28.2 Stop Abandoning the Severely Mentally Ill with Nick Rosenlicht, MD

[00:00:00] A young person born today has a lower life expectancy than their parents. That's the first time that has ever happened. Somebody get this guy some help.

[00:00:21] Disclaimer, this podcast is for informational purposes only. The information provided in this podcast and related materials are meant only to educate. This information is not intended as a substitute for professional medical advice. While I am a medical doctor and many of my guests have extensive medical training and experience, nothing stated in this podcast nor materials related to this podcast, including recommended websites, texts, graphics, images, or any other materials should be treated as a substitute for professional medical or psychological advice, diagnosis, or treatment. All listeners should consult with a medical professional, licensed mental health provider, or other healthcare provider if seeking medical advice, diagnosis, or treatment. Or put more simply, If you need help like this guy, call your own doctor.

[00:00:49] The psychiatrist who came on to CarLatt right after you, and there's three or four episodes. Oh, Alan Francis? It's Alan Francis, yeah. And I was talking to a colleague of mine the other day. You know, I've listened to a couple of the recent ones on CarLatt, and he sounds very, very reasonable.

[00:01:07] But my other understanding, and picked up a lot of this from Nasir Gami and Rith El-Malik, who I got the chance to work with in my training program, that there was a huge transition from DSM three to four. And I understand that Alan Francis was the kind of head of the committee. He was the chairman of that.

[00:01:26] Right, with four. So my friend and I were talking, well, it seems like he has reversed course, but I also have heard more about the problems with DSM five with him, as opposed to these were some of the problems that happened with DSM four. I'm just curious if you have any other insider knowledge on where he's at, and maybe what your ideas about the role of DSM four and five are.

[00:01:53] Well, I haven't personally talked to Alan Francis, a good friend of mine who passed away, was a colleague and knew him well. And I think he's done a lot of good. And I really like what he's been saying and his very vocal criticism of DSM five, I think are very valid. You bring up a good point, though, that DSM, a lot of the same criticisms belong to DSM four.

[00:02:19] The gross conflicts of interest, the number of industry paid individuals who are making these criteria. There's a lot of blame there. The fact that the DSM is not really just a diagnosis manual, it's a billing manual. So you are setting a billing criteria by people who are beholden to the drug companies. It's a tremendous conflict of interest. And I think DSM four bears a lot of blame for that.

[00:02:48] It was one step further towards DSM five. And I haven't heard him discuss that. All the other things I've heard him talk about, I think they're very valid and very good. I really wish he could maybe talk about that, maybe a little me a couple about he was his excitement to try to fine tune DSM also had some negative consequences. I agree with you.

[00:03:10] From a bird's eye view, you know, the DSM four came out right around the time that all of the new SSRI drugs. Exactly. Went on to patent. And, you know, that by itself is not the best evidence. But when you put it with all the other historical examples of manipulation and drugs coming out and looking, you know, phenomenal and state of the art.

[00:03:34] Now, I think most psychiatrists recognize that that class of drugs maybe has more problems associated with it than were initially recognized. Well, I remember I was around when Prozac came out and it was great. We can get rid of the sexual side effects of the tricyclics. It was like you want to give it to people because of its pro-sexual function. And, you know, often people are depressed. You know, you get depression better. But I mean, these these hopes that didn't pan out.

[00:04:03] It was right with the biological revolution. And it really oversold this stuff. You know, DSM was in many ways such a benefit because especially in analytic literature, what did people mean? Two people would talk about the same patient and you couldn't understand they'd have a totally different diagnosis. So I think DSM was really useful for that. But as it's developed and, you know, what is it like 400 and something diagnosis? I find I use it less and less, particularly when I don't have to give it to the insurance company.

[00:04:33] And I've got so many people, it's kind of embarrassing. My diagnosis is angst slash death because, I mean, is this person anxious or are they depressed? They go together and there's artificial distinctions we make. The SSRIs, for example, I really feel are far better at anxiety than they are depression. And they also they blunt people and they make them less sensitive to interpersonal slights.

[00:05:01] The antidepressant properties they have are almost secondary to the lowering of anxiety and the lower of interpersonal sensitivity. And people get better over time because these things are better. I think it's almost a mistake to call them antidepressants. Yeah, in my experience, very limited compared to your experience.

[00:05:20] But what I find is it's so easy to overshoot your target with the SSRI dosing and lead to way too much apathy. You know, if you can find that good balance of taking somebody who's more kind of classically fits into the OCD or that severe anxiety spectrum and reduce that to a degree where they can function a little bit better, but not to the degree where they don't care. Yeah, that's ideal.

[00:05:51] Well, I think a lot of it was Prozac was the one size fits all. I do find that if you got patient, 10 is plenty for some people and certainly maybe 50. I have a lot of people that do really well in 50 to 75. You just got to give it time. The drug that I have had the absolute most success with, even at, you know, doses that are subtherapeutic, according to the guidelines, is lithium.

[00:06:20] And at low doses, it is also one of the safest drugs that I've ever used. When I'm not pressing close to the toxic level, there are people that I've had on it for three to six months. And we can't say for sure that it's really, you know, positively impacted mood in any way. But there's others who, within a few weeks, it's not just them that notice. No, no, I agree. It's your family members that notice.

[00:06:46] The renal effects, if you keep somebody from getting in the toxic range or keep them under one, minimal and the reduced GFR is reversible. And I think the fear of nephrotic injury is real, but way overblown. If you properly monitor them. The trouble is you're not seeing the person in weekly therapy and getting a lab test every six months nowadays. They're being seen by their doc once a year and maybe getting a level checked.

[00:07:17] And they're not discussing how they're taking it every two years. It's a monitoring problem is what it is. You know, I do talk about our best drug for psychotic disorders is clozapine. Our best drug for bipolar disorder is lithium. The most effective drugs for anxiety are benzodiazepines. Their results are so much better than everything else we have. These drugs are all more than 50 years old. I was in Mexico recently.

[00:07:46] You can get lorizapam over the counter. Are you hearing about the benzodiazepine craze in Mexico? These drugs are very safe if properly monitored. It's how we are using them. Well, we don't monitor them. We don't have a good relationship with our patients and they become unsafe. The worst thing is a benzo addict. I have had people, so many people on them. And you can reduce the dose and wean them over time, but it involves a fair amount of therapy and a lot of support.

[00:08:14] The problem is how we use them. I agree. I think benzos are very, very effective. My use of them is very typically short term. But in mood disorders especially, to me, they're such a better rescue agent than antipsychotics. Usually you can combine them. You have to because they don't themselves have a mood stabilizing component, but they lower the need for the dose. I worked on a ward where we were trying, the manufacturer wanted to do a study of Klonopin

[00:08:44] as an anti-manic drug. We're trying it as the sole agent in mania. And we would have people who couldn't stand up. And one guy who was, he was ex-military Air Force and he would be like on the side on the floor marching off. We go into the wild blue yonder because he was so atactic. But they can allow you to way lower the dose of the antipsychotic. And also the idea that, you know, the antipsychotics are mood stabilizers. No, they're anti-manic agents.

[00:09:12] Those are bullshit studies of too short a duration. They do not change the time to the next episode. They are anti-manic agents. And mania does not last a few weeks. I ran a group for a long time. You could see subtle changes in people lasting for months and months post-episode, both cognitive and emotional. The recovery from a bipolar episode takes months. And I think people are misunderstanding the time course.

[00:09:41] You can suppress somebody's mania in a couple of weeks, but they are not over their episode. Right. What do you think are the best five best or most useful drugs in mental health today? Well, I mentioned, I think, benzos, which are who are very dangerous. And we've dealt with people who are addicted. It's horrible. The lithium, clozapine. And I think, you know, SSRIs, when properly used and understood are.

[00:10:06] I mean, the problem is, is that 80% of them are prescribed by primary care doctors. We never hear from them. They get better. But they need to be, as you mentioned, properly dosed, proper expectations, managing about side effects, but they do lessen the burden of anxiety and depressive symptoms in a large number of people. The problem is, Americans, this is our pursuit of happiness. Life sucks.

[00:10:35] Life is unfair. We're trying to sell happiness to people. These drugs can blunt people, which then reduces happiness, but they can also help them weather the slings and arrows of life. We need to have proper expectations in our own goals and our patients' goals to understand that these drugs help for disorders. They don't make life good.

[00:10:58] The risk of suicidal thoughts or suicide on these drugs is one of the reasons why I have a really hard time using them for the population that seems to use them the most in young people. I don't think they work in pre-adolescence. They lower anxiety. They are not antidepressants, and that's pretty clear. Right. That risk, even though it may be very small, and folks like David Healy will tell you that

[00:11:27] that risk is not very small, but other well-informed psychiatrists will say, yes, the risk is there. Most well-informed psychiatrists I've talked to acknowledge the risk of suicide or sometimes even homicide or if you want to put it all into impulsive behavior. For me, I have such a hard time prescribing that to somebody who's 16 to 25. An immature brain and also the suicidal, because the restless and akathisia and insomnia can go with them,

[00:11:57] can push someone over the edge. I would be very cautious about using it in an adolescent. I don't do work with pre-adolescence, but my limited experience and my talking to colleagues, they just really aren't that effective there, and they can add a risk. I don't want to be the one who provokes a suicide. And when you've seen that happen, that will stick with you, right? Oh, yeah.

[00:12:21] When you hear about a patient who has had a drastic change in behavior over the course of a few days with signs and symptoms that have never been there before, that really locks in like, no. Even though I don't see it very often at all. You know, you can make a couple people somewhat better and another one kill themselves. That's not a great trade-off. Right.

[00:12:47] The other thing is like with the lack of availability and the stigma about mental illness, people are going around the healthcare system. They're going to TikTok for their answers. They're learning how to slash. They're learning, you know, the symptoms that was the TikTok ticks. This is not where we want our youth to be getting their healthcare. And if mental health were more available and more palatable and wasn't just throwing out drugs that might make people suicidal,

[00:13:17] I think we could be doing a much better job. But our system is very happy to let TikTok treat these people. To be honest, it's a little bit about what I'm trying to do is be a little bit of that other voice on, you know, media forms like TikTok. Not offering any specific recommendation or medical advice,

[00:13:39] but having a platform for education to talk to people who actually know what they're talking about and don't have an ulterior motive so that you can hear what well-informed psychiatrists from around the world have to say on these issues and not just get it from the mouth of, you know, Optum, for example. Well, yeah. And I think even our field is this whole thing about empathy.

[00:14:05] I have a friend who's very much at empathy and a book on it, Jody Halpern, is that I think there's a misunderstanding of what empathy is and it's spreading. I just cringe when I hear people say empathetic. The adjective and adverb to act with empathy is empathic. And some people started saying empathetic and it's been around for a while. It's like you add extra syllables that makes the word sound better,

[00:14:29] like irregardless or dilatation or preventative instead of preventive. It makes you sound more attentive. And people, and I also confuse it with sympathy, sympathetic. But the word empathetic is so overused in the press now. And I'm hearing, even hearing some professionals use it. It is a virtue signaling saying, I am basically being sympathetic to these pathetic people. It doesn't understand what empathy. And I would recommend a lot of people read it.

[00:14:59] It's Howard's book. There's an old paper on the misuses of empathy. It's as a way of distancing from those suffering people rather than joining them and feeling it. And our health care prescribes things like vaccines and, you know, Seroquel, rather than joining people in their pain and hearing what's going on. And I think our field has become pathetic and empathetic.

[00:15:26] And our media is misunderstood and embrace this. Oh, look, I'm caring about these people, but I'm not one of them. You're absolutely right. To have true empathy, you have either walked that road, you've had that experience, or you are truly putting yourself into the mindset of... Exactly. You feel it. It's like people saying that machines can act empathetically. A machine cannot have empathy by definition.

[00:15:56] Feeling empathy, you could finish the person's sentence, but to do so would be unempathic because it'd be infantilizing. And that's what people are doing. They're trying to finish people's sentences. And that's not being empathic. That's being empathetic. Or if you're in the South, you'll hear all the time, you know, bless their heart. Exactly. That's not empathy. That is ostracizing. That is bless their heart. They have this problem.

[00:16:23] That is othering, which is what we've done to the mentally ill forever. We stick them in pig pens and in basements and in asylums and in homeless camps. We other them. You pointed out in your book and appearances that those with severe mental illness or SMI have been left behind, so to speak, by society, that we have abandoned these individuals with the

[00:16:48] abandonment of institutions, which were well-intentioned, but a lot of them poorly carried out, which has led to this boon in homelessness in the SMI population. And you and I talked a little bit before we started recording about Finland's Open Dialogue program, which works to meet people in crisis within 24 hours and daily until that crisis is resolved.

[00:17:15] They try to avoid hospitalization, decrease the use of antipsychotic medication. I think somewhere between one in three people are prescribed an antipsychotic drug. There's a lot of good in that. And, you know, President Kennedy, his last act as president signed the Community Mental Health Services Act, whatever, to set up the community mental health centers. They was then defunded, you know, after he was killed, and they were never adequately developed.

[00:17:43] What we had was set up with lesser trained clinicians who were not familiar dealing with severe mental illness, and they just couldn't serve those who were kicked out of the institutions. Today, we have 130th the number of hospital beds in this country. And we should be, you know, we don't need so many more, but we definitely need more than that. But pitting people kindly in the community with housing and services and understanding the use of peer.

[00:18:11] Our model was imported by an Italian psychiatrist back to Italy in Trieste, which is the WHO model for treating psychotic illnesses. They need very few hospitalizations. They use less medications. The people are kept in the community. They're kept housed. They're given roles. There are very few people who can't have some role in society. And that's so important to not just extrude them into homeless camps or institutions or whatever.

[00:18:40] And, you know, I think the open dialogue is one model of that. Outcomes for severe mental illness are better in most countries. I think even in rural India, outcomes are better than here. And they don't even have medicines because the people are kept in the community and valued for what they can contribute. I mean, we grow from helping others. It doesn't diminish a community to help someone with a disability. I don't know how we got that aspect that, you know, the whole NIMBY thing.

[00:19:08] I think people would feel less NIMBY if they knew that the government would take care of a house with some maybe disturbed people in their neighborhood. If they knew they weren't going to be shitting on your doorstep or yelling at you, if we took care of people, they could be kept in the community. And which would save us so much money that we wouldn't have to pay for revolving door hospitalizations or the 500,000 or more people we were paying for their prison, you know,

[00:19:37] because they can't be left in the community and they've committed, you know, pathetic crimes due to their illness and we won't treat them. This is costing us money. I think it was a couple of years ago, somebody tracked, there were 9,000 fires caused by homeless in the LA County, probably had nothing to do with the recent fire. These things cost us, you know, to have fire departments go out taking care of fires. 20% of law enforcement time in many major cities is spent dealing with mental illness.

[00:20:07] We are not saving money by not treating mental illness. We're offloading into other aspects of our society. It's just not serving us. And I would add to that, and I think you would agree, these are termed diseases or disorders for a reason, but there are some disorders that do have this other side to them where, you know, it's not just severe mental illness and I'm more referring to somebody with a mood disorder, somebody that suffers from, you know, periods where they are in more of a manic

[00:20:36] state, periods where they're in more of a depressive state or somewhere in between. And I think when you look at some of the research of folks like Kay Jamison and looking at the Poet Laureate, there's been research on professional athletes with trauma. You look at people with some severe problems mentally. Sometimes there's a flip side to that, an ability for creativity or imagination or perseverance.

[00:21:06] Very much add to society. I do want to be careful. I mean, severe mental illness is clustered and very creative and also disabled people that most people with mental illness, and there's lots of them, are just regular people. I don't be careful that, ooh, they're magic and they're dangerous and all that. No, these are regular people. But the amount of disability and drain on our society from mistreatment of mental illness is profound.

[00:21:35] They worry about the cost. It will actually end up saving us because our health insurance is so expensive and so bad in mental health care. It would save money to do that. And it also adds, if we could be a little bit more, as you were saying, permissive about what is an aberrant behavior up to a certain point. Thurgood Marshall, I think it was, said, you know, the right to swing my arm ends in someone else's nose.

[00:22:01] And if we could be count on our medical system to let people swing their arm but not hit other people's noses. But we don't. We just don't. Yeah, I want to jump on this. I read part of your book or what was available online, at least. And you mentioned a lot of the same figures that I've mentioned on this podcast that, okay, you can argue with me that, you know, we should be doing it this way or that way.

[00:22:27] But there are realities that indicate that our health care system sucks and it is absolutely failing. And I want to add some specific numbers to that. You talked about we spend twice as much on health care as any other country in the world. And yet we live four years shorter lives than most other developed nations. Can you add maybe some more numbers on top of that? Oh, you want numbers? Sure. Yeah.

[00:22:56] Let's give the people the specifics. Let's see. Here's something. A Harvard Business Review analysis found that from 1990 to 2012, the health care workforce grew by 75%. But 95% of these hires were administrative staff. Today, the ratio of doctors to other health care workers is one in 16, but only six care for patients. The other 10 are purely administrative role.

[00:23:22] Nearly every industry in the U.S., this is another study, has experienced significant improvements in productivity in the last 50 years, with one exception, health care. A typical U.S. services industry, for example, legal services, education, securities, and commodities, has approximately 0.85 administrative workers for each person in a specialized role, a lawyer, teacher, financial agent. In U.S. health care, however, there are twice as many administrative staff as physicians and nurses.

[00:23:51] The Commonwealth again rated the United States' last, the Commonwealth, last place of the developed nations. An earlier study found us 37th. That was what Sicko, the Michael Moore movie, was about. I think we tied with Azerbaijan and were head of only Albania, the most corrupt nation in Europe. We are consistently rated worst in the world in developed nations in our health.

[00:24:21] As you say, we are the only developed nation which, aside from the blip around COVID, has worsening lifespan. A young person born today has a lower life expectancy than their parents. That's the first time that has ever happened. That is crazy. That statistic is crazy. You know, we have one of five world overdose deaths, yet we comprise a little bit more than

[00:24:50] 4% of the world population. Our overdose deaths are like a quarter of magnitude greater than just about every other nation. And that's just the deaths, too. That's scraping the surface of the problem. These 125,000 people, which is probably an underestimate due to some of the factors we were talking about. Like, I know that with my origins in Southern Kentucky, there's a lot of people who don't want to say that their kid overdosed on a drug and died.

[00:25:19] They'd rather it be the car accident or the, you know, pneumonia. Well, first of all, you know, we used to spend about the same on health care as other countries until the HMO Act in 73. We now spend twice or more than most other countries. World Health Organization, who rated us back in 2000, there's 191 nations. We ranked 37th, the lowest of any developed nation, just behind Domenica, which I didn't

[00:25:47] mean it's not the same as Dominican Republicans, a tiny Caribbean country, and Costa Rica. For the last eight years now, I think the Commonwealth has rated U.S. health care dead last among 11 developed nations in quality of care, access, efficiency, and healthy lives. Yet it's the highest in cost. In 2018, Bloomberg business ranked 56 nations on their health efficiency.

[00:26:11] U.S. tied for 54th with Azerbaijan, ahead of only Bulgaria, it was the most corrupt nation in the European Union. Those Albanians are going to be pissed at you. Yeah, I know. I'm just kidding. This is the first, in recent years, the first generation to face greater infinite death, maternal mortality, and a lower life expectancy than their parents before the COVID. Also less well appreciated is that four out of five pregnancy-related deaths in the U.S.

[00:26:40] are entirely preventable. And the most common cause of these deaths are mental health conditions, suicide and overdose, not what we think of like preeclampsia or gestational diabetes. You know, this is just a horrible shame. You know, this is supposedly the greatest country in the world.

[00:26:59] That's what really gets me is hearing that message promoted, like, in this extremely, like, you know, 1920s jingoistic way. Oh, yeah. And it's like, no, we're not. The data says otherwise very, very clearly that we are not. We hear this stuff about how things are falling apart in Canada and Britain. And yeah, things are really rough in Britain.

[00:27:26] But that's because they've been strangled to death by the Tories over the last 15 years, because they're trying to get rid of the nationalized health care. The Brits in general love their health care. And yes, it is in current crisis because it's been so cut back. Again, you know, we spend like two and a half times as much with a very minor infusion. They could go back to a health care system that everyone loved. Same thing in Canada. We hear about, oh, the long legs and all that.

[00:27:54] They are so much more favorable about their system and ours. But we don't hear that. Yeah, there are problems because their costs are going up in part because often prices of things are sort of driven by the U.S. It's basically propaganda. And these countries have much better systems. And they're right there. They are right just north. You're living in Seattle.

[00:28:18] Your life expectancy is four years shorter than if you're just a little bit north of that border in Vancouver. You know, that's why we go to Canada to get our health care. And what is driving some of these statistics is mental health and substance abuse. The wealthy in our country do pretty well. It's just, you know, the deaths of desperation from people who are struggling, who can't get health care, can't get mental health care, you know, overdose deaths.

[00:28:47] If we invested a little more in mental health care, we could do a lot of catch up. I mean, 125,000 people dying is one thing. But when their average age is around 30, that's really going to drag your life expectancy down. Even more than 400,000 65-year-olds dying from COVID. Right, exactly. It's the young people dying of overdoses. 1.3% of philanthropic giving to our society goes towards mental health.

[00:29:15] People just don't want to believe it's a problem. It's embarrassing. I've certainly had experiences out with family or friends and people understanding what I do and automatically putting me in a category of being part of the problem. No, it's the courtesy stigma it's called, where public disapproval is a consequence of associating with a stigmatized person. That, you know, people, oh, you're a psychiatrist.

[00:29:41] But they're going to call me the next day or corner me at the party and talk about some problems that they or a family member has. They don't want to talk about it. But this is out of Skull's book. He's a guy at UC San Diego who studied the history of medicine. And mental illness haunts us and frightens us. Ironically, the stigma that surrounds those who exhibit a loss of reason has often extended to those who have claimed expertise in its identification and treatment.

[00:30:08] Of all the major branches of medicine, psychiatry throughout its history has been the least respected, not just by those whom it ministers, but also physicians and the public at large. You know, you're shamed by dealing with a shame population. And I think we're fighting that, too. People just don't want to deal with mental illness or they're embarrassed by people who will deal with mental illness. What was it like in your training program? Because I know my experience was, oh, those are the people going into psychiatry.

[00:30:38] They didn't do as well on the tests or they're not as smart as the they're just doing it because it's easy. I mean, all of these different. Oh, yeah. No, no. There was shame in it. Yeah. You know, there's sort of the thing that, you know, the guy in my class who really wanted to go to cardiology because his dad had just a heart attack. There is certainly when people are personally touched by something. But who hasn't been touched by mental illness? You know, a friend in med school who became an ER doc.

[00:31:07] You know, it's like my mom always told me, don't waste your time talking to crazy people, you know. And there's some wisdom that you don't want to argue with somebody who is insane. But there's a shame with somebody who would spend time, you know, ministering to those who do not have control over their inner mind. I do worry that some of the American philosophy is leaking into some of these other countries' health care systems as well. You know, countries are mattering less and less. Corporations are mattering more and more.

[00:31:36] They're just multinational. And, you know, they don't want to let another country get something for a bargain when they can get more of it, you know, in the United States. More for the United States. They won't even supply it to another country because I can get so much more here. And how our system does is that the shareholders in, I think it was Moderna or maybe it was Pfizer, voted to restrict access to the international property that produced COVID vaccines because then it could be sold cheaper in another country.

[00:32:05] This is the Crazy Like Us, Ethan Waters book. This is really an interesting book, The Last Caboo, by a psychologist, actually, Daniel Kruger. It's really fascinating about our views about money. It's old. In 1986, it predicted so much of what occurred in our health care system.

[00:32:25] That's been the most despairing aspect of doing this podcast is having either, you know, more experienced clinicians reveal it or just through doing additional research, revealing that so many of these issues have played out historically. Oh, yeah.

[00:33:10] It's predicted the cream skimming, elimination of low profit, but necessary services like mental health, exclusion of unprofitable patients and how these businesses would acquire unwarranted influence. This is what was this 20, 35 years ago? This is not new. I know. I know. I know. It's wild. Well, you keep it up. Keep fighting the good fight. I will certainly try to do the same. And like I said, try to find other avenues to do this.

[00:33:39] I mean, that was one of the more surprising parts about listening to Alan Francis is, you know, he said, no, we need to do this a different way. We need to be more vocal. He has been a real voice of reason, really good. Your question is an important one as well. How much worse was the SM5? The SM4 started a bad thing and he was well intended, but there was unintended consequences, which he hasn't really copped up to about. Yeah. Whoops. You know, there were some problems with that. Yeah.

[00:34:09] Well, I may reach out to him and see if he's willing to come on. You know, you might ask him about his thoughts about, you know, how the DSM that he worked so hard on, he feels it's been co-opted by bad influence. You know, did mistakenly DSM4 sort of go down that path a little bit more? Right. Because I think like anybody else with a functioning brain that, you know, we have this mind, we have this conscious part that kind of seem at odds with each other.

[00:34:36] My mind wants to categorize him in that, you know, good or bad way. But obviously everybody is so much more complex than that. Oh, yeah. No, I think he's a very smart, very well intended guy who has a lot of good things to say. Yeah. But whether somehow his efforts got co-opted, you know, you can put it that way that he got misapplied. When I was in residency, it was shameful to have somebody have an ad in the yellow pages of psychiatrists.

[00:35:04] The idea of publicity and going in public or podcasts and all this is so new to me. I'm just learning. Well, and I felt in a sense silenced in my own training program. Like, no, you can't say that. I mean, this is the same time where I was, if I was to finish training and get my residency certification, I had to get COVID vaccines.

[00:35:27] And, you know, I was mandated to do so as I'm sitting in the, working in the ER and my attendings are at home and I'm the one carrying around a video monitor so they can sign off on the notes. And I'm like, this doesn't seem right. But, you know, it is what it is. We jump through the hoops that we got to jump through. The problem is when we're not, I mean, I was doing internal medicine in the hospital in L.A. during, we didn't know what caused AIDS. You know, we didn't yet have HIV.

[00:35:56] It was HCLV3 and then it was HIV. And, you know, somebody needed CPR, you know. I mean, you were in the trenches and up all night, but everybody was, you know. The burnout is when you're feeling you're having to do things that are worthless and you're not part of a team, I think. We live in a world now where the amount of information that we're aware of is just exponentially overwhelming every day.

[00:36:22] I mean, I just saw that Congress and I know California Attorney General are now interviewing doctors who used to work for United about how they were directed about the kind of care they could give and how they could bill. So that things are happening. And in California, we have the care court, which is really well intended and all that stuff. But we don't just don't have the resources. And I don't know how we're going to fund. We are going to need some more hospital beds.

[00:36:51] The reason that we hospitalize people is because they're going to kill somebody or themselves. It's criminality is what gets people in the hospital. Having some resources that at least you could do some sort of sheltering of people who are just very, very ill. I mean, whether we're going to start paying for it, you know, I don't know. We certainly need to be more efficient with our resources. And I think it's only going to happen because it's like whack-a-mole with all these different players in the health care system.

[00:37:17] You just can't control them all is having a single system that mandates what will and won't be treated and how much it gets paid. I just don't see any way around it, despite my frustration with our government. You know, with the Medicare Advantage stuff and United basically sending people out calling patients and saying, hey, we will come to your house. We just want to make sure you're doing okay. And we'll do an evaluation.

[00:37:44] My understanding is the EMR itself that they were working with were tailored to shuttle the provider to a certain diagnosis. There was a lot more work. It was easier to check off these diagnoses. You had to exclude things. I think it was Practice Fusion, Purdue, the opiate manufacturer, used to put pain questions in Practice Fusion, which they would give to physicians free. So you had to click through to opt out of offering pain meds.

[00:38:14] It's just crazy. Yeah. So it got me wondering with Medicare Advantage. I'm like, well, Medicare Advantage has said that they've audited these companies and they don't see any wrongdoing. For a little while, I'm like, that's confusing. It's pretty obvious that when you have one company whose HIV treatment rate is 30 percent, but every other smaller insurer, their HIV treatment rates are 90 percent because it's a public health crisis. Right. To have untreated it. And then it dawned on me.

[00:38:43] Well, who's paying? Yeah. Oh, that's right. I'm paying. You're paying. The American taxpayer dollars are paying. And Medicare Advantage, it just makes you wonder, OK, so there's some back alley deals going on. Oh, yeah. That $50 billion is essentially being taken out of our pocket and being used to line the pockets of executives. Why do we want to have these middlemen? That's, you know, it's just certain. It doesn't serve us.

[00:39:13] Now, these people are just pulling money out of the middle and they get money by restricting care and billing more. Their incentives are not aligned with whatever. The sign if I've ever seen one. Yeah. That was the sign if I've ever seen one. We're in a standoff here with the system, right? Well, yeah. I quote Upton Sinclair, who said, it's hard to make a man understand something when his income depends on him not understanding it.

[00:39:39] What are you going to do something like 14 percent of our population is working in the health care industry? And if more than half of them aren't needed, but we could retrain them to actually do something good. Deliver care, not obstruct care. Yeah. The hardest part is that it's going to be destabilizing in the short term, but it needs to be destabilized in order for the long term. Actual progress in what we're doing. I think we can grow Medicaid and Medicare so they can meet in the middle eventually.

[00:40:09] And some people will pay different. I don't think we should try to have a different system, but some people will want to pay for their Cadillac care and concierge. But, you know, by lowering Medicare age and raising Medicaid age and requirements, we can sort of eventually evolve towards the system. And we'll give people the time to modify what they do from blocking care to supporting care. Yeah, absolutely.

[00:40:38] Somebody get this guy some help. Thanks again for watching and or listening. If you're passionate about the subjects that I discuss on the channel, do me a favor and like, comment, subscribe. Do whatever you can to make your voice heard that these are problems that must be addressed in our society.

[00:41:08] If you have any questions, comments, or concerns, I want to hear them. Feel free to reach out on social media or email us at renegadesyke at gmail.com. And if you'd like to be a guest of the show or you have a connection to somebody that you think would be a good guest, let us know. Thanks again for listening.