Welcome to Healthcare Triage Live. I hope we're up now. We've been trying to get things going through hard work by both Mark and Stan. This is our second live show. We're going to continue to try to do this mostly on a weekly basis; although, it will probably take us a little bit of here and there as we get started. We may miss some episodes, I think, in the next few weeks actually due to travel, both me and the team here.

So, we're going to start right off. Let's get going! Comments, uh, if you have questions, I'm told you're suppose to put them in the comment section below the video. Stan and Mark are act-- are actively monitoring those, and they will keep feeding them to me and trying to prepare them with graphics as we go.

Let's hit the ground. Let's go!

Ian Parlimen starts off with "What is your stance on pharmaceutical spending? How much of an issue or conflict of interest is it that doctors can receive kick backs from pharmaceutical companies?"

Well, amazingly enough, there's a Healthcare Triage video for that. We did an entire episode on conflict of interests, business specifically with financial conflict of interest, and why it's something that's important to monitor. And, in fact, the government, because of new law, is monitoring those things, and forcing pharmaceutical companies to disclose when they make payments of almost any kind of physicians.

And you can go online right now, it's a, ah, I can't remember... It's the Sunshine Act, but it's the open-something-database, you can search for it. You'll-- conflict of interest, you'll find it. You can type in your doctor's name, and you can actually see all the payments that they received from any pharmaceutical company over the last year or so. The database is a little bit behind, but you could look me up, for instance, and see what pharmaceutical spending has gone to me. And, I think the answer is none.

Having said that, there-- what is my stance on this? So, you know, saying what is my stance of pharmaceutical spending is sort of odd, because of course pharmaceutical companies have to spend money; otherwise how would they do research, how would they market their drugs. I mean, they have to spend money.

I think what you're asking is, you know, how do I feel about them spending money directly to physicians. And, there's lots and lots and lots of research that shows that it influences physician behavior. It's the reason that they do it. It's the reason that most of the money that goes from pharmaceutical companies to physicians goes under categories of marketing and administration or, you know, advertisement, not necessarily to research, because that's what they're doing with it. When they spend money taking docs out to dinner or, in the past, taking them on trips or buying them gifts in the office or even buying them lunch, it does influence their behavior in subtle ways. There's a reason ten-cent coupons exist; it's because they work. Small financial incentives can really drive behavior; imagine what large, large incentives can do, and they're often large incentives that go from pharmaceutical companies to physicians.

The most compelling story I saw recently and the one I think we highlighted even in the video, was a study of FDA approvals that showed that if doctors were sitting on FDA panels to approve drugs and they had received money or said sat on boards or even had sat on boards of the companies of for which they were making decisions, they were significantly more likely to vote for approval. And, that's the kind of thing you hope that doctors will be able to not [static], but it happens. It just, they're human beings, like everybody else. And, when you give them money or you, you know, give them things, that often drives their behavior and changes the way they make decisions. 

Ok, next question. Typing it... Here we go. Logan Dunlap, "what does the research into ECT or electro convulsive therapy for the purpose of treating mental illness say, and what are your thoughts on it?"

Oh, alright, this is a tough-y. So, there is, I believe, unless I'm totally wrong, there is some evidence that it does work. Unfortunately, that evidence is not as clean and as perfect as we'd like it. And, it also is usually only for people with really severe mental illness. And, part of the problem that we often see in medicine is that we do some research for things that are for very small, distinct groups, and then, because it works, we spread it and it gets used more widely. Having said that, there is, I believe, some evidence that for short term, it does improve symptoms for people with severe mental illness. But, it does have some pretty bad side-effects, including, you know, differences with memory and some other issues that can crop up as well.

And, I'm not sure how long the effects last. In other words, they may come back. And, because of that, it's not widely recommended or done as, you know, as commonly as it has been in the past. Especially, because there are now a lot of other options, specifically medications, for people with mental illness that probably work as well if not better, and have nowhere near the same side-effects.

So, I don't think this is something that is done very often anymore. If you ever get to see it done, ironically enough I have seen it done when i was a medical student, it's nothing like what you see in the movies. People don't shake around. In fact, they are usually given drugs which sort of shut down their muscles before they're given the electro-shocks. And so, it's almost just... it's very quiet and it's very calm, and it looks nothing like what you see in the movies with people in jittering around or what you see with electric chairs or things like that. So, it's not very common, but it's nothing like what most people think it is.

Our next question comes from Delaney Beckner, "When nutritionists suggests limiting sugar intake, do they mean all carbohydrates or just simple sugars? Is there any significant difference in how the body processes them?"

Well, of course, you'd have to ask any individual nutritionist to get their take on what they mean, but I think when people are saying limiting sugar intake, they're talking about sugar. They're talking for the most part about like sucrose, as that is the form of sugar that most of us are getting.

Complex carbohydrates, well, of course you don't want to eat too much carbs, period, but people would-- I think most doctors, most nutritionists would rather you be eating complex carbohydrates than very simple sugars, such as sucrose.

And, a lot of the focus these days is on added sugars on things that are just, you know, being added through beverages or through food. And, added sugars are almost all simple sugars. Nobody's adding complex carbohydrates really to food to make it taste better.

So, I would say that when we talk about limiting carbs, we're talking about all carbs. But, absolutely, if you had to grade them, simple sugars would come lower on how people would feel about it or how much they'd want it than, than more complex carbohydrates.

I'm going to take a break here for some product placement. These are on sale, by the way. As is, for that matter, that poster. Anyway, dftba.com. That's it.

Hank "Past-Eek", you think that's what it is, "Past-i-k", P-A-S-T-Q-U-E, I apologize right now for mispronouncing your name, if I did so.

"I've heard that limited alcohol consumption can be beneficial to one's health. Is there any evidence to support this?"

Is there evidence? The answer is yes. So, this is not randomized controlled trial data. We don't have randomized controlled trials which can prove that, you know, drinking a little bit is going to improve the long-term or short-term health outcomes that people want; however, there are a fair number of cohort studies or epidemiologic data that show mild to moderate alcohol consumption can be associated with improved heart health, with lower raters of cardiovascular disease, and with some other health benefits. Having said that, you can also find studies that show that it can be associated with increased risks of some cancer, like breast cancer.

What you see is that, again, the media or other people will take this and run with it too widely, and they'll say, well, we've proven that alcohol causes breast cancer, we've proven that alcohol makes people healthier; neither of those is true. Having said that, I do think that there's a reasonable, a decent amount of data that says that mild, you know, limited alcohol consumption without going overboard, you know, everything in moderation, probably isn't harmful and could be helpful in terms of some diseases, and, specifically, heart disease. And, given that, you know, heart disease is still the number one killer of people in the developed world and even very much so in many other countries, there's reason-- no real reason to avoid, you know, limited alcohol consumption because you're worried about its health effects.

Next question. Avoisen, " Is there any hope of moving medical research in the US to a more publicly funded system? The 100,000 price tag on some medicines is a bit crazy."

So, we got to separate out a few things here. The 100,000 price tag is from the company that's selling it. That is somewhat disconnected from research. Even if we had a publicly funded research system, the government in the United States is not going to sell the drugs. The drugs will be sold by some pharmaceutical company, and they will still put any price tag they want on it. In fact, lots of times drug companies will buy almost completed or completed drugs from smaller drug companies, and then market them themselves. They haven't done the research, but then they're putting any price tag on it that they want. So, it's not necessa-- there's not a crazy straight line between the price of a drug and how much it costs to develop it.

See, we often have to break when trucks drive by like that for Healthcare Triage. So, you're getting something special there.

So, it's also important to think about how much public versus private investment there is for drug development already. There's already a fairly large amount of public investment in research, especially in basic science research that goes towards drugs. There have been many studies, I've written about this in the blog, that show that often the big, the big, important drugs, and sometimes even the blockbuster drugs, a significant number of the key papers and their patents were done with NIH research or with public funds. Then the pharmaceutical companies often come in at later stages, and then take the drugs and move towards, you know, doing the tests, making the drug, doing the product placement, doing the development, all of that, because that's what companies do. The government doesn't do that.

Could we have more public investment of research? Sure. We absolutely could. But, I'm not sure that that would still change the way that drugs are sold in the United States, because those decisions are still made by individual companies. The actual sale is where the price gets determined, and it's still not possible in the United States for the government to step in and tell a company how much they're suppose to charge for a product. 

So, the reason you're seeing hundred thousand dollar price tags on some of these drugs is because, and it's really because, the pharmaceutical companies think they can get that much money out of people. They think that the drug is worth it. And, having said that, there are arguments to be made that it is.

You know, Sovaldi is the big one that's, that people are arguing about right now, because it can cost 80-some thousand dollars for a treatment, but it can cure hepatitis C, like pretty quickly. And the, and the difference in cost between curing the hepatitis C quickly and extended lifetime treatment, eighty-some thousand dollars is actually less than it might be for some of that treatment. In fact, when they do the cost-effectiveness analysis, which is another video you should watch, they found that it's, it's not that expensive. It's like twenty-some thousand dollars for quality-adjusted life year gained. That's not terribly bad when it comes to cost-effectiveness and how much things cost in the United States.

And, in fact, there are people who believe that, you know, they had number-crunchers that sat down and figured out exactly how much they could charge, and still have the numbers come out to look cost-effective. That's where the price is in. That's where it comes from. It's not they have a straight way and they said it cost us this much to do the research, that's why we're charging this much. It's how much do they think they can get for it, and that's, that's how prices are set for almost anything in a capitalistic system. That's the system we've got.

Emma H. asks "Thoughts on the new findings on artificial sugar and waistlines?"

Oh, Emma. [Sips from mug] Alright, Emma. So, these new findings, if I know which study you're talking about, is basically a cohort study of like 65— [audio cuts out]— that followed them for four years and looked at, you know, how much, you know, artificial sweeteners they, or how much diet soda they drank, and then how much weight did they gain or what was their waistlines. And, they found a correlation between how much diet soda they drank and, uh, and that they were heavier.

So, we got to— there are so many things to discuss. One, it's a study of 65 year olds. That's not the same as most people who are actively dieting and trying to lose weight. Um, it's also, they're not the biggest consumers of diet soda. So, they're not the market and what we really need to think about.

It's also a cohort study, not a randomized controlled trial. There's no causality there. There's not evidence that the people that are drinking the diet soda are the ones who are, you know, gain— oh, I'm sorry, there's no evidence that it's the drinking of the diet soda that makes them gain weight.

Here's another problem: it's, what, what if it turns out that people who weren't drinking the diet soda were dying, and therefore the people who were left were the ones drinking the diet soda in the cohort. Because, it's a population of older people. 

It's also possible, and I've seen this kind of behavior before, that people who drink diet soda believe that they're saving so many calories that they overcompensate in other areas. And, they wind up eating more dessert, because oh, I'm having a diet coke, I can have dessert tonight. That's not the diet soda making you gain weight. That's, you know, your behavior, you know, because you think you're saving calories in diet soda. 

None of this is evidence that taking a diet and keeping the same diet, but replacing the soda with diet soda is going to make you gain weight. There's no study that shows that. Ok, that's not— that is not the study that they showed. They showed that the people in the age group, over these years, with whatever diseases and problems they had, that people who drank diet soda were also the ones who were likely to gain weight or to be heavier. That's not the same thing as saying that artificial sugar— or, I'm sorry— yeah, that artificial sugar makes you gain weight.

Unfortunately, that's the way the media always covers it, and that's the way it always goes. But, that's not necessarily what is true. If you can have the discipline to maintain your same diet and replace the sugar drink with a sugar-free drink, you will be consuming fewer calories in a day, and you will lose weight. Because, of course, weight gain is how many calories you put in and how many calories you burn off. And, if you can manage to calorie restrict while doing exercise, you're going to lose weight over the long term. The problem is people often lack that discipline or lack the ability to maintain it, and if they take the calories out of one area, they replace them in another.

Margaret Taylor asks, "I'm hearing from some sides—" Oh, some sides. Never trust some sides. "I'm hearing from some sides that women should never take statins and others that increase the number of people who take statins." ...oh, those are others, I see. "Do you have data?"

Well, of course we have— Ok, we always have data. You're asking me if I think that too many people takes— too many women take statins, and then— or should we increase it.

So, here's the problem: um, there's a large number of people that think we're treating too many people for high cholesterol with statins. That when the drugs were first developed, of course, they were testing, and, this is a running theme in today's show, on a small, distinct group of people who had very high cholesterol. And there was evidence that it reduced their cholesterol, and there was even some evidence and some secondary outcomes that it improved things. And, therefore, we, as a medical community, started to developing guidelines and creating it so that so many people are on statins to the point where, these days, if you go to the latest guidelines and plug in your risks, if you're an African-American male over the age of 65, you're supposed to be on a statin. And that's— there's a lot of people who think that's too much. Um, with women, as well. There's a lot of evidence that more people are on statins than they need to be. 

Having said that, there's also evidence that there's lot of people who have very high cholesterol that probably warrants medication that should be on some sort of therapy, and are not getting it. So, it's hard, because we want— you hear some people say we don't have enough, some people say we have too much, and they're both right.

Um, but I actually worry these days that the pendulum has swung a little bit towards too many people being treated. Uh, we discount sometimes the side effects. The number needed to harm for muscle pain is quite low (you should watch the number needed to harm episode, by the way). The number needed to harm with diabetes is actually debatable, where people are worried that, you know, a real number of people are getting diabetes more on statins than not on statins, and that might actually might be a significant side effect of the long term use of the drug. That's a worry, especially if we're treating people who really are at that higher risk.

My anecdotal information tells me I know lots of friends who've been put on statins that absolutely don't really meet criteria. I think there's a real case to be made that they're being over-used in some populations today. I have a borderline cholesterol level, and I'm not on a statin. My doctor and I have discussed it many times, and I'm like "no. I know what the criteria are. I know where danger lies. I know what the risk factors are." And I, regardless of what the calculator might say, it's not, it's not for me at this point. I think that that's probably true for many others.

Having said that, you should always talk to your doctor. Always. Because, you may need a statin or you may need to be treated for your cholesterol level.

Mickey Petterson, "Could you talk about the benefits or risks of vegetarian and vegan diet compared to diets including meat? Which is better, avoiding meat totally, or balancing?"

I've tried to be consistent with this. We've done episodes on diets, as well. The best diet for you is the one you will stick to. That's really the answer.

You know, the pros of a vegan or vegetarian diet is they're almost always pretty low in calories. I mean, unless you're sort of gorging on milk, (which you shouldn't be and watch that diet, too) of course that's not on the vegan diet— If you're gorging— Unless you're doing things with the dairy products— you know, vegetarian diets, you know, avoiding meat products, they generally have less fat in them, they generally have fewer calories in them. And, therefore, many people who can stick to them do lose weight and are reasonably healthy. You do, however, unless you are really careful about it, you can miss out on some nutrients. You can miss out on iron. You can miss out on some other things.

Did we lose the camera there? 
[Off-camera]: Yeah.

You can lose some things and that, uh, that could be a problem.

This is all exciting. Fly by the seat of our pants. 
[Off-camera]: They can still hear you.
Oh, still hear, oh, ok, very good.

So, um, so, it's important to make sure you're getting all the nutrients that you need. You still need amino acids. You still need proteins. And, it's a little easier sometimes to get that from meat, because, of course, living animals have almost all of the proteins and amino acids that a human being needs. They're animals. It's a little harder, not impossible certainly, but a little harder to make sure you get that through a well-balanced diet in a vegetarian manner. 

So, I don't push any of these. I don't. If people ask me, I always go, well, what do you want? If you're avoiding meat because of ethical reasons, then of course you should avoid meat. If you find it's easy to maintain a vegetarian diet, by all means, do so. If you find it's easy to maintain a vegan diet and you love that, by all means, do so. If, however, you find that, you know, you can still eat a well balanced diet and still include meat in your diet, than that's what you should do. Um, and I don't think it's probably helpful or correct to say that any one is superior or better than the other.

Ok. Scott Steiner, hm, I know a Scott Steiner at work. I wonder if it's—

"Please discuss the National Residency Matching Process. This week will be a very emotional one for medical students and graduates across the country, and the 20th is the day we find out where we go."

I, so— Yes. There is actually a day in March in, uh, for medical students, the day they all find out where they're going for residency, and it can be lots of places. I can still remember this in my school, this is back in, what, 1998? Yeah. They had a ceremony; like, we all went to this big auditorium and they called us done one-by-one. And, we had to go down and get an envelope. And then, on the way back to your seat, you'd open up the envelope, and you could watch the people, you know, either shriek with glee or just break down in tears, which was somewhat depressing.

Um, I also remember that I had to ask my wife to marry me, um, now my now wife, before Match, because I wanted to make sure no matter where I was going that she was going to come with me. And, since I was leaving for Philadelphia and I really wanted to go to Seattle, I figured we better, better make sure she was onboard. 

Anyway, what residences— what medical students do is they send out applications first to all residency programs that they think they might be interested in. Most people have at that point chosen a specialty. So, I knew that I wanted to do pediatrics. Other people might want to do medicine, internal medicine. Other people might want to do surgery, or, you know, pick something else, OB-GYN, whatever it is. And so, you go and you send out applications, and then, if you're application is good, you are invited to interview with those residency programs. And so, you spend a lot of time and a lot of money traveling around the country, if you're looking all over the place, interviewing in places where you might want to do residency training, which can be from three to five, even more, years, or seven years depending upon which specialty you pick.

So, you interview with them. Of course, they're interviewing you at the same time. And, you both get a sense of how much do I like this place or like this person or not. Then, you come back, and, at a certain point, you go to a computer and there is usually like a computer at every medical school, at least there use to be, and you sit down and you enter your "list." So, it's the ranking of all the places that you got to interview, from like one to last, this is the top place I'd like to go, this is the least place I'd like to go. Any place you don't enter, you can't be sent to. So, there's no worry that you could be sent somewhere you hate. If you hate it, you don't put it on the list. But, if you put it on the list, you can go there.

And so, it's this sort of game of, like, you know, how— you want to make sure you get in somewhere, so you need to rank low enough enough places so that you're going to get one of them, but you don't want to go so low that you wind up going somewhere you don't. The medical— the residency programs do the exact same thing with all the residents they interviewed that they want. And so, they submit the list of anywhere between say, I don't know, like a hundred and hundreds, depending upon how competitive they are, of, you know, how low do they think they're going to have to go to take people. And, they shouldn't go lower than someone that they actually like, because they don't want to get someone they actively dislike. On the other hand, they want to fill. They don't want to wind up at the end with people that, you know, with too few residents for the program.

And then, on one day of the year, the magic algorithm happens, and it starts matching people to actually, you know, put the people at the programs they want. And, you know, depending upon who you want to believe, it's suppose to favor the students. So that, you know, you won't get yanked out of, uh, your order if it's possible you could get your top match. But, the algorithm is suppose to place you at the top choice with a program that still actively wants you, and that. 

A day or two before the 20th, or the day that they announce the match, they actually let all the people who didn't match know. And so, people— students who didn't get into any programs find out. And then, there's what's called the scramble, where you start to look around for programs that didn't— that also didn't fill, and you start to negotiate and see if you can get into those programs. It's also so you don't have to go to that ceremony, and be very, very upset when, like, they don't call your name and you get an envelope.

But, all— you know, most medical students match. Um, they get, you know, a program, hopefully, that they like. If they get a program that they hate, they shouldn't have put it on the list. But, it is this sort of bizarre game-like process that all medical students have to go through right before they graduate.

So, if you know a medical student, give them a big hug, you know, in the upcoming day, because the 20th— is the 20th today? It's today! Go say hello to them today, and find out how they did. Uh, and ask how they did in— and if they did well, congratulate them and buy them a drink (not too many drinks, because we're limiting our alcohol). Um, and if they didn't do well, buy them a drink as well.

Anyway, I think we're out of time. Um, oh, should we do this last one or are we out of time?
[Off-camera]: It's up to you
Alright, we got time.

Lynn Griffin, I'll do this fast. "Are there any negative long term effects of taking the pill? I'm worried it could permanently throw off my hormones."

This is one I decide if I should tell an anecdotal story or not. I don't— no, I won't. I haven't asked my wife.

Anyway, so, um, there really aren't any long term negative effects that people know of. It's does inhibit ovulation for a period of time. I think you will talk to OB-GYNs who will tell you that when people go off the pill, it sometimes can be a little difficult to jump-start the process. And so, it can be, you know, you might need to take a drug, like, um— oh, now I'm totally blanking. But, there are drugs which they can give you which can just jump-start it, and that can actually make things work better immediately. But, you know, there are no really long term, that I should say like it shuts down your system or it makes it impossible to have a child later or, you know, that you're more likely or less likely to get certain diseases. The effects are the effects and long term doesn't make that much of a difference. And, again, so many women have been on the pill for so long, we would have solid evidence if it looked like any of these things existing, and we just don't see that. 

Clomid! Clomid was the name of the drug. So, sometimes people will be put on Clomid, uh, and that will jump-start their system. 

Anyway, thank you for everybody who's tune in. The next Healthcare Triage Live is going to be April 8th at 10:30 A.M. Link will be in the description. Please tell everyone about it, and get your questions ready. You know, send them to us either ahead of time or, you know, in the comment section during the show, and we will answer as many as possible. We will look forward to seeing you on April 8th again, at 10:30 A.M. If not, tune in to Healthcare Triage News, today! Every Friday. Um, and tune into Healthcare Triage, the regular episodes every Monday. And, hopefully, we will try to get Healthcare Triage Live going every Wednesday in the future. Buy a mug. Buy a poster. Thanks for watching.