50 HCN - Art Caplan
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Every society runs on a kind of fuel for healthcare. That fuel is in technology or capital, it's trust. And when trust erodes, data becomes noise. Science becomes opinion, and we start mistaking what's loud for what's true. Today, we're living through that fracture. Government agencies struggle to hold the public's confidence.

Misinformation spreads faster than any vaccine ever has, and the private market, the one driving our AI tools, our biotech breakthroughs are digital. Front doors is racing ahead of the ethical guardrails meant to keep patients safe. That's not a political statement. It's the reality of a healthcare system that's learning in real time.

What happens when the engines of innovation outpace the moral code of the system. So today I am sitting down with one of the clearest moral voices in modern medicine and someone who shaped how I think about healthcare more than he probably knows Dr.

Arthur Kaplan, founding head of the division of Medical Ethics at NYU Langone. And we're gonna [00:01:00] talk about three things that cut to the core, the government's responsibility to be a source of truth in public health, weaponization of misinformation, and whether social media can ever be an ethical public square.

The line between innovation and exploitation when private capital drives clinical decisions. This isn't an academic debate. It's about who gets to define truth when lives depend upon it. I'm your host, Rick Janata, and this is the Healthcare Nation podcast. Let's dig in.

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Dr. Kaplan, great to have you back. You, I just have to say this first of all, second time on the show, I wish you, I could say you've been here, um, like 10 times already because I have that much to cover with you.

But look, you're always busy, it seems, and as of late there's been [00:02:00] a bit more of an uptick, I think with your, appearances that I've seen on the media, certainly the past month. And we're gonna cover some of those topics today because I think your perspective, your expertise always enlightening for me.

But also I know our viewers are gonna love that. So if, if you're good, how about just jumping in my friend?

Thank you Rick. Sure.

All right. Fantastic. Look, I wanted to cover three, three big broad categories today. One, I, I'll just say the weaponization of misinformation and social media and the ethical kind of boundaries around that.

And then, then talk about private equity and, and what that means from you know a care delivery perspective and holding up the patient side of the bargain. But let me start with the, really the source of truth side and the government's role in that. And I can't help but think about what's been happening, and we'll go back obviously a month or so ago with the the executive statements on [00:03:00] Tylenol by the president and the secretary, and it's linked to autism and, and it makes me think about just generally speaking, executive kind of statements in the in, in.

That office and is it verse science or weighing in on science? So my question to you is when you have leaders move, I guess I'll just say faster than science, and outside of the bounds of even what we might consider science, what's the ethical responsibility for separating, you know, that perspective from.

I think someone's just general views on things and the implications of that to the public, particularly when it happens to be the citizens of the country. How do you square that circle Art.

Well, first of all, what is warranted? is justified, and there are a lot of ways to get knowledge. Some people have transcendental experiences on mushrooms, and they're pretty sure that they got wisdom out of it [00:04:00] about something. There are people who. Read books, the Bible that they believe give er truth and they try to believe in that document. But really for the culture, if you're not in a religion or you're not a mushroom books, the Bible that they believe give er truth and they try to believe in that document. But really for the culture, if you're not in a religion or you're not a mushroom books, the Bible that they believe give er truth and they try to believe in that document. But really for the culture, if you're not in a religion or you're not in a mushroom books, The Bible that they believe give er truth and they try to believe in that document. But really for the [00:05:00] culture, if you're not in a religion or you're not a mushroom books, the Bible that they believe give er truth and they try to believe in that document. But really for the culture, If you're not in a religion or you're not a mushroom books, the Bible that they believe give er truth and they try to believe in that document. but really for the culture, if you're not in, a religion or you're not a mushroom books, The Bible that they believe give er truth and they try to believe in that document. But really for the culture, if you're not in a religion or you're not a mushroom books, the Bible that they believe give er truth and they try to believe in that document. But really for the [00:06:00] culture, If you're not in a religion or you're not a mushroom physical principles. Theories and I see the guy standing there with a little flag. books, the Bible that they believe give er truth and they try to believe in that document. But really for the culture, if you're not. in a religion or you're not a mushroom So there's a pragmatic aspect to what makes truth. Can you act on it and get results? Can you deliver on what you say is? So if I see one more announcement, by the way, about when the rapture is coming, it'll be one more, too many, but they failed a thousand times. That's bad for religion science, if you fail a thousand times, it just says, revise the theory. mean, come up with a better idea. thing that [00:07:00] makes science

Arthur, can I, can I ask you one, one question along those lines? It it, for me, it makes it that much more difficult when Yes. I think some of our, let's just say the institutions that we depend upon and have historically thought upon as the, these are the places which are the sources of truth, the guidelines, if you're a clinician, et cetera.

And when you have books, know, wholesale change out. give leadership there from folks who had been career scientists and folks who really, I think, dedicated their lives, you know, in that space of discovery. in then you have political appointees coming in, and then you have the rank and file. In this case, let's just say clinicians saying, I no longer really believe what's coming out of.

The FDA as much as I used to. That's another layer. It's a flipping of that whole narrative now where I, I don't even wanna look at those institutions as necessarily the source of truth. They used to be.

Yeah, [00:08:00] I don't think there are anymore. think when you have political appointees vetting messages by political people with no science background, which is. A good number of people that RFK Junior has appointed and Trump has appointed no credibility. None. I wouldn't go there for much information about anything.

The federal government in the science space, not on climate, on pollution, not on vaccines, not on how to deal with autism, and a lot of topics would not go there. They don't. Believe in science, they believe in ideological responses. to be free to do what I want. So you take your vaccines when you want to, because they work or they're safe, or they'll save your neighbor. I believe in individual choice, says the sec. The surgeon General of Florida says RFK. [00:09:00] Junior says McCarey, the FDA guy. That's nice, but that's an ideology that's not got anything to do. Science sometimes makes you do things you don't wanna do. And by the way, I don't like getting shots either. And I do.

But you know, there are plenty of things that science tells me like, don't eat candy and don't drink too much. And maybe you shouldn't look at your iPad 24 hours a day. I don't really like doing that, but I believe that they know that these things are not good for you if you do them. our authorities have never been jeopardized like they are now.

And it's the part of the political polarization, but it's also deliberate. Trump and MAGA see science as an enemy. It doesn't get them where they wanna be. They don't like data collection. They've killed off a lot of databases. You remember, [00:10:00] is part of science too. They don't like the unemployment numbers. Get another person deliver you unemployment numbers. Well, that's hardly science. of economics is not me the right guy to gimme the right numbers or numbers I like. I also think they have a religious. Element that supports them. Conservative religion that doesn't really find comfort with science, and they play to that base sometimes. of religion has had no problem with science for a long time. I mean, granted, it took the Catholic Church about 400 years to accept Galileo, but okay, they got there eventually. And evolution has not been a problem for most religions around the world. They sort of. Live side by side. Here's a story from the Bible.

Here's a story from Darwin, but not this crap. So you might then ask me, well, if you can't trust the Feds, and by the [00:11:00] way, I think federal science, N-I-H-F-D-A DOE, department of Energy, they have an obligation to be conservative. Not just tell us the science, but until it's really proven, don't give out advice. They're going in the other direction. I saw a study somewhere in a weirdo journal from someplace I'd never heard of that says, Tylenol causes autism. Hey, Tylenol causes autism. It's like, wait a minute, you gotta like get 30 papers that show causation, not some fruit ball somewhere. Who looked at 10 people who took Tylenol and saw an association, not causation. So you wanna be conservative. Medicine is conservative. Inherently. It doesn't jump to the latest fad. Maha, what Kennedy likes is fad of the day. It is, takes these supplements. It is, I like to take this particular [00:12:00] non fluoride filled beverage whatever it's going. Day by day to the latest fad science at the federal level.

You want it to be cautious, conservative, totally evidence-based, in that it shows it either something causes harm or something does you benefit, and the administration's thrown that out the window, so I don't trust it.

Yeah, but, and, but Arthur, let me ask you, how do we again, I was saying how do we square this circle? And when you think about, and I'm putting clinicians in this box as well, who are, who are looking at things like, well, what if I prescribe this? What if I, you know go down this, will I be supported?

Will I, you know, comport with guidelines? Are things going to change? I put that all together, both patients clinicians and even consumers because this. Kind of this discordance has created such confusion. Again, docs on one side, now, agencies on [00:13:00] another patients caught in between. Is there gotta be some level of e evidence threshold?

Should there be, or some external way before something like this announcement goes out?

Yes,

I, I know the, the president can say whatever he wants, but, and does and does say whatever he wants, including awfully statements, but yes,

Yeah. Is there an ethical standard for, for changing guidance publicly? That's one question, but the second thing I really wanted to ask you is have you seen in all your studies, anything like this before in the, let's just say the history of the United States, where there was that kind of juxtaposing or contradictory messaging?

No, the only place I've seen it before is in the old Soviet Union. Joe Stalin had a favorite scientist by the name of Trophy Senco, and Senco went to him and said, I know how to grow wheat and corn [00:14:00] in bitter cold Siberia. theories are that the environment can modify plants over generations make them more cold friendly. there is part of truth in that in genetics, if you select out the plants that don't do well in the cold, sort of. Tip the crop of seeds toward those that are more resistant. But what Liko was saying is, I can do this in one generation. And Stalin loved to hear that. 'cause he wanted a revolution.

He wanted to change everything in Russia in one generation. So he made him the chief scientist, somewhere around the 80000000th person to die of starvation. They decided maybe like Cinco wasn't their guy anymore. So. Yeah, I've seen it in Germany. Nazi Germany had it where they just said, you know, these theories a lot of them are Jewish scientists, Jewish physics, we're not gonna follow that. We got the atomic bomb first. [00:15:00] 'cause they didn't want to do physics that they thought was tainted by, jewish thinking, let's put it that way. Um, also in areas like anthropology and genetics, they had all these theories about inferior races, about people who were prone to alcoholism, prostitution, laziness. believe those theories 'cause it fit their view of why they had to eliminate inferior people. And I'm sad to say. The resurrection of that is Donald Trump when he talks about immigrants bring US disease, replace us. You probably heard the great replacement theory. That's the old German racist biology. So I'm seeing that back here, but I haven't really seen it before here. Not.

So I, you know, picking up on that and, and if I could just [00:16:00] overlay that on what I guess would be American perceptions, I think it's like in the low 20% of Americans trusting the federal government. Right now with what's, I guess in, in, in the health world for being the accurate source of any kind of information.

And if that's the case, how does, you know, and we're gonna get to the social media you know, question next, but where do you go from that? I mean, is it just,

Yeah.

I mean, what happens.

So I have some ideas about that. If you're lucky enough to have a doctor and some Americans don't, sadly, but if you do, you go there first 'cause the doctors are getting information. From their medical association, from their peers, they go to medical meetings they're usually pretty up to date on what the journals are saying about the latest news in their area. I would ask my doctor first. I wouldn't ask [00:17:00] RFK, junior. I wouldn't ask Donald Trump, I would say to my doc or pediatrician or gynecologist. In the case of Tylenol, what do you think about Tylenol? What they're gonna tell you is has been. A suspect for autism for 10 years. No one's found any proof. The fact that it got trotted out at that press announcement is ridiculous. And what it treats is fevers. And what we do know is that fevers kill fetuses. The mom gets sick, high fevers cause miscarriages. We know it. And by the way, Dr. Oz was in the back of that. Press conference and he was nodding away. He learned in the first year of med school, fevers are really bad, whatever.

It's risk in my answer to how much risk would be nothing, but maybe not. Maybe everything has a teeny

Greater good.

you don't wanna have a fever [00:18:00] when you're in the first trimester of pregnancy. So second, after you talk to your doc, go online to trusted sources. Who are they? They are the professional medical groups.

Just go on and say Google, take me to the American Medical Association, the American Academy of Pediatrics, American College of Obstetrics and Gynecology, Psychiatric Association. They all have the autism websites to use that example. They're pretty good, easy to read, tell you why they think. The federal guys were wrong, flat out wrong. And what you should do, and, I mean, look, a lot of, we ignore one fact. Moms wanna protect their babies. It's not a bad ethical desire. So they're listening. What would be risky? On the other hand, when the president says You have a fever, you should suck it up. Suck it up. I mean, come on. Now, that's morally repugnant because A, it's [00:19:00] telling a woman bad advice. You wanna protect your baby, don't suck up a fever. And you know, he's blaming women for autism. 'cause they're all thinking, gee, I took Tylenol, 50% of Americans have 50%. Did I harm my baby? Is that what happened?

Because I don't really know why. You know, they're autistic or whatever. ethically disgusting. Third, what do you do? can look at websites and information from overseas, Canada, Britain, Switzerland, have their health Min, the Health Minister of Britain was on within I think, four seconds saying, this is all nonsense. This autism Tylenol business. Do not listen to this. It's stupid. It doesn't have any evidence. It's dangerous. And those I think can be checked. And that takes us to the last thing. not get advice from social media about [00:20:00] health ever. I mean, general social media. I mean just X and TikTok and whatever other sites are floating around out there for health. No movies maybe.

Let me on the social media side, I just gotta jump on that. I think there was a stat I saw that there's an estimation that misinformation now spreads six times faster than factual content. In a public health crisis in social media and that TikTok searches for a natural cancer cure and vaccine detox rose more than 400% in the last quarter of 2024.

So how do we, I mean I guess.

way, if we, you can, we can do this listening, Google. Google vaccines. I think the top 10 sites that come up are anti-vaccine sites, and the people who don't like vaccines know that and they spend a lot of time visiting their own sites to boost them up through hits in what shows up [00:21:00] first in the search engines. Science isn't very good sadly, at getting into public communication.

We all know during COVID we saw scientist Tony Fauci, who's been demonized for it, but was out there. And we have maybe other names like Peter Hotez, Paul Offit, some people saw me and you know, giving messages about what to do.

Get your shots, wear a mask, don't go to school, stay home don't sneeze on one another. All this sort of stuff. always messages that people wanted to hear, but they did it. But there were very few of those people. I mean, for every one of those, there must have been social media people up there saying, if I were you, I would take Ivermectin and I would take hydro chloroquine and I might swallow some bleach and I would lay out in the sun 'cause that kills COVID.

And on and on and on and on. [00:22:00] Science got outgunned. Totally outgunned. One other thing where science also fails is that a lot of these battles are won at the local level. Yeah, social media, but also at the high school, who's at the church, who's at the four H Club, who's giving a talk for the Boys Club or Kiwanis or the Rotary? it usually isn't the scientists, it's usually. Some housewife who was on social media and has an interesting view about why something's happening. So I think science has to get out to the local level, do more talk there. You win a lot of those battles locally.

Arthur, let me ask you. There's a generational reality here, though. I think like 70% of Gen Zs and about the same number for millennials in the study. I thought they're using social media for their health advice and over a quarter of them act on the [00:23:00] information that they, they find there. So if, if this next generation right that's coming online, literally.

Start their health journey by going on TikTok or Instagram before they ever see a clinician. What does ethical public, you know, response, communication, and I would even say education look like. Now given that just generational swell.

Well, I wish we would put more health and wellness information. Into our elementary and secondary schools. 'cause you wanna get thinking about where to go and how to think and what to criticize and what to watch out for early. And we don't. I think another important thing is demonstrate things like. What's in my school lunch and why is it there? And do we grow vegetables anywhere around the school if it's climate possible to do that? And why do we do, in other words, learn about your health and your wellness at [00:24:00] basic levels? You

Make it real. Yeah. Make it real for them. Yeah.

don't have to learn immunology in the sixth grade. Why is it that you know, whole plant food is something we're trying to push in the school cafeteria? And what do we know about that? And if you grow it. You can see what chemicals are used or not used, and, question it or do say whatever you want. I'm not saying everybody then has to become a vegetarian, by the way.

I'm not. I think I should be, but not quite there. But, um, you know, you learn in a practical everyday sense. Similarly, we could build it into sports. Why do people get concussions? What about power drinks? What do you do? What's a good training regimen? Would you take steroids? Why not use what their experience is?

Early short of, that hope for ideal transformation someday? Um, I'd say, [00:25:00] I'm gonna say three things. One, if it's endorsed by a celebrity, don't trust it. Why are they using a celebrity? It's 'cause they don't really trust medicine or the regimen or the diet. They think you're gonna trust the spokesperson. And I, I don't know whether it's the rock or you know, doja Cat or Taylor Swift or whoever, I don't care about their views about health and wellness. By the way. Most of what you see from our celebrities is pretend because they're all undergoing cosmetic surgery, huge amounts of makeup. They have their own trainer who

Have their own trainer, own chef,

whatcha

right.

about? They're not stressed 'cause they have five people to help them raise their kids. Um. So in any event, a [00:26:00] celebrity run away. Second bit of advice. If you see something recommended that you do or take, would then try to check it out on by going to other web sources. You know what, what? else is said about seven day hotdog diet or the, you know, I'm shredded by staying on the broccoli only diet. things like the pedo, lithic diet. People got into, well, we gotta eat a lot of meat and meat and meat and meat. It turned out it was bad for your kidneys. It's bad for the planet and it's probably not particularly good for you. 'cause actually, paleolithic people didn't just eat meat. So the whole thing was, but you, you could see it getting debunked if you just pushed a little further on that particular The other thing I would say about, you know, I go to the web or the internet first to get my information is. Come on [00:27:00] scientists.

Let's recognize that and let's get out there more. I'd like to see more legit debunking and tweeting. I know scientists are gonna say indoctrine and say, I don't have time. Just don't have time to do that. Here's what I would say. Ethically, professional responsibility. a month, go online. Correct something.

That's fine. There are a lot of nurses and doctors and scientists. Everybody did it. Once a month, you could have a real impact.

I Li Arthur. I like that. And along those lines is, do you think these, let's, let's just think about the social media platform. Should they carry some kind of legal or moral liability for any. You know, misinformation, that's number one. And number two, should there be a caveat that's even like, here's another point of view, something like that built in.

Now I know in the, in the world of free speech, and we hear a lot about that lately, I could see [00:28:00] folks saying, no, no, no. I'm entitled to my own opinion. Maybe yes, but not necessarily your own facts. And that's kind of where I'm coming.

I'm, I'm, I like free speech. I'm not favor even of censoring people who don't like Charlie Kirk or say stupid things about, you know. Antisemitism or whatever. I mean, I, I, I get the no fire in a theater kind of restrictions. You don't wanna cause deliberate panic and harm. I, it's so hard to control speech anyway, not just according to whose standards, but just in general on the internet.

They can't, you know, the internet gets hacked about once every 32 seconds. I don't know that you could regulate it in any serious way anyway. Not to count for the dark web and all the rest of it. So, um, I think better for this is we need a tougher federal trade commission to follow up claims. Say, how do you [00:29:00] know that Vitamin BX will cure your autism? it on here. Stem cell therapies, they're really good to stop Alzheimer's. I see that all the time. Really. Who's better? Where are they? Show me somebody. will cure your cancer. The only place people talk about that is when they go to somebody's funeral. 'cause it didn't, but we don't see the regulatory agencies correcting completely unsubstantiated claims, by the way. That lets me mention in addition to celebrities. You know what else? You gotta be very wary of I, Rick tell you. There's one let me change that. I there's a commercial on for medicine that says it will help you maintain your memory. And they have an old guy who's a pharmacist who comes on and says, I take this and it's made from jellyfish extract. [00:30:00] Really happy to take it. It's helped me out. First of all, I'm looking at it thinking, where is that guy, the pharmacist? 'cause. I don't think I wanna be going there.

Yeah.

Um, but secondly, testimonials don't prove anything.

He doesn't know

Right.

he was losing his memory. Maybe he was and maybe he wasn't. And there's no confirmation, much less a diagnosis. So all this stuff, even silly stuff, like keep yourself mentally going by playing Sudoku or doing crosswords data for that. Now if you like it, great, but.

And the, and the scientific side is an N of one, so if there's, there's no power, but, but art along those lines, from an ethics standpoint, what's the line between responsible. Action and censorship, like when does defending the truth become paternalism?

Part of defending the truth is to give it a value spin. You could call that paternalism, but I would call it experience, [00:31:00] and I don't, if somebody has done. Knee replacements and says to me, you are a bad candidate 'cause you're a little too heavy, you gotta lose some weight. Now I can do it, but I don't think the outcome will be as good. Sounds paternalistic. He's telling me whether I, but he's not. He's telling me from what I know as an expert, how many people think that if you get a recommendation about how to build a house from an architect, it's paternalistic. Do you think it's paternalistic for the lawyer to tell you how to make up your will? Do I think it's paternalistic If some media person, like you, says to me, well, I'd present my ideas more briefly, or you should gesture more or whatever, to be a more effective. In other words, expertise and experience come with a kind of, I wanna do what's best for [00:32:00] you. I'm gonna give you a value spin.

You don't just say, Hey, here's a choice. could take proven for breast cancer, or you can take what Gwyneth Paltrow has up there, up to you. Here's, you know, one side and here's the other side. I don't want it. Doctor like that. What doctor says, I favor this and here's why. Never saw anybody get better Gwyneth Paltrows, nostros. But I have seen people get better in my own clinic or from the people I work with. So paternalism is when you're telling people what you think they ought to do because you have better values, expertise, and experience is telling people what to do because you have data.

Big distinction. Big distinction. Listen, I, I want to, so much of this, I think, and I may be, this may be stretching. It is driven by, um, cer certainly social media. When I think about what's happening with just the capital markets and the [00:33:00] money and the flow of money and going from this world of, first, I want your attention, certainly in social media now to one that is more like, I want.

Your intimacy as well. And of course, I mean intimacy in every way, including what's your credit score, your financial perspective, you know what are you eating at Whole Foods? Can I build a digital avatar? And maybe, you know, from a risk perspective, you know, actuarily. Hedge this so that I can have a big margin.

And by the way, full disclosure, um, I'm a free market person. I really believe in innovation and creativity, but this is an area I'm really interested and I've wanted to ask you about this, this kind of profit. Paradox. When you think about, and I'll just take a good healthcare example. You look at private equity owning and operating, you know, a, a chunk, a large percentage.

I think over 10% of US hospitals and well over that maybe 30% of, of physician [00:34:00] practices. And, and in fact, some insurers are the biggest. Physician employers in the country you know, can healthcare innovation driven by profit? Because these for profit companies, they have an obligation return on investment, right, to their, to their shareholders.

Can they ever be ethically neutral or does the profit motive inherently distort? I mean, this is just something even with ESG and everything else we've seen. I mean, what's your, what's your thoughts on that? And I say that knowing that I think the market was over 46,000, you know, this morning and, and we're seeing record highs and it's, it's just something that I think is a real certainly for me, top of mind, subject.

So here's a question. Who would you say is the founder of Modern Capitalism?

The founder of Modern Capital. Wow. I'll tell you, you're testing me, but please school me on that Arthur,

Smith, the Wealth of [00:35:00] Nations.

right?

Really laid out the principles of market's capitalism, why he felt the invisible hand

Mm-hmm.

was a good way to resolve social issues, that they would sort out eventually by the market forces. What people forget is he wrote a book before that on sympathies. He wrote a book about the fact that ethics is essential for markets. You cannot just have a raw, free for all cutthroat market because that falls apart. People don't trust one another. They won't honor their contracts. They don't honor their promises. They can't trust the information that you give them in order to invest if you don't have the theory of moral sentiments, as he called it. Now, when Milton Friedman came along a modern hero to many of our capitalists, he dropped the ethics part. I think that was a huge mistake. So I'd begin there [00:36:00] saying, if you don't have an ethical infrastructure in basic ways, tell the truth. Make sure that your audit is honest. Make sure that you disclose where you're investing. If you have insider information, it's not fair. You can't do that. I mean, of insider trading out there, I would even say that market is lightened with it. Now, I, know, I know about this. Why? 'cause in my field. I get a ton of tips about what drugs are coming through that are gonna be good. And no, you can't audience call me and find out, but I never use them because I know it's insider.

I mean, somebody says, give us ethics advice on this trial. And I'm looking at thinking this thing is really going somewhere, it's gonna be good. But there are plenty of people who get that info and use it. And you know, again, the ethics. It's not a fair playing field. It's not something you need trust in order to [00:37:00] have capitalism.

You just can't run it for, it'll collapse on itself. think also, I'm a little bothered in our markets about inheritance. Why do my kids get the money that I made? And you can see some billionaires, the Gateses and the buffets sort of saying, I'm gonna leave enough money. So they're okay, not leaving 'em. Whatever it is, 86 gazillion dollars. And I don't think the laws should permit that capitalists. John Locke was another one, a buddy of Adam Smith's inheritance tax. have a minimum that you can do, but you don't get to be the third generation of Rockefellers and Kennedy's and uh, Walmart, fortune people.

What did you do? You did nothing. You inherited it. That's not merit, that's not prudence. That's nothing. So I don't think that's honest capitalism. I would not allow that. I mean, put the money into a [00:38:00] foundation. Another comment on markets. Markets in healthcare stink. They can't work. They've never worked here. not sure any other country has magic bullet solutions. I mean, people point to Canada, but they get huge waiting lists. They're underfunded. The British National Health Service, government run and sponsored. Underfunded, Germany of doing a little better. But in any event, why not here and what's wrong? First of all, the poor and the sick. Nobody wants to insure them. Why would I take somebody who's born with a chronic illness and take them in my plan? And I don't, and the insurance company don't do anything it can to get rid of those people. They're It's like saying I'm gonna insure. Uh, Naval commerce. If you have a leaky ship and a drunk captain, come on in here and we'll ensure nobody's taking that so risk is [00:39:00] not evenly distributed. With need. a lot of healthcare is not insurance. You know what it is? It's a benefit that you have to buy. Everybody if you live long enough, will need a nursing home. You don't ensure that you pay a premium to make sure that it's there when you get there. How does Profit Square up with that? it doesn't square up very well if again, you can predict who's gonna get Alzheimer's and who's frail and who has bad habits. You just don't want them. So you can't have an EA equity insurance.

I think insurance market where you can have private markets in healthcare is certainly on the stuff that's elective. You want cosmetic surgery and equity wants to buy up. The clinic that gives you that you want Lasix. 'cause you want a little better vision. Great. Let dermatology you don't like your spots, have a ball,

outta pocket. Yeah.

way in, compete good luck.

But if [00:40:00] you're saying something like, for children are born with a genetic disease like spina bifida who need wheelchairs and you know, disability help. That's not a private market. I, I, I'm not sure whether it's a premium on all of us to cover that or whether we have to have some sort of I guess I would call it universal access insurance that the government subsidizes.

'cause it's paying for known risk. I don't know. But it's just a crummy area for markets and I too am not anti-market. You want to have a beer industry. I don't care. You wanna have a underwear industry, only the enemy's gonna be dead. If you make crummy underwear, you know, you sort of avoid it after time. But healthcare is so weird because everybody needs it. A lot of people have. Way out proportion needs. are a lot of people can't pay their way through 'cause they're too [00:41:00] young or retired or demented or mentally ill or something. So they can't even play in the market space. Somebody's gotta take care of them. then, as I said. Need. And the need for service for some things inevitable. I mean, sorry, wellness people, but I've learned something. Everybody gets frail everybody dies. I don't care how many supplements you take.

Yeah, there's a finite number of heartbeats, Arthur, along those lines, I have to tell you, I work with a lot of startups and I really sincerely believe, at least from my perspective, that so much of the innovation that is necessary for healthcare is coming out of the private. Side of, of things and, and tech is, is influencing all of those.

One of the parts of this, when I, when I might, you know, engage someone and they want my opinions on clinical validation, one of the disappointing perspectives I have had to [00:42:00] add is, look, you've got a great idea. This could be revolutionary, but have you thought through how someone's gonna pay for this?

Because there's no economic structure that is going to, you know,

I mean,

recognize.

of models out there. There's something called gene therapy where we can now tweak genes, alter genes, in fact, alter many genes with newer technology and repair. Things like sickle cell, tacs disease, cystic fibrosis, probably juvenile diabetes. Um, many. bad hemophilia, life threatening diseases, the cost of the technology right now, innovative as it is, it's in the hundreds of thousands of dollars per intervention.

No model sustain that, so you either it or you say upfront, is a rich man's treatment. It's not in your basic package, and you ain't getting it.[00:43:00]

Yeah. And at the same time, um the institutions, we started the podcast thinking about, let's just say the N-I-H-C-D-C, where government really had a responsibility for the moonshots. They're no longer, you know, in that same position for a number of different reasons. So it, it leaves a big hole in that, in that space.

You know, where I think I've been disappointed about innovation in areas like home care and the use of ai. think there's room for robots. I think there's room for companion avatars. I think lonely people interactions, whether they're actual humans or. Maybe not. I think telemedicine has a role to play, but I'm not impressed with the way it's un unfolding.

What I see more of is, are you worried about your sex life? Go online. We'll get you some Viagra. [00:44:00] It's a 32nd survey, by the way. I did it to test it within 30 seconds. I had as much behavior being sent to my house as any mail could ever use on a harem.

the consumer model. It's the straight up consumer model though, right? Remember when you think about it.

when you need it. home care make nursing homes more responsive to safety and falls. The market isn't dragged over there 'cause they don't see the consumers able to buy. So that is a almost what we call the medicine side a translational problem. You can't get the innovation over to where. I think it would have the biggest bang for the buck. I, I'm not worried that people are, you know, middle class people are going without their baldness treatment and text bills.

They'll it out. It'll be fine. But there's [00:45:00] some of the areas where we could use it. Um, I'll give you one other stupid one, just transporting people. Healthcare, you call for an ambulance, it costs, I don't know, $2 trillion. Try taking an air ambulance somewhere.

Oh, I did that for many years ago. That's.

Well, I'm surprised you're not digging coal in West Virginia as a result to still make some money back.

Because have to chart, but I mean, can't we innovate in those spaces, make it cheaper, automated Uber, I don't know, something.

Anyway, you know where I'm going here.

Arthur, one, one last question to, to bring it home and you know, this is I'm gonna go back to even my roots as a clinician and thinking about my time with patients and just a lot of the issues we, we come across that.

We're highly loaded propositions every day clinically, but I think more and more about moral injury, and I don't know if it's applicable in this case, but when you see [00:46:00] this kind of whether we call it misinformation, that that's on social media or trust in, in the institutions we had, and if you're a clinician and you're trying to, again, reconcile that and do the right thing, but you're in an environment where.

Wow. You know, things have changed so much. I may be putting myself at risk or at, or ex even legal exposure. How do we, how do we reconcile that for the folks who are out there who wanna do the right thing? The clinicians who are at the bedside, the physicians, the nurses, and even the hospital CEOs who are there, and the other folks who are trying to, to move, what I would say is an imperfect system forward.

Yeah, that's a really tough, tough question. Might even be the subject of a whole other show. First of all, I don't like it when health systems make announcements like. We're going to [00:47:00] have yoga at six. If you're feeling stressed or overwhelmed, then they kind of hint at moral injury being asked to do things you don't like. mindfulness at 11, yoga at six. I mean, I'm not against those things too,

You might as well be passing out Xanax, right?

and it's not solving the problem. You're gonna be in these sessions for the rest of your career. And I'm not sure, you know, I'm sure some people benefit there's some data for that, but it is not the answer to the resolution of the dilemma. It's a bandaid. I don't like that as much. I'm not, again, just to be clear, I'm not against it. I think supporting who are stressed is okay. That's, that's something we try to do. But let's get at the stress. Secondly, I try to urge people to do what they think is right for their patients. If you're facing a coding situation with an insurance company and you think, if I just upcode this a little bit, I could [00:48:00] get them the benefit, I do it. Is it for, is it fraud? That's on the edge. But I go to court and say, I did this because I thought it was what, what my patient needed and it was the best medicine or the best whatever, wheelchair. I didn't think waiting another year for this kid would make them better off. My ultimate duty is to do what's best for my patients and that's how I sleep pretty good at night 'cause I that. Third, we do have to go after the sources of the moral. So if you're being asked to spend 12 minutes per patient on a scheme of, know, management efficiency, and you can't, I'm sometimes laughing at one end. We have ethics, guys like me. see the patient, here's what I want you to do. Talk about gun safety.

Why don't you ask 'em if they get all their vaccines, talk to them about their drinking. How's their [00:49:00] sex life? Why don't you inquire about their driving habits? Do you think they wear a helmet when they ride a bike? do you think they're taking their prescriptions the way you ordered them to do it?

Are they doing it every day at noon or whatever it is? These poor guys, ladies, what do they got? 12 minutes. I mean, they're gonna say something. What's your problem? Oh, you gotta, know, your elbow's killing you. Uh, let's maybe order an x-ray and make some motions for me and let's see. Oh, bye. they're not doing these, the only place they go on is in that equity side. The boutique practices, you know, the or bougie sort of primary care stuff. So we gotta fix that. I mean, everybody knows it's wrong. You can't do medicine. can make money more, but you can't do good medicine with 10 minute visits. And that makes people really feel injured. Plus, I said, the people sitting in their [00:50:00] armchair, they're like, well, why don't you bring up, you know, tell them they should support legislation that prohibits Medicaid cuts. And why don't you ask 'em what their kid's eating for school lunch? They don't have time at all to get anywhere near

It's literally the time. Yeah. And, and you know, this, it's, it's the, the, the electronic health record and, and the, the push to have volume come through and the value.

Any, any system where you have to hire a medical scribe to work with you as a system that is not really efficient that that's not doing the job. Hey, I'm gonna give you one last food for thought thing about wellness. So again, I am not anti wellness. I think medicine does know the keys to wellness.

They're simple. Get enough sleep, exercise. Eat modestly, drink modestly. Don't abuse drugs wear helmets when you're operating [00:51:00] vehicles. Um, it's a pretty short list. The problem is, is boring as hell and it's also sometimes a little bit hard to achieve when you are pursuing wellness on the internet.

You're pursuing stuff at the margins. I mean, it's the sort of thing somebody says, well, I took these supplements and I think it added six months to my life. Okay, but if you're becoming demented, I don't know that you want that six months, but let me give you another example. Run every day for an hour. I do believe that will maximize your fitness, but for every hour you're running, you are only adding an hour for your extended life. So it's a wash unless you like running. All you're doing is torturing yourself and you're not actually. It's getting more value time back. It's a kind of what they call Pareto optimal situation.

You can't really, of the wellness behavior, if you don't like it doing it, then you're just wasting time now [00:52:00] to gain the same amount of time later. And in some ways it's better now 'cause you're more able to enjoy it anyway. So I don't know that I want to every day for an hour. You know, I'll do my 30 minutes three times a week, but. Every day for an hour or ultra marathons and stuff like that, you're gonna say, well, I tacked on an additional year and a half of life when I was 78. Okay. Since I'm almost 78, I can tell you take the, take the benefit at 30.

Right. And Arthur, I will tell you, it's like anything in the extremes, right? I wanna get away from what's bothering me, so I go deep in the pleasures. I'm so deep in the pleasures. I forget about doing business, right? It's, it's the.

Yeah.

Well, my friend, on that note as always, fantastic conversation.

Interesting, deep, I mean, more food for thought than I can eat in a week. But [00:53:00] the good news is it gives me an opportunity to have you back. All right. Thank you so much Dr. Kaplan. Great to see you and looking forward to connecting again.

See you soon.