0:00
Science is not political. Medicine is not political. We want to seek truth. We want answers, and we want to take care of patients. Unfortunately, it's become the opposite. Welcome

0:17
to off the chart a business of medicine podcast featuring lively and informative conversations with health care experts, opinion leaders and practicing physicians about the challenges facing doctors and medical practices. My name is Austin Latrell. I'm the Assistant Editor of medical economics, and I'd like to thank you for joining us today. In today's episode medical economics, senior editor Richard Pearson sat down with American College of Physicians president, Dr Jason Goldman. They cover a lot of ground, but primarily focused on a challenge that every physician is physician is facing right now, that's misinformation. Dr Goldman talks about how patients are arriving with doubts, the politicization of vaccines, and how hard it is to restore trust when rumors outpace evidence. He also touches on some of the bigger pressures on primary care, like shrinking reimbursements and administrative burdens like prior authorization. Dr Goldman, thank you so much for joining us. Let's get into the episode. Into the episode.

1:07
Dr Goldman, thank you for joining

1:08
us today. Thank you so much for having me. One of the

1:12
issues that we're going to talk about today is kind of the current atmosphere, or maybe some of the attitudes surrounding medicine and science, there's been a lot of skepticism. There's been misinformation out there. In your own words, how would you describe the current state of trust in medicine in the United States? And do you feel like science may be under attack?

1:35
Well, that's an excellent question. And if I could use one word, I would say polarized. It shouldn't be that way. Science is not political. Medicine is not political. You know, we want to seek truth, we want answers, and we want to take care of patients. Unfortunately, it's become the opposite. It's become polarized. People have gone to their echo chambers. They don't know where to get information from, and it's really impacting the way we're able to take care of our patients. It's impacting the way we deliver healthcare, and it affects all of us, because especially with vaccines, which I'm sure we'll talk about later, it can affect the health of not only the individual, but society in and of itself.

2:17
You had mentioned about vaccines, and we can jump down to a question that I had regarding the Advisory Committee on Immunization Practices during that September meeting. You said that you'd be willing to debate with members about vaccine studies and what the results show about safety and efficacy. What topics would you like to debate with them about?

2:38
That's a good question. I'd like them to actually bring up real science, real evidence, real studies, so we can actually have a discussion. You know, the reason why I said the willingness to debate is because the day before the chairman of the committee made a point in his intro to say that when there's conflicting information, the only people you can trust or those willing to engage in discussion and debate. So I used his own words against him, and said, I'm willing to debate and discuss with you so the public can trust me. The biggest issue I have right now with the advisor with Secretary Kennedy's Advisory Committee, is they're not using any rational evidence to recommend framework. They're not using the standard practices that we've always done to come up with good recommendations. What they are doing is presenting conspiracy theories half researched or flawed studies that support their theory. They're not backing up any of their claims, but just creating more confusion and innuendo. What I would discuss with them is, let's go back to basics, and let's look at the benefits and harms. Let's look at the facts behind the intervention. Is it a value to the population? Is it feasible to implement? Is it acceptable to the population, what is the benefits to equity and resource use? That's the basic evidence to recommend framework. And then we can start there. So when they bring up, you know, all of these harms, or perceived harms, we look at that too normally when we evaluate any information, but what they're not bringing up is, what is the benefits? How are these decisions going to affect the population? And that's really key in any discussion of public health. It's not just pointing out what you think is a problem or a harm, but what are the risks and benefits, and what are the benefits of that intervention? And they're failing to do that.

4:43
And a few minutes ago, you had used the word polarized, and another word I had written down was politicized. As a physician who has counseled by now probably 1000s of people on vaccines, how does it feel to see the concept of immunization politicized?

4:59
So it. Is absolutely devastating to public health and to way we practice that we are seeing such a politicization and polarization of even vaccines. The two greatest advances in public health are sanitation and vaccination, because that has really allowed us as a society and a civilization to advance by getting rid of or preventing basic, harmful diseases. You know, we look at the bubonic plague, if we didn't get sanitation under control and fleas and rats and learn how diseases were spread, we would still be dealing with the plague. If we didn't have measles vaccination, more people would get sick for measles. Unfortunately, we're starting to see that outbreaks continue because people aren't getting vaccinated. And what is really troubling to me, and what I'm seeing when my patients come in, even patients who previously had no problem with vaccines, are now confused and there's doubt, and what Secretary Candy's vaccine committee is doing is creating confusion and doubt where none need to exist. You know, if we know that the world is round, and people keep saying the world is flat, and we show them evidence to the contrary, but they create that confusion, and people keep being unsure of the reality, then it creates that confusion. And so when they come into the office and like, Well, I'm not sure anymore, so now I have to spend more time not just counseling them on what is good for them and their risk and benefit and why they should get vaccinated, but we have to go all the way back to basics, as to what is even basic science. And so the foundation of those discussions have been pulled out because of the confusion created, and that is so harmful, because patients need their vaccines that will help protect them from getting very sick ending up in the hospital, and instead of being able to have that discussion and move on to other things, we are just mired in this confusing disinformation cycle where they don't trust any of the sources of where they're getting their information. You know, what

7:21
doctor it's a great segue, because, frankly, I wanted to ask a little bit about some really practical effects, and we're going to get to the exam room in just a second. But one thing you got me thinking about here was not just necessarily theoretical debate or discussion, whether it be in Washington, DC or at medical practices around the country, but the practical effect of availability, and I just didn't know if you had come across anything yet, that is indicating that the that confusion and the debate is actually leading to lesser amounts of vaccine going out to doctors offices and pharmacies.

7:58
So it's twofold. One, there's the delivery of vaccines, and two, there's the uptake, so the access to care versus the patients accepting that's when you get into the resources, as well as the acceptability of a public health intervention. And I'm seeing it in both ways. So as far as vaccine delivery supply, you know, I've still been able to order all my vaccines. I've still been able to get access to, you know, the pneumonia, flu, shingles, etc, covid in Florida has always been difficult, especially when you have a surgeon general who's telling people not to get an mRNA vaccine, which, quite frankly, is is horrifying to me that a physician is doing this because the mRNA vaccine, the platform of messenger RNA, has been around for decades. That's not new technology. The application to a vaccination is, of course, what helped get us out of the pandemic, but to blanket statement that it's harmful is really irresponsible. So what I'm seeing for my patients having access to the covid vaccine has become more difficult. I have patients who are 65 and up, which clearly is an indication as well as there are other indications scientifically, but pharmacies are requiring them to get prescriptions, which creates further barriers to care, because they have to have a physician, they have to get a prescription, they then have to go to the pharmacy with the prescription, as opposed to being able to just go and get their vaccine. So that creates barriers, that decreases the availability. And when we look at the uptake, we have the issue of patients who are again unsure of what they should be taking, so they are now resistant or hesitant to wanting to accept these vaccines, when even previously they had accepted them. I had a patient today who was a little confused, but he said I tried. Trust you. You are my doctor, and what I'm seeing in the real world is patients are trusting. Fortunately, many of them still trust their personal physician, even though they're getting all of this noise outside the office. So it's really incumbent upon us, especially as internal medicine specialists, to really understand the science, counsel our patients appropriately, correctly, avoid all of this rhetoric and noise outside the exam room and continue to do what's best for the patients, to make sure they have the best information possible.

10:36
Many primary care physicians now find themselves on the front lines of medical misinformation. What communication strategies do you believe are the most effective for physicians and other clinicians in countering vaccine misinformation and other medical misinformation?

10:53
I wish I had that answer and in a tight, complete playbook, unfortunately, I don't think there is one right answer. I've tried every strategy, and I really have to tailor it to the patient. You know, sometimes what has worked is taking a step back and saying, Okay, what are your concerns? You know, you don't want this vaccine or intervention or for anything, medication, whatever it is. Why? What is it that you are worried about? Sometimes it's simple. It's, I have a event this weekend. I don't want it to take the chance of getting a fever. Can I do it next week? Okay, fine, that's an easy one. But sometimes it's, I'm not sure what is the benefit? Why should I get it? Or I heard that it will cause all of these problems. And then you educate the patient. You go through point by point and say, you know those are you validate. You know those are valid concerns. I understand why you're concerned, but here's the science, here's the data, here's why it doesn't cause the issues you're worried about for these reasons. Here's why it is beneficial and why you should take it. You know, that's how it's supposed to be. You know, where they have questions, we answer them, we have a discussion. The hard part is when it goes beyond that, and it's we heard in the news, we saw this, or our political leaders are telling us that, why should we trust you over them? That's the challenging one. When it comes down, not to, let's discuss the science, but who do we even trust? You know, and you can start with, well, you've been my patient for 510, years. I hope you can trust me, or else, why would you be here in the exam room? You know you've trusted me for your heart disease, your diabetes, your families come in. You know, you've trusted me for all of this. Why on this one issue, do you now not trust me? So you try and turn it around and say, Okay, you brought up these concerns. Have you looked at the source? Where is that information coming from? Why do you trust them? What is your analysis of their recommendations and why, and you get them to try and question, but unfortunately, there are some patients who are so resistant, and people in general, they're so resistant to even having the discussion, that it becomes a lost Cause, unfortunately, and those are the most challenging ones that I still have not figured out how to reach, because they have preconceived notions. And nothing you tell them will change that you know

13:31
what doctrine I don't want to belabor this point, but you you really got me thinking about when you use that phrase, lost cause, because you know, I'm trying to articulate this here, hopefully, but this can involve a matter of personal choice. But I guess where I'm going with this. I wanted to ask about especially young parents of young children. You know, then it becomes a matter of choice that involves not only the parent but another person. I mean, even if that person is a baby who is not able to make a rational decision for themselves through the course of your experience and practice. I mean, have you encountered any families who've had to deal with preventable diseases because they were reluctant about vaccines?

14:14
I've had to deal with that all the time. I mean, I'm primary care internal medicine specialist. We deal with everything from the complex, comprehensive, compassionate care of the patient, preventative health, prevention of disease, screenings, that's what we do. I've had patients, especially during the pandemic, where a family member refused to get vaccinated and brought covid home to the rest of the household, and some of the family members got very sick, and one of them even passed away from complications of covid that could have been prevented. And then, of course, the response we always get from naysayers is, well, it's your choice if you want to get vaccinated. Go ahead and get vaccinated, leave us out of it, and it shows a lack of understanding of how vaccines work and what we're trying to accomplish, and it to be completely, you know, critical, open minded, reflective. During the pandemic, there was poor communication, but it was on both sides, and I feel that we did not have good, effective communication to really get the public to understand number one, but number two, the public also didn't necessarily want to receive the information. So coming back to how vaccines work and why it's so important that we understand this to protect ourselves and our family. A vaccine is not a shield. It's not a force field. It doesn't repel infection. Our immune systems are magnificent, amazing things where, if you get exposed to anything from a pneumonia to a bacteria to a virus to a flu to whatever, your immune system immediately looks at it says, This doesn't belong here. How do we handle it? And then it tries to generate a response to be able to get your body healthy, fight off the infection, get rid of it. If it's never seen it before, it's trying to learn as it goes, to get rid of that infection. And sometimes the infection is smarter, more effective, and kills the patient before it has a chance. The body has a chance to fight it off. If you give a vaccine, if you give a marker, a tag, something that the body can recognize that's not going to hurt it, because, you know, vac, majority of our vaccines are not living so when you get this marker that recognizes and identifies, this is a covid virus, this is a flu virus. This is a streptococcal pneumonia, bacteria, whatever that tag or marker is, the body takes it in says, I'm going to catalog this. I'm going to recognize this in the future. So if I see it again, I'll be able to have a very quick response to get rid of it. So when you inhale a virus, flu, covid, etc, those cells in your body, in the immune system, will recognize that tag and then release its defense as quickly as possible. So instead of the virus getting inhaled all the way into the lungs and spread through the rest of the body that can cause serious hospitalization and death, it can stop it there in the nose and get it neutralized before it infects the rest of the body, but you're still carrying that virus. So if you bring it home, and viruses have different incubation periods from infection until initial infection till full effect, and you may be spreading that so the faster you neutralize it, the less chance you have of spreading it to other people, which is why it's so important to both protect yourself as well as others, because we're assuming everyone has a perfect immune system. But what about the elderly, those with comorbid conditions, those who are immune compromised for many reasons, an immune system doesn't work. You know, at the end of the day, we all live on this planet together. We're all part of the same humanity. We need to be our brothers and sisters keepers, if you will. We need to take care of ourselves, but also take care of other people, and part of that is making sure that we're healthy and we keep others healthy. And that's why it's so important for the vaccines to be used. So to answer the original question, yes, I've had families where the parents don't want their kids vaccinated. The kids get sick. It infects the grandparents, other people are affected by it, and not everyone fully recognizes how the vaccines are going to or how the diseases in the unvaccinated are going to progress. You may have measles now, you may recover, but in the number of years, you get an encephalitis and your brain melts. You know, you get polio. You know, we don't have we got rid of the polio virus years ago through vaccination, but people forgot that you ended up on a ventilator or paralyzed or died from it. So you know, the luxury of being anti vaccine in a day and age where vaccination has gotten rid of the diseases that were affecting us is quite ironic, and that's where we are today. But why it's so important that people realize the effectiveness of the vaccine.

19:43
You know, doctor, we've talked a lot about vaccines, and we can continue that conversation, but I did want to touch on at least a couple other things, because lately, in the news, especially from federal leadership, there had been an association between vaccines and autism, or at least looking for a connection. And as well as discussion about potential dangers of pregnant women taking taking Tylenol acetaminophen during pregnancy, and potential effects on the unborn child and then effects on the child later in life. And have you encountered any patients who've had questions about those, or have you spoken to any doctors who have

20:23
of course, I mean everything that seems to be coming out of the news today is speculation, hyperbole, innuendo, conspiracy theory, without data or evidence to back it up. But because it's being put out there, it starting to get traction, and that creates more confusion. As scientists, as physicians, we always have the right and obligation to question. That's what we do. We question. We have a hypothesis. We look for an answer, but once we have discovered that answer, and it does or does not prove our theory, we move on to something else because it is not helpful to the patients, to the public, to our physicians, to our scientists, to keep trying to prove something that we've already proven doesn't happen. And when you look at Tylenol and autism, just as a historical note, in 1943 was the first confirmed diagnosis of autism. Tylenol wasn't widespread use until 1955 so if Tylenol was causing autism, how did it create autism before it was even generally used in the population? If we had so much autism, increased, yet vaccination increased dramatically more. Why didn't we see an equivalent rise in autism rates? We haven't. You know we're getting better at diagnosing it, better at identifying it. We know that there are many factors, genetic, environmental and otherwise, that may contribute to autism. We've looked at vaccination, we've looked at thimerosal, we've looked at all of these substances, and the evidence just isn't there to prove it. So I would challenge our federal leaders, instead of wasting time, energy, money, resources, on trying to prove something that we've already looked at, why not use those federal health care dollars to find the actual cause to do good research, to stop gutting programs that do research, to allow the NIH and other organizations which are dedicated research to properly function without being stripped of all their resources and allow us to find the correct answers instead of pushing political answers. And that's really the key. We want answers, not politics.

22:53
Any any additional thoughts, maybe anything I didn't ask about regarding medical misinformation and a war on science that you'd like to share.

23:00
The problem is, people are living in an echo chamber. You know, they are only going to sources of information that they want, as opposed to looking to all sources of information. You know, I had a patient who came in and was talking about, again, you know, vaccines being the top of of the conspiracy theories, but saying how all and but this applies to misinformation in general. You know, all of these people are saying this is what's wrong, and so I challenge them. I said, Well, did you go to the actual meeting? Did you look at the publicly broadcasted, transparent, available meeting where all this was discussed? The answer was no. It said, so you're using third hand information from sources without questioning their agenda, or while they're giving you the information, instead of actually researching it yourself and looking at the source. And I was at that meeting, so I can tell you what was said. So it's twofold, and this goes back to I referenced before about the communication on both sides. The communication wasn't given clearly, but the public also wasn't putting forth their effort to find the information. They were only going down the rabbit hole of information that they wanted, and that's just as dangerous, because we need people need to be critical thinkers, people need to take a step back and say, Who is giving me this information? Why are they giving me this information? How does this information affect me, and what is the veracity or truth of that information? And always go to the source, and that's not what's being done. And so what we're seeing is people just believing what they hear on their news or from their political leaders or from friends or from social media, and they're not looking at the actual source or data to make their own decision. And that's creates compounds the problem even further you. Keith,

25:04
hey there. Keith Reynolds here and welcome to the p2 management minute in just 60 seconds, we deliver proven, real world tactics you can plug into your practice today, whether that means speeding up check in, lifting staff morale or nudging patient satisfaction north. No theory, no fluff, just the kind of guidance that fits between appointments and moves the needle before lunch. But the best ideas don't all come from our newsroom. They come from you got a clever workflow, hack an employee engagement win, or a lesson learned the hard way. I want to feature it. Shoot me an email at K Reynolds at mjh life sciences.com with your topic, a quick outline or even a smartphone clip. We'll handle the rest and get your insights in front of your peers nationwide. Let's make every minute count together. Thanks for watching, and I'll see you in the next p2 management minute,

25:55
you're a physician who has worked in private practice. What do you feel are the greatest challenges for private practice physicians right now,

26:03
you know, I've been a solo, independent private medical practice physician on my own practice over 25 years. I've worked in a hospital initially in my career, and then opened up my own practice for close to 25 years. One of the biggest challenges is honestly the government regulations and in how healthcare is seen, the reimbursement rates have not been increased in over 30 years. We're still getting paid when you account for inflation, essentially 1990s rates. And it's not even about making money. It's about keeping the doors open, paying my staff being able to see my patients. They the health system has created such a cumbersome, burdensome, administratively latent amount of paperwork and hurdles to overcome that you need to hire staff just to understand the administrative regulations without even understanding how to take care of patients. So there's all of this waste that we have to deal with in dealing with different insurance companies, with government regulations and fee schedules before we even take care of the patient. Some estimates are 50, 60% are all administrative burden. Less than 4% of the health care dollar goes to primary care physicians. Yet we're constantly being cut every single year automatically, the government has created budget neutrality, where, if they increase payment to one specialty, they decrease it to others, which is inherently unjust and unfair. Yet we're the ones who are having all of the burden without any of the recourse. And if this continues, we're not going to have physicians left to take care of patients. The National Academy of Science engineering and medicine report showed that investment in primary care reduces hospitalization, promotes life, and is a investment in public good. So as an internal medicine specialist, we are actually making a healthier population, but all of these regulations and payment issues are preventing us from doing what we're meant to do, which is simply take care of the patients and make them healthier.

28:28
One of the things that you know, I've we've encountered just medical economics, you know, among our audience constantly, it deals with prior authorization, and the administration has announced an initiative with insurance companies to streamline the prior authorization process. Have you seen any noticeable changes so far, and what would you like to see done to improve that?

28:53
I'm certainly hopeful that the administration will tackle these issues. Prior authorizations are one of the many problems we face, especially in primary care. As physicians, we know what's best for our patients. We take care of them. If we believe a medication works, we should be able to prescribe it, the patient should be able to take it, and we shouldn't have to go through a series of medications that we know won't work just to go through the hoops that the insurance companies create in order to get to the place where we know what works, we should be reimbursed fairly and equitably for the work that we do, and we should have less of the insurance companies being able to have their retroactive denials. I don't know any other field, any other service where you perform a service, you get paid for it, and then a year later, they can just take the money back and said, we changed our mind, even though they paid originally. I don't know any other field where you can perform a service at an agreed upon rate, and they turn a. Around and say we're just not going to pay you that, and we're going to lower it, or come up with rules and change their policies without warning or notice, to say we're just not paying you for the work that you've done. I haven't seen any improvement. I've seen it getting much worse. I see the insurance companies, at least here in in Florida, continue to cut reimbursements, to not negotiate with physicians at all, to take money back arbitrarily and change the rules without notice in how we get reimbursed. So I am hopeful that the administration will fix some of these egregious problems that have been created through the insurance issues. I have not seen it yet, but hope springs eternal. I'll tell you what

30:53
doctor I'm going to switch veins for a second here, because this has been something that even in our own coverage, we've we've kind of gone from referencing the projected physician shortage to just saying, No, we're there is a physician shortage. And given that there is a shortage of physicians in many parts of the country, patients need care. What reforms would you like to see to medical education in our country, to increase the number of physicians?

31:19
It has always been a challenge in getting physicians into the areas we need them, especially when you look at all the challenges we face, the dwindling reimbursements, the administrative burden. We need more physicians. More specifically, we need more primary care physicians. What we need to see is an investment in primary care. We need to do away with budget neutrality. We need to reform how we are reimbursed. We need to make sure there is incentive for people to go into primary care when medical school debt is greater than the cost of a first house for many people, and then they go into diminished reimbursement, and you might be going into a field that could take you 20 years to get out of debt before even considering buying a house or starting a life, and you've already delayed getting into the workforce by going through residency and further training, there is an incentive now for people to go into high paying specialty fields and not primary care. We need to invest in a primary care infrastructure, when you consider that, and many people don't realize, after you graduate high school, then most people will go to four years of college, four years of med school, three years or more of residency, and then even 234, years of a specialty, before you are able to start opening up on your own. You're now looking at after graduating college anywhere from seven to 15 years before you're essentially in the workforce compared to others who go to college and get a high paying job. So there's little incentive to get the best, to get people to go into primary care under the current infrastructure. And that doesn't just hurt the physician workforce, it hurts their patients, because they don't have access to the care that they need. Then the patients get sicker because they don't have preventative care, they end up in the hospital. That increases the cost of healthcare, because hospitalization is more expensive and you have a sicker population, so investing on the front end will pay dividends down the road in a healthier, lower cost to the system, better population, with less drain on the health care dollar, and a healthier population.

33:53
One question I always like to ask our main audience is primary care physicians. What would you like to say to them? Or what would you like them to know

34:01
well for all of my primary care colleagues, especially those who are internal medicine specialists, I hope they're all members of the American College of Physicians, but we represent over 160,000 internal medicine specialists throughout the world. We are there advocating for the patients, for the practice of medicine. We are all in this together. You know, the more of us who are on the front lines, the more of us taking care of patients, the healthier the population will be. I want my colleagues to know that it Yes. We are all aware of the struggle. We know how hard it is. I myself am in primary care my solo practice, so I know the struggles of running that practice, but there is hope. There are people who are fighting to try and make sure we have a healthier, more equitable health care system and population, and we will continue to do so for the betterment of our patients and the population.

34:56
I'm Richard payer chin reporting for medical economics, my guest today has. Been Dr Jason Goldman, the president of the American College of Physicians. Dr Goldman, has been a great conversation. Thank you so much for your time.

35:08
Thank you so much for having me happy to do so. Once

35:13
again, that was a conversation between medical economics senior editor Richard pearton and Dr Jason Goldman, the president of the American College of Physicians. My name is Austin Latrell, and on behalf of the medical economics and physicians practice teams, I'd like to thank you for listening to the show and ask that you please subscribe so you don't miss the next episode. Be sure to check back on Monday and Thursday mornings for the latest conversations with experts, sharing strategies, stories and solutions for your practice. You can find us by searching off the chart wherever you get your podcasts. Also, if you'd like the best stories that medical economics and physicians practice published delivered straight to your email six days of the week, subscribe to our newsletters at medical economics.com and physicians practice.com off the chart, a business of medicine podcast is executive produced by Chris mazzolini and Keith Reynolds and produced by also the trail. Medical economics and physicians practice are both members of the mjh life sciences, family, thank you.