talking]

Amanda Cook! Ok, I see Amanda Cook has asked about chiropractic care. Is there evidence for benefit? It seemed to help me a ton during pregnancy, but it might have been placebo, which is fine by her.

Well then, ok, look, if you're fine with the placebo effect and you don't care about cost, far be it from me to destroy that from you. So, sure, go ahead and get it, and turn off your computer now so you don't hear the rest of my answer.

But, for the rest of you, there is no proven benefit to chiropractic care. There have been, you know, good systematic reviews and randomized controlled trials of this for a number of different things (back pain and everything else). The problem is it's very hard to do placebo-controlled trials. What is placebo chiropractic care? But, when they do it, when they figure out ways to try and add it, it turns out that there's just not a lot of evidence to support it. Insurance rarely covers it, and I'm not even arguing that it should. Because, if it's without benefit, why are we doing it? Why should insurance cover it? And, there's always a tiny risk of harm, and it is tiny. I mean, most chiropractors aren't going to hurt you. But, a lot of the benefits are anecdotal and they're vastly overblown. There's just not a lot of good evidence for it.

Having said that, it's your money. And this is in, most, most countries where this is broadcasting, it's your money, you're free to do whatever you like. And, if you want to pay from chiropractic care, you know, if you're feeling like yo're getting a benefit from it, even if it's from placebo, I'm not going to take that away from you. I'm not going to tell you never to go do it. However, if you're not totally loaded with cash and have a ton of disposable income, there are probably far better things that you can spend your money on than to continue to do so with chiropractic care, as there really is not proven benefit.

 Rural Health (16:16)

Do we have another question here? Oh, James Sassic.

James Sassic asks, oh no, he's the one who asked about the Soylent. So, which question am I missing?

[Off-camera talking]

I don't see that.

[Off-camera talking]

M. Havrey asks about rural health. Is there any hope? He lives in the mountains, and he's worried about that. And, he wants research grants and everything else.

So, is there hope? Sure. You know, technology is always improving. So, we have two problems here. One is that we don't necessarily have a doctor shortage in the United States, even though we say that all the time. It's that we have a maldistribution. We have too many doctors in some areas and too few doctors in other areas. And, too few other level providers in some areas and too few in other areas. And, it's hard to fix that in a world that's free, because you can't make doctors go or make nurses practitioners or, you know, other mid-level practitioners. You can't force them to go practice in rural areas. This leaves a number of rural areas without doctors. 

You know, we live in Indiana, and, you know, almost all of the sub-specialists, at least in pediatrics, are really centralized in Indiana and people have to travel a fairly large distance to go see a pediatric endocrinologist, pediatric gastroenterologist. That's a problem.

There's a lot of potential, though, in things like tele-medicine and distance medicine and trying to care for people from further away. That's the kind of technology that Apple wants to break into, as we discussed earlier. It just hasn't worked yet. [Garbled] for it. We haven't figured out how to recognize if, and of course there's some things that you just can't do by distance. Sometimes, you actually have to lay hands on a patient, and actually make a diagnosis by looking at them or feeling them, or, well it sounded terrible, but doing physical exam or, you know, finding something that you otherwise couldn't.

And so, I do think that there's real potential to improve the way that we do rural health, but, until we can come up with a better distribution of our providers, there's still going to disparities between what you can get it a rural environment and what you can get in an urban environment.

 Probiotics When Taking Antibiotics for C-Diff Infection (18:30)

Our next question comes from Ricky Rampulla, who's watching, who asks, is there a benefit from probiotics when taking antibiotics for prevention or treatment of C-Diff infection.

So, we actually talked about this in a recent question video that I did with John, and so I encourage you to go what those. They're very, very entertaining as well.

There are some good studies that show that probiotics, even a randomized controlled trials, can have a benefit in sort of overcoming diarrhea from things like having taken antibiotics, because your gut is full of all kinds of bacteria and some of them are good and some of them are bad, and it's a nice balance. And, enough good bacteria prevent the bad bacteria from sort of overtaking things and becoming too prevalent.

When you take antibiotics, often what can happen is you kill off the good bacteria, which leaves the bad bacteria a real chance to thrive. And that sometimes happens when we, when you get antibiotic diarrhea is that you get an infection from something like C-Difficile, which, Ryan is it, Ricky is asking about, when that starts to overgrow, because you've killed off the good bacteria; which is a real good not to over take antibiotics. 

And, probiotics, which sort of re-infect your gut with the good stuff, are ways to try to get rid of that. And, as I said before, there are some, there is some evidence that for some things probiotics do work. There's a decent amount of evidence for diarrhea after antibiotic do work. There's some evidence that things, like for prevention of eczema or other atopic diseases, it does an ok job. And, some other things it's just totally not proven for. But, probiotics are one of those things where, you know, unlike chiropractic care, there is some good evidence. And so, in certain situations, you will find doctors recommending it, and I think they have a leg to stand on based upon what we've seen in the literature. 

 Rash (20:20)

Alright, we'll try one or two more questions, I think, here. Let's see. Ben Mooe, M-O-O-E, asks, "hey, you're a doctor. Can you take a look at this rash?" No. No, I can't

 Mental Services (20:34)

Ok, so DHJShiShi asks, "why are mental services so hard to get?"

Ok, that's a great question. So, in the past, it was often that we-- that it was difficult to pay for them, that insurance wouldn't cover them. We had a very, you know, skewed, almost bigoted, way of looking at things; that physical disease was something that insurance had to pay for, but mental disease, not so much. That's changed. A lot of mental healthy parity laws have been passed, the ACA sort of cements thing, and so it is much easier to get mental health services paid for.

Having said that, you know, getting referrals can sometimes be difficult, and we do have a shortage of mental health care providers, as well. And, they are, like with other providers, skewed heavily towards urban areas. So, it is often difficult to get appointments, just because we don't have as many practitioners to sort of overcome the need.

I always felt, you know, if I had my way, I think, you know, therapy should be as common as well-check-ups. I think everybody could almost benefit from it, but we have it distributed in such a way that we think physical health check-ups are a necessity even with no proven evidence, but mental health check-ups are just craziness, we don't do that. I think that's a real mistake. I wish there was a way to fix that. 

 Pain (21:50)

Um, why don't we take one more question here. I won't do A. Frakt again, because he had one. Let's try TheNudie asks "why have we not found a reliable way to turn off pain yet?"

Well, we have reliable ways to turn off pain. The problem is that it turns off all other sensation as well. I can give you an epidural, I can give you, you know, a shot of Novocaine; I can absolutely remove your pain, but you can't feel anything and often your muscles won't work then. And so, that's a problem. It's not that I don't know how to overcome your pain completely, it's that I know how-- the only way to do it is also going to turn off your nerves completely. And, we need nerves. You need, you know, pain serves a function. It tells you when you're in danger. It tells you when you need to pull your hand away from that hot stove, because otherwise you'll burn yourself. If I've removed all pain, I've removed your ability to function in a normal environment and prevent injury, and also know when things are going on. You need that tactile sensation.

And, unfortunately, you know, the difference between tactile stimulation that's pressure almost getting to pain is subtle, and we're not very good at removing one without removing the other. And, you need that really to function in society. 

 Outro (23:04)

So, I think we should stop there. I want to thank everybody that participated in this. We're excited that it's worked out this well. We know now behind the scenes information. We tape Healthcare Triage almost always on Wednesdays; that's when we do News for Friday. It's also when we tape our regular episodes to be batched on future Mondays. So, I think we're going to continue to try to do this on Wednesdays, depending upon when we film, usually in the morning. We'll try to update information by Twitter and other means to keep people informed about when we might do this.

But, if you find this of value, spread the word. We're going to keep answering your questions live on the air, and then probably put these videos up for consumption afterwards for people who want to go back and watch them in not real time, asynchronously.

So, again, thanks for tuning in. We'll see you on Friday for Healthcare Triage News.

Where's my thing to hang up? I can't find it. We're going to hang up. I'm going to. Here you go... Oh! There it is, and hanging up. There we go. And we're--