Hey everyone, Dr. Z.
Welcome to The ZDoggMD Show.
Marty Makary, Dr. Marty Makary,
is a Professor of Surgery
at the Johns Hopkins.
We're gonna call it, what up, Marty,
the Johns Hopkins, and
author of "Unaccountable"
and "The Price We Pay".
You're all over the news.
You're like the talking
head for the COVID,
that I actually trust.
And we're just gonna talk
about stuff and things.
What are we talkin' about, Marty?
Welcome to the show.
Welcome back to the show.
- Good to see a Z, I missed ya.
And we have not been reunited
in person during COVID-19.
It's, I've thought
about breaking protocol,
just to come out there and see ya.
- You know what?
I wear a mask made of lace.
It's a placebo mask and I'm,
I'm part of a trial where,
we think I'm wearing a mask,
but it's really placebo,
and then someone else is wearing an N95.
So if you wanna be part of that study,
that N-of-2, please come on
down and see me in the Bay area.
There's not much COVID up here.
- Well, I wear a mask,
and a gaitor, and an N95,
and a face shield, and
an orthopedic space suit.
(laughing)
- Well, if you believe,
if you believe the press misrepresentation
of the gaitor data, gaitor-date,
the gaitor actually
negates all the effects
of the other masks, and
actually makes everything worse.
So by just, by putting that
one layer of gaitor fabric,
you're pretty much killing grandma.
So I just wanted you to know that.
- I, it's funny, I've
been wearing a mask most
of my adult life, and
then for some reason,
all of a sudden, right now,
I don't enjoy wearing a mask in public.
It does not make sense.
- What? Okay, tell me if this is crazy.
I felt the weirdest I've ever
felt first putting a mask
on those months ago,
when people were talking
about masking up, and I go into Safeway,
our local grocery store, whatever,
with the mask on, I feel like
everyone's looking at me.
I have this deep sense of shame.
And I almost feel like it's
worse because we're doctors.
We're not, we, we would never,
it's like the kind of like,
dude that goes and wears
his scrubs out in public.
Like, yeah, these are
OR scrubs, and you know,
you're like, "O...R they?"
Right, I mean, like from
the movie, "Rushmore",
it's just, it's, it's obnoxious.
And so I always had this
weird sense of shame masking.
And now it's like, culturally,
especially in the Bay area,
if you don't wear a mask,
you feel like you're naked.
Like, like someone's gonna call the cops.
Do you have that in D.C.?
- I've heard, I've heard people can be,
accost others who are not
wearing a mask on the street,
but I think most people are,
are reasonable about it now,
and most people are wearing masks.
And it took a long time for
everybody to get religion.
I think it took everybody knowing somebody
who got really sick or, you
know, a loved one or something.
Did you see Chris Chen got
COVID-19 and he survived,
but I think he was in like, in the ICU,
and he was sick and had trouble breathing.
He wrote about it in "STAT" news.
- Chris Chen of "Chen Med"?
- Yeah, Chris Chen of "Chen
Med", the CEO of "Chen Med".
- I didn't hear that.
Is he, is he older?
Like older than 60?
- 44.
- What? He was in the,
in the, in the hospital?
- Yeah, this is like
really starting to hit home
for you and me, right?
I mean, 44, total picture of health.
I mean the guy, I think he
played college football.
He's in great shape, right?
The absolute, last person
you'd ever think has
metabolic syndrome.
I don't think, I mean, he
basically said he's healthy
in the article, and a really good article
in "STAT" by Chris Chen.
I mean talk about, you know, hitting home.
I mean, here was a guy who basically said,
"I know every beep in the ICU, you know,
I've worked in the ICU for many years,
and all of a sudden,
those beeps were for me."
And a really good article,
really incredible humility,
humility, not just with him,
but that entire organization.
- I will have to check
it out, and you know,
"Chen Med" is one of
those orgs that's like,
"Iora" like "Turntable", like, you know,
this kind of direct primary care model.
And so it kinda hits
home, but you're right,
it's like, you have to
know somebody, right?
If you're like, in a town where
there's not a lot of cases,
it's natural human impulse
to say, "Well, I'm not,
I don't wanna put a mask on.
Why would I do that?
That's crazy talk."
And it takes time for this thing
to surge through different communities.
You know, what's going on?
Have you been to New York recently or no?
- Yeah, I went to New York once.
It was about 30% of the
normal foot traffic,
and maybe 20% of the
normal street traffic.
So it was very strange.
Maybe a quarter of the
businesses are shuttered up,
either went out of business,
or just closed for the time being.
Restaurants were only
seating people outdoors,
when I was there, you
know, it's a little sad.
I mean, how many people do you
know who have basically said,
"I've moved out of New York,
and I'm really never
planning to move back."
- Yeah. Yeah, and it happened
in San Francisco, too.
They're all moving out to the suburbs,
and driving up my real
estate costs, which is good,
'cause now's the time to sell, Marty.
- Well, the real estate agents say
that having a Zoom room is
now part of the conversation.
- Oh my gosh, oh my gosh.
You know, it's kinda funny.
That's what I have here.
This is my Zoom room.
It's like a safe room.
Like, you know, there's a code to get in.
You know, it's separate from the family.
It's a huge asset now, actually.
Maybe we should design like,
a plug and play Zoom room
for doctors to have tele-health
visits with their patients,
that doesn't involve like,
a cat or a baby showing up
and smearing feces.
- This is my Zoom room, my office,
my call room, and my minor procedure room.
(laughing)
- Oh man, so how are, as a surgeon,
you specialize in pancreas, right?
Like how, how are you, do
you do a lot of tele-health?
I imagine just for followups,
or how's that working for you?
- Our hospital is doing some tele-health.
I think, you know, with,
in my particular area
of surgical oncology,
and what I'm doing now,
which is kind of focusing on
the pancreas islet transplant,
auto transplant procedure,
we were kind of, I guess,
shut down for a little bit for COVID,
and recently sort of started back up.
So things are good.
You know, the hospital's
quiet, it's strange.
I kinda miss the community,
to be honest with you.
Like, even the support staff
that are working from home.
I'm ready for this thing to be over.
- Yeah, I think all of us are.
You know, I, I did a rant
that I haven't released,
basically saying, "I'm
really tired of this.
I think that there's a lot of
catastrophizing that happens
where people think it's
never gonna be over,
where they're extrapolating
the current situation
to the rest of their lives
and they're losing hope."
And I think that's simply not true.
If you look at past pandemics, you know,
you get through it, you get over it.
And I actually think that
we will attain a vaccine,
plus or minus some community immunity,
plus or minus there's innate immunity,
plus or minus improvements in treatments,
but we have to science the crap out of it,
and get through it, and stop, you know,
this doom and gloom, like
we're, we're over it.
And I think, you know,
we need to open up and do, do it wisely.
Use the things we've learned.
You know, I think these blunt
instruments of lockdowns now,
so late in the game,
don't don't make sense,
but what do you think?
- I mean, they closed beaches, I think in,
are beaches still closed in California?
I mean, you talk about the
safest place in the world.
It's gotta be a beach, right?
I mean, you know,
ventilation, like, you know,
you could never design, right?
A nice sea breeze.
You've got an open area.
You're outdoors, UV
light pounding on people.
I mean, closing beaches made,
never made any sense to me.
I mean, I guess if
people are all, you know,
group hugging at a beach.
You can't have too many
people close to each other,
but I don't get the closing beaches part.
- I don't get closing beaches.
I don't get compelling
people to wear masks
on outdoor trail systems,
because that's what they make us do.
I'm like, "Really?"
Oh, well you might pass
close to an old person.
We'll watch what happens.
People turn away.
They cover their mouth when
they're passing other people.
This is like, you know,
nanny state gone insane
at some point, right?
You just go, "Why, why
where's the data for this?"
- Well, that is, you know,
that is not the primary vehicle of spread.
Our battle is not giving the,
spreading the infection
on hiking trails, right?
That is, is gotta be, you know, one,
one millionth of the number of cases.
Actually, they did a study in,
in Asia that looked at
super spreading events,
and out of all super spreading events,
I think out of 31, two were outdoors.
And so the reality is that
this is primarily now,
something where the science has caught up,
and we have to evolve
our strategy to recognize
that it's poor ventilation,
primarily driven indoors,
in people that are exhaling
for some prolonged period of time,
and it's proportional to
the amount that you exhale.
If you're singing, you know,
karaoke bars in Japan were associated
with a very high rate of
super spreading, right?
It's a lot of loud, micro-droplet,
over a prolonged period of time indoors.
So I think we're learning.
The question is, can our,
our healthcare system learn as fast
as we're learning from observations?
- And that's the question, right,
because we are, again, our
knowledge base is expanding.
We're like, okay, this whole
idea of stay inside is crazy.
Get out, stop discouraging
people from going outside
by forcing them to wear a mask
when they walk on a trail,
or not go to a beach.
And it's, and again,
this is nobody's fault,
because they just didn't know,
but now we know, so now it is their fault,
if they're still doing this,
but getting back to the healthcare system,
and this is kinda your specialty.
What's going on?
We were totally unprepared
for this disaster.
I mean, what happened here?
- Well, I think our healthcare
system was not set up
for emergencies, and never was
set up for a health crisis.
And I'm not just talking
a virus health crisis.
You could argue the
same for an earthquake,
a mass shooting, fires,
any health emergency, okay,
and now we're seeing it
with this massive strain
from a viral pandemic.
Our healthcare system is set
up for peace time protocols.
All the processes are
set up for peace time.
The IRB meets once a
quarter, or once a month.
Why, because in peace time,
they're evaluating studies,
you know, at that pace.
And then all of a sudden
you wanna do a study
on COVID and guess what?
You can't do it because you
don't have the IRB waiver,
not approval, because it has
de-identified information
from the data, you don't have the waiver,
and the IRB meets once a month,
so you've got a wait, okay.
Mayo Clinic does a study
on convalescent plasma.
Okay, it was posted on
MEDRX on August 12th, okay.
35,000 patients-
- The pre-print server, yeah.
- Yeah, 35,000-
- Yeah, and just for, sorry,
just for people who don't know,
just the people who aren't in medicine,
IRB is Institutional Review Board.
It's the committee that kind
of determines the ethics,
and so on of your, of your study.
- Yeah, and the IRB really sort
of served an important role
after the Tuskegee experiment where,
horrible things were done
to minority communities to,
you know, with really no supervision.
I mean, terrible experiments
that should have never been conducted,
and it was a really, it
was a horrible thing.
So IRB has basically said,
"We're going to protect research
from harming people without any, you know,
for, for no good reason."
Well, they have massively overstepped
that role of protecting,
you know, patients and
vulnerable populations,
to now saying, "Oh, you know,
this study doesn't seem like
it would be valuable enough
of a contribution to
research, or we'd like it,
but you'd have to add this part,
or you have to include this."
It's like, "Wait a minute,
that's the role of the journal."
- Right, right, and then,
now you were talking
about the 35,000 patient,
convalescent plasma study.
- And by the way, I think the IRB today,
hinders a lot of great research.
I believe that.
Now they also serve a protective function,
and you do see that, right,
but they, they can be
a bureaucratic hurdle.
Why don't we have more clinical trials?
I was just talking about
this with Vinay Prasad.
We chatted for "MedPage Today".
- Yeah, and you're the
editor-in-chief, yeah.
- Yeah, so I did it in my role there.
So we, we basically talked
about why are not more people
in clinical trials, right?
In our own field of oncology,
why doesn't everybody
with cancer go on some trial,
or at least get offered
participation in a trial,
so we can learn?
And the reality is that
these trials are clunky,
and they're bureaucratic
and they're hard to set up,
and they're expensive. Why?
In part, because of things
like, the IRB process.
Now that process needs to be there.
We need some external
review of, of research,
but it doesn't have to be as clunky.
I don't have to fill out a 62 page form
to do de-identified data research
that has nothing to do with drug safety.
And so these are the,
these are the problems in
healthcare that get magnified,
when all of a sudden,
we have a health crisis.
For example, Mayo Clinic did a giant study
on convalescent plasma.
You've heard about, you know,
this big buzz about
convalescent plasma lately.
35,000 people, okay,
during a health crisis,
when, for at least for the first two weeks
of that article submission,
it was submitted on August 12,
1000 Americans or more were dying a day.
The journals, okay, take
it with their own rules,
and we can only review it in sequence.
Only one journal at a time.
You can't submit to two journals.
It's their own rules.
It's their games, right?
It's not with the patient in mind.
Okay, then they send it to somebody.
Voluntarily, some doctor without pay,
will review it on their own
time, then send it back,
and then some editor will
make a decision, okay?
Can that be expedited?
Can we get input during a health
crisis faster than a month?
What, what are they doing?
When they get this article,
showing that convalescent plasma
has a real world, clear
cut survival benefit,
and that benefit is dose dependent.
The more antibodies in
the convalescent plasma,
the Mayo Clinic researchers found,
the greater their survival benefit.
Okay, clearly convalescent plasma works.
When Chris Chen got sick,
guess what they gave him?
Convalescent plasma.
If you or I are in the ICU with COVID,
guess what we're gonna ask for?
Convalescent plasma
among other things, okay.
What the hell are the journals doing,
sitting on this manuscript for four weeks?
It's 10 pages.
You're not, you don't, you're
not going to the hospital
to review, interview the subjects.
I mean, the journal just reads
the 10 page output, okay.
Now we're in a health crisis right now.
Review this thing in 24
hours, and turn it around.
- Now, was it, is the
paper you're talking about,
is that a randomized trial,
or is that the retrospective trial looking
at dosing of plasma
without a placebo group?
- It was the retrospective review.
So it was their experience with 35,000.
In total, 70,000 Americans have
gotten convalescent plasma,
with no statistical
significant untoward events,
and a clear survival benefit
in a lot of these large series.
Okay, we use convalescent
plasma at Johns Hopkins.
We have from early on, and that's,
the reason it works is, it
has antibodies in it, right?
The same thing vaccines
are designed to produce.
What are we doing?
First of all, what are we doing
giving this to 70,000 people
without any randomization?
Second of all, now that we
have 70,000 data points,
what are we doing arguing with the FDA,
when they give an emergency
use authorization, right?
You had people flipping out, all right.
You had people flipping out,
including a piece I saw in
"Medscape", flipping out that,
you know, Dr. Hahn approved
convalescent plasma
for an emergency use authorization.
That's not even an approval.
That just means that some, you know,
doctors can freely use their discretion
to give convalescent
plasma to patients sick
with COVID-19, without having
to be formally enrolled
in an IRB trial.
Okay, how bad has it gotten,
that we cannot use convalescent plasma,
because somebody is saying,
"You don't have a placebo trial",
when you have all of this data, okay.
There's no placebo
controlled study to prove
that parachutes work
and there shouldn't be.
Zubin, it would be unethical
to give somebody placebo,
and deny them convalescent plasma today
in the United States.
And if we're so stuck on
these rigid protocols,
during a health emergency,
if we can't combine a promising
and safe small molecule
to do a phase one and phase
two combined trial, I mean,
what are we doing?
Just letting people die?
And I'm not saying this is
what we do in peacetime,
but when you have a quarter,
and we're gonna lose a
quarter million Americans
at this pace, right?
When you have this many people
who have lost their lives,
I mean, I think today
it said about 190,000,
it's time to redesign our systems,
redesign our study design,
redesign our approvals,
meet more regularly as an
IRB, provide expedited review.
The, the FDA will now get
back to you in seven days,
if you submit a drug,
if it's for COVID, okay.
What would the world look like
if they did that routinely, right?
If they did that for cancer drugs?
So there's a lot of lessons here,
but one of them is
we've gotta move faster.
The dexamethasone study,
okay, from the UK,
that trial showed about a
33% reduction in mortality.
I mean, you talk about
maybe the largest reduction
in mortality that we've seen
has probably come from steroids.
Why are we learning
about that in June, okay?
The pandemic hit us in March.
Why does it take us all of this time,
and the clunky processes and the reviews?
Meanwhile, in the UK, they
looked at dexamethasone
in a randomized controlled trial,
that they designed early and we got,
and they got the results, and
the world benefited from it.
We were invited, the
United States was invited
to participate in that recovery trial,
and the U.S. declined. Why?
Because we didn't think
the study design was
as elaborate as was necessary.
You can pick apart any
study, okay, and we did this.
I remember Harvard
School of Public Health,
in our Epi class.
They gave you seven articles.
Everyone got seven different articles,
and you had to rip those articles apart,
and they were in all the top journals.
And you know what?
You can do it.
You can rip any article apart.
The question is, is there
beyond a reasonable judgment
of some degree of rationality, is,
does there appear to be greater benefits
than there are risks?
And that is the real question
that we need to be asking
in a health crisis, in an emergency.
This is an emergency.
- And I think, you know, and,
this idea of distinguishing
between emergency times
and peace times is very important.
Now, so playing devil's advocate,
because I agree with you on a lot of this,
it's like, our science is
slow at the best of times.
In war time, it ought to be really fast,
and you should be able to enroll patients.
So IRB ought to be modulated.
Peer review ought to be modulated,
but what probably shouldn't
be modulated is what you said,
people then looking at the data and going,
"Okay, is there a reasonable doubt
that this thing makes sense?
Is there harm that can
potentially happen?"
With convalescent plasma,
there wasn't seen a lot
in this data set of,
you know, 35,000 plus,
odd 70,000 patients, but,
and then the question
of randomized controlled trials
taking away bias is important.
And you brought up one thing which was,
and there's a couple of
things I want to follow up on.
One thing is, why wasn't that just done
as a randomized trial in the beginning?
Like why, there's probably
a higher bar to it,
or just answer that for me?
Like, why, why didn't they just randomize
that in the beginning?
Is it just because they didn't think of it
until after we started
giving convalescent plasma,
or what was going on, do you think,
knowing that you're not involved?
- Well, I'll, I'll tell
you what Vinay Prasad
and I concluded in our
conversation is that,
there's a, there are a
tremendous amount of barriers
in the way of doctors
studying things in a way
that they want to study them.
There are a huge number
of bureaucratic steps.
There's expense with
limited funding, right?
We have historically been funding drugs
that give marginal
benefits for things like,
cancer survival, and lifestyle drugs.
Our system is basically set up for that.
Is it set up to study anticoagulation
in the ICU during COVID-19?
No, no, what drug company is gonna sponsor
if anticoagulation in an ICU is going,
where's that money gonna come from?
The NIH division of anticoagulation?
No. Where's the funding for food, right,
for understanding foods
that are, you know,
food that is pro-inflammatory
and anti-inflammatory?
Where's the funding for
studying environmental exposures
that cause cancer?
Zero, right, except the one giant study
that came out of the movie, "Dark Waters",
which showed that yes,
in the one of the 100
plus forever molecules,
inert synthetic molecules
live in the human body
of every American, this one
molecule studied, causes cancer,
all sorts of different types of cancers,
and neurological problems.
That was one study of one of
the 100 plus inert molecules
from environmental exposures.
Why did we study that one?
Because there was a giant lawsuit,
all explained in the
movie, "The Devil We Know",
in the Hollywood version with
Mark Ruffalo, "Dark Waters".
The largest public health
study ever done was conducted
as a result of a lawsuit with DuPont.
They studied one of
these forever molecules,
and found a strong association
with many different kinds of cancers,
I'm sure, including the
cancer I operate on,
and neurological problems
and all other things.
So we wonder, "Oh, why
is there more autism?
Why is there more, you know, Alzheimer's?"
Could it possibly be
that there are all sorts
of environmental exposures
that no one has ever studied,
because we don't fund those studies?
We fund a reactionary approach.
We fund drugs that we can throw at people,
not what causes some of
these underlying problems.
- That's a fundamental to
how we treat disease, too.
We don't prevent it.
We don't focus on those things.
We focus on the Band-Aids after the fact.
One interesting thing, though,
that I've realized the more
older I get with studies is,
you can have associations
and correlations,
but then when you really
try to unwind them with a,
you know, a randomized
trial, you find that no,
they were actually
correlates, not causation.
So maybe you're seeing this
stuff in the blood, but these,
the people who would
have that in the blood,
live next to a radiation source,
or a chemical factory or something,
or there's other things.
How do you think about that?
How do you tease that out?
- That's why I think the, the result
that an association is dose
dependent says a lot, okay.
And granted, we can never
prove with 100% certainty
that anything is true in science, okay,
but you have a lot of data points,
and you start putting them together,
and it is enough to inform our decisions.
About 60% of all decisions
we make in medicine
are purely discretionary,
with no science or evidence
to support doing one thing or the other.
That is in the words
of the editor-in-chief,
of JAMA, Howard Bauchner, okay.
- Yeah, I believe that.
- The reality is, if we,
if we are making a lot of
discretionary decisions,
can we learn from things
besides randomized trials?
I'm not saying we don't
do the randomized trials.
Actually, I'm saying we should
do, and do more of them,
but can we learn from other things?
Can we learn from that one patient,
who has an incurable cancer,
and is still alive at 20 years?
Okay, can we learn from
the patient who has,
I heard recently of a case
on Peter Attia's podcast,
of a woman who has MS, okay.
She believes that she has been
able, and she's a physician,
she has been able to manage it
much better than other people
with MS, by changing
the food that she eats,
and she has a whole logic
and rationale to it.
I don't know if she has, you know,
beat MS or is doing much better with MS,
but I do believe we can
learn from her, okay.
And we can learn from individuals
as much as we can learn
from groups sometimes.
You know, there's a case
at Johns Hopkins of a guy
with a glioblastoma multiforme.
Years ago, I mean, this is,
this has been presented
over and over again,
at local and national conferences,
but the patient's a longterm survival
of this really incurable cancer type.
What happened? Well,
decades ago, it turns,
turns out if you go back
and look at what happened,
there was an infection of the
surgical resection bed, okay.
Something happened there.
I don't know if it triggered
an immune response.
I don't know if the infection
chewed away at the tentacles
of the cancer in the
surgical resection bed.
I don't know, but we can
learn from that case,
and we don't only learn from
randomized controlled trials.
We can learn from direct
observations, from case series,
from the wisdom of practicing doctors
in the front lines of medicine,
from before and after study designs,
from controlled historical controls,
from improvements over time,
from dose dependent relationships
in the absence of placebo.
So we can learn from these
other types of study designs.
And by the way, people who think
randomized controlled trials
are the only gold standard,
if I hear that one more
time, I'm gonna vomit.
Vinay Prasad has published that like,
roughly half of those randomized
controlled trials published
in these journals get overturned
when they get repeated,
or subsequent research comes out.
- So there's bias in
the design of the trial?
- These are what are called
medical reversal, right?
- Right. Medical reversal.
Vinay has been on my
show and he's coming back
on this week actually,
because he's local here,
and I really like what he says.
You know, one interesting thing,
because we started this thing,
we ought to have more therapeutics,
and so on that have been studied.
His whole thing is the bar for, say,
cancer therapeutics ought
to be even higher than it is
because we have, we let
so much garbage through
and it actually causes harm.
And what are your
thoughts on that in terms
of this research milieu?
- Why are we funding tiny,
incremental improvements in science?
Why aren't we funding the big ideas?
Why aren't we funding novel things, right?
I mean, you talk to, you talk
to researchers in the field
of say, Alzheimer's,
they're gonna give you
massive alternative hypothesis
of what's happening with Alzheimer's.
Now are those getting the NIH grants?
No. We find incremental benefits,
so we can get our little abstracts
presented at our meeting,
and stand by the poster, and
explain to the four people
that walk by, that this is
what we think is happening,
and then you add it to your resume.
And then when you go to
get a job, or a residency,
or promotion, they say, "Oh,
it looks like you presented
four times at a national", what
kind of game is this, right?
If we actually funded things
that matter to patients,
we would fund the things
that they actually are interested in.
Like, when I tell somebody,
"It looks like you have
a pancreatic cancer."
Do you know what one of the
most common questions I get is,
right off the bat?
- "Is it something I ate?
Is it something I drank?
Is it something I did?"
- Yeah, what, "Is it
something I, what caused it?"
I mean, that's, what's
on their mind, right?
And am I gonna go into
the fact that, you know,
my dad practiced in the coal
mine region of Northeastern
central Pennsylvania,
and as a hematologist,
he saw this incredible breadth
of leukemia and lymphoma,
that he was certain was associated
with the coal mine region,
but he could never get
funding to, you know,
I mean, he, he could, I mean,
I'm not saying it's impossible,
he certainly could, but it's, it's uphill.
If he tries to get funding
because there's a clinical trial
of a new chemotherapy and is, you know,
for a cancer, that's a
million times easier to get,
than studying some of
these underlying drivers
of human illness.
- Mm-mm it's tough, dude.
And you know, it's, it's weird.
Rarely in an interview, do
I just sit back and listen.
You're passionate about this.
You've been doing research all your life.
You know what's wrong, what
works, what doesn't work,
and during this time, when it's so urgent,
I have a question which
is, and then again,
just back to the, my question
is how do we fix this?
Right, but, but before I forget,
one of the criticisms
that Stephen Hahn got was
that he's just misrepresenting
the magnitude of that data.
So looking at the
retrospective data, saying,
it's a 35% improvement on the,
so what was your take on all that, 'cause-
- Yeah, I mean, he was excited.
He was excited, you know, and
there might've been other,
you know, reasons to be excited.
Like, you know, it would look
good to have some good news.
I don't know, but there
was a survival benefit
in that study, which, you know,
I think one of the few
people that actually read it,
because it was a pre-publication release.
The survive, the mortality
went from about 11% to 8%.
Now, if you were to ask
me, "What was the finding?"
I wouldn't describe that
to you as a 35% reduction
in mortality, right.
When a patient comes and
talks to me and says,
"You know, what, if I have
it done laparoscopically?"
I don't say "There's an 87% reduction
in surgical site infections."
I don't say that.
I say, "You know, if
you have it done open,
the surgical site infection
rate is about 10%.
If we do it laparoscopically,
it's about 1%."
Right, so-
- Absolute difference, yeah.
- And let's be honest,
we're in an election season.
He works for President Trump.
There's a lot of haters out there,
but to anyone who thinks
we should not have,
the FDA should not have given
an emergency use authorization
to the community doctor in rural Georgia,
who wants to give convalescent
plasma to his patient,
but can't, because it
does not have an FDA EUA,
then, you know, to, to them, I would say,
"That authorization should
have come a long time ago,
probably should have come after
we had 10,000 patients who
took convalescent plasma,
and the safety had been established."
We have a century of experience
with convalescent plasma.
The mechanism works. It's plausible.
It's scientifically sound.
It worked for Ebola.
It appears to have early, you know,
survival benefit in that early population
that got convalescent plasma.
Now fast forward, and
we've got 70,000 people,
and a Mayo Clinic report with
a clear cut survival benefit.
And somebody's gonna say, "No,
we can't let doctors use this
because there's no placebo."
I mean, it would be unethical
to give somebody placebo today,
now, with all of that data.
- Let me ask a question.
Well, so, and then that's one of the,
that's one of the criticisms
of EUAs is well, okay,
and once you give an
emergency use authorization,
then it becomes unethical
to give a placebo,
and now you can't do the
randomized controlled trial.
- Good.
- What do you say about that?
- Yeah, good. I mean no one
should be getting placebo.
I mean, you're gonna
tell somebody, "Oh yeah,
we're concerned about you not surviving
from this COVID-19, you know, ARDS."
We're gonna enroll you in a
study where you may not get
convalescent plasma, and
then you'll be on it.
Maybe you're honest enough to tell them,
"If you don't enroll in this study,
we can just give it to you."
- Just give it to you, yeah.
So what's gonna happen, yeah.
- Yeah, so, I mean, yeah, if
you can look at 70,000 patients
and this dose dependent survival benefit,
and tell me that, that's not
convincing enough to give it,
even though it's safe, it's a safe drug,
and we have to subject
people to a placebo?
Then I would say, "They're
walking a fine line with the,
with, you know, with playing
with the ethics of trials,
because I do not believe
there is the equipoise
to justify administrating placebos,
that is, for this drug at this time."
- So, so let's back into something
that's been politically
charged around that,
that also has this kind of valence to it,
hydroclorothiaz, or hydroxychloroquine.
What are your thoughts around that,
and how that's been managed?
- I was, you know, I was hoping,
as I think a lot of doctors were,
that there would be a survival benefit,
but the studies have shown
that there really is
not a survival benefit.
There have been a number of studies done,
and one or two have suggested
or shown a survival benefit,
but they had worse study
design than the ones
that showed no benefit.
And so we gotta be scientific, right?
We've gotta let the data speak for itself,
and let the better studies
interpret the poorer studies.
- Let, let me, so that's
why I asked that question,
because what you just did,
was you showed that you're a scientist,
and not a politically charged activist.
And the reason I say that is,
the way you were passionate
about blood, convalescent plasma,
what you'll see in the comments,
and because we're in a
crazy election season,
what you'll see is people saying,
"Well, you know, yeah, well,
he goes on the news and he,
you know, you know, maybe
he's a conservative,
and this and this and that.
And of course, he's
gonna want blood plasma,
because it's going to get
Trump reelected, right?"
So then you ask,
"Well, so what about
hydrochloric, hydroxychloroquine?"
And you say, "Well, I looked at that data.
I wanted it to work.
It doesn't, so far as we can tell,
the study design was poor
in the things that showed."
And that's my interpretation
of it as well.
I have not looked at the primary
blood convalescent plasma
data, so the fact that two,
two science minded people agree,
means that you can take
the political valence,
and shove it up your
butt, because it's not,
it's not gonna color
our ultimate decision.
That's very powerful,
especially for an audience
that doesn't know what to believe anymore.
They don't know who's telling them truth,
who's politically motivated.
I mean, what are your
thoughts around this?
- Well, first of all, I don't
know why everybody feels
like they have to pick
a side on everything.
- It's a tribal badge, yeah.
It's like a tribal badge.
- It is, and, and honestly, you know,
there are legitimate things to
criticize the President for,
but if he says something that is correct,
or that you believe in,
you don't have to criticize it,
just because it's coming from him.
And I believe that with everybody, right?
When somebody on rounds,
who says dumb things a lot,
says something that actually
should be considered
with a patient, if
you've got the open mind
to consider things, right,
and that's what we try
to create with the surgical checklist,
is a culture where people
feel comfortable speaking up.
And everybody in leadership,
as the captain of the ship,
we, as physicians, have an open mind
to take those considerations
in the best interest of the patient.
Not, "Oh, this is a person
I've gotta retaliate against,
because they said something
that was not useful last time."
How does anyone read the
Mayo Clinic study on 35,000
patients, and in their
heart, tell a patient
that I'm not gonna give
you convalescent plasma,
and instead, puts you on a study
where you could get placebo.
Yes, we have this allegiance
where we worship some higher,
you know, scientific advancement concept.
And I believe in science,
but do they really,
if that was their own mother or father,
are they gonna put them on placebo?
I mean, yes, early on, yes.
The first 100 patients who
got convalescent plasma,
1000 patients, 10,000
should have been randomized,
until that trial closed.
We didn't get that, okay?
For whatever reason, maybe
their IRB met once every
five years and they didn't get approval.
(laughing)
Maybe there was no funding.
I don't know, okay.
Maybe there weren't, who knows,
but now that we have the
data, have an open mind,
look at it, and interpret that data,
and make a reasonable decision.
And I think that's what
distinguishes a scientist
from a hack, which is what you see
on this thing all the time, right?
- Yeah.
- The echo chambers of, of social media.
- I have nothing to add to that.
That is absolutely the
conversation we need
to be having.
We need to revolutionize
how we do the science.
We need to streamline it
during wartime and peacetime.
We need to focus on the
high, high value outcomes,
which means not this marginal, oh, we,
you know what, the number needed to treat,
to see a benefit with
my new statin is 3,046,
and you'll save one nonfatal heart attack,
so that'll get us approved by FDA.
This is insane, and yet,
that's how we're monetized.
That's how we do it,
and like you said, that's how
I get the thing on my resume.
I can then go present
this thing, and it's safe,
instead of asking the
real big, hard question,
which every researcher in their
heart has those questions,
they just know they'll
never get funded in a way,
that's streamlined in a
way to actually test this.
And the, and the risks of
actually having that concept fail
and show nothing are so high.
And the negative study bias, meaning the,
those don't get published as
much as positive outcomes,
or positive studies.
It becomes a science crisis.
Combine that with reproducibility
problems, like you said,
with even randomized controlled trials,
and you have the urgent need
to transform our scientific endeavor.
Not throw it under the bus,
not become anti-scientific,
not go to crystals and witchcraft and woo,
but just fix what we know can work.
I mean, right?
That's what it feels like.
- And it's, you know, it's not
just in research, by the way.
How about hospitals having
capacity resilience, right?
Where's that expandability?
Where's that adaptation to be able to,
to respond to a health crisis, right.
When there's a hurricane
blowing through Houston, right.
Do they have enough vent?
Do they have extra ventilator
capacity or are they running
things so tight that you
just cannot possibly do,
anything will throw off the system, right?
- We saw it in Katrina, you know,
we see it in the pandemic.
They are running so close to,
because that's how you make money.
How can you, you know, you're
gonna hire all these staff
and keep them on standby?
How are they gonna pay for that?
So how, what, what are,
what's our, I mean,
when medicine is a business like that,
then it has to be run like that.
And then something
happens and you're like,
"Well, there's gonna be
a delay of five months
before we can spin up
enough PPE and enough staff
to manage it."
- It reminds me of the TSA,
when I go through the airport.
You know, it's like you,
somebody in front of me forgets
to take their belt off and
they walk through the thing,
and they scold that individual.
Then they come back into the line angry,
and scold every person
in line, telling them,
"You have to take your belts off, right,
and take your laptop off",
'cause somebody just forgot
to take their laptop out.
And it's like, what is
this reactionary approach?
This is illogical, it's non-scientific,
and that's exactly what we
do in healthcare, right?
We scramble, we don't have
adaptive systems set up early.
And then when things happen
and they go bad, we think,
"Oh, this shouldn't have happened."
Why are we shopping for
drugs and PPE in China?
Like, can we fix that,
or is that something
that's just gonna keep going, right?
There's a lot of these issues.
And I think the new term now
that we're hearing a lot,
is resilience, healthcare
resilience, hospital resilience.
And hopefully there's some
important lessons here
that we're gonna learn and act on.
- I think you nailed it, and
as I run out a disk card space,
'cause I've got two shows and
forgot to delete one of them,
we'll have to wrap it
up, but one, I wanna,
this has been fun, dude,
and like, we had no,
we had no agenda going into this,
it was, let's just talk about
what we wanna talk about,
and I thought you brought up things
that people need to hear, man.
And, and here's the thing,
I think the term is,
it's Nassim Taleb's term,
which is anti-fragility, anti-fragile.
So you used the word, resilience.
Resilience means, a system resists change.
So in other words, you come punching at it
with a problem and it's like,
"No problem. I'm resilient", right,
but anti-fragility, as opposed to fragile,
where you come at it and it crumbles,
which is what our system actually did,
in the face of the pandemic.
Anti-fragility is where a
system is designed in a way
that when a challenge comes,
it actually adapts quickly
like an organism, evolves,
and gets stronger than it ever was,
in a way that it can adapt to challenges
in an exponentially better way.
And that's what little
kids do when they are,
when they have certain levels
of stress, certain challenge,
which we've now been protecting them from,
by helicoptering them around,
and they get stronger,
and more adaptable, more
able to conflict resolve.
That's what kids do.
That's what organisms do.
Why can't our healthcare system
and our institutions do that?
Be more anti-fragile.
Our financial system was fragile.
It fell apart in 2009.
You need an anti-fragile system.
That's where Taleb got his thing from.
So that's what we're hoping for,
and at least these conversations may
at least set us the problem,
so that we can start
working on solving it, yeah?
- I love it.
- Dude, Marty Makary, man, that was fun.
When are you gonna
interview me for "MedPage"?
I want some serious street cred, dude.
- You will be the next guest on "MedPage".
You let me know when and
we'll do a nice interview.
- I love it.
I'll throw most of the nudity
and all of the cursing in it,
'cause I know that's your audience there.
- If you could do 20% less cursing,
I think it'll meet the bar.
- That's, you know what?
That's a statistically significantly
less amount of cursing-
- Actually, you've had
to do, what am I saying?
There's been zero, you've
done zero, not (indistinct).
And I've heard that you stopped cursing
in the last 50 or so episodes.
I haven't watched them.
I'm not caught up yet,
but that's what I heard.
- I've made it, I've made
cursing a special thing
I do only for my subscribing supporters
who pay 4.99 a month to
see me talk every night.
And for those guys, it's
like F this, F that,
S this S that.
I had this effin' conversation
with effin' Marty Makary,
and we effin' did this, and they're paying
for that HBO level of quality,
but the rest of the world,
I just want them to
share it with their mom.
And so, even though, you know
their mom curses like a sailor
at home, they don't know that,
so they won't share unless I stop cursing.
So I keep it clean for the masses.
- Well, I know we've got some
moms that read "MedPage",
so I'll find out what our policy is.
- Well, speaking of moms,
my Mom sees you on the news
all the time and told me,
I think I might've mentioned
this to you before.
"Oh, Dr. Makary, he's been on
your show a couple of times.
He seems like he knows
what he's talking about."
And I'm like, "Looks
can be deceiving, Mom.
Let's have him on my show."
(laughing)
All right, Marty Makary, thanks
for being back on the show.
Z-Pac, share this thing.
This is an important discussion.
Leave a comment.
Are you a researcher?
Do you work on an, are you on
an institutional review board?
Do you have, do you have strong
feelings about, you know,
the data on convalescent plasma?
If you've read it,
if you've read the piece,
let us know what you think.
Share the video, become a
supporter, if you love democracy.
I just have to say that Marty,
because you know, it just
feels right, and we out. Peace.
