What would you do if you were fired by your employer over something you had said on social media? Would you be able to survive or would you have to scramble to find work? That scenario is exactly what was faced by today's guest, general surgeon Dr. Buck Parker. And his solution was a surprising one.

It doesn't appear that Dr. Parker never set out to find ways to be financially secure outside of medicine. His path through medical school and his general surgery residency seemed fairly traditional. However, there were signs that he had an entrepreneurial streak about him as he began a very small online business selling gym equipment. Following that, he landed a role on a reality TV series which led to another starring role on a second show.

Aside from practicing clinically as an acute care and trauma surgeon, Dr. Parker leveraged his appearances on TV and built up a following on social media through Instagram and YouTube. And that's where the trouble began.

Dr. Parker's termination within his hospital system in 2020 happened a lot like the old joke in bankruptcy. "How do you go bankrupt? Gradually and then suddenly."

Parker's CMO had been very upset with his YouTube channel and social media presence for some time and when Parker published a video stating that the highest risks for COVID are those who are obese, elderly, and with medical co-morbidities, it was the final straw. Perhaps it was because the video went viral and the light it shone on an institution that didn't want any attention paid to it. No matter the reason, it was the end of the line for Dr. Parker's Salt Lake City surgical career.

Perhaps by happenstance, Dr. Parker had researched and eventually took the plunge to mine bitcoin. Fortunately for him, the price of bitcoin exploded from a few thousand a coin to tens of thousands from the time he started to the time he had been let go. It more than supplemented his income lost as a surgeon and gave him the financial freedom to be able to walk away and not worry about scrambling to get another job.

It's now been almost 18 months since being let go and the CMO has been replaced and the hospital has been busy. So busy they actually asked him to return but he declined. For right now, Dr. Parker doesn't see himself going back to medicine but time will tell.

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Dr. Jay Bhattacharya returns today to further our discussion on the dysfunction within the scientific community around COVID-19. Specifically, we discuss what exactly happened to Dr. Bhattacharya after he co-authored the Great Barrington Declaration where he and two other prominent academicians laid out a case for a more focused protection plan for the elderly than the widely adopted general lockdowns and mandates at the time. Dr. Bhattacharya was not surprised to face opposition to their plan - but the way it formed and by whom did. 

After the publishing of the GBD, the attack against Dr. Bhattacharya and his co-authors was blistering, numerous, and seemingly coordinated. Those on the outside, and even Dr. Bhattacharya himself, believed that the scorn from media, government, and academia was due to a general disagreement with their position - not a coordinated attack. It turns out that FOIA documents of emails from Drs. Fauci (head of NIAID) and Collins (head of NIH) prove that they worked in tandem to discredit the GBD through their contacts within the scientific, media, and government communities.

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The US health care system is fraught with all sorts of problems. Many of these have to do with consolidation in the market and scores of rent-seekers (those using legislation and regulation to maintain their market share. Those issues can probably be best resolved with fundamental changes within the halls of government. However, some of these problems can be addressed with new technology which offers solutions not even dreamed possible a few years ago. And the driver of much of this innovation rests on block chain technology.

Block Chains to the Rescue?

The basics of block chains have been discussed on this show where we explained the basic concept of what it is and how it works (here and here). We also looked at some helpful business applications such as decentralized finance and how that could unlock capital and make for opportunities for small medical practices. However, the real allure of block chain is whether it can solve some of the bigger problems in health care and bring about real structural change to the problems that plague doctors and patients alike: information sharing, supply chains, and payment processing.

Patient Information Sharing and Storage

Big Data is big money and there is no more valuable data set than patient health information. Companies pay millions of dollars for this data to develop health processes and businesses to manipulate the data to change patient behavior, physician behavior, and new businesses. However, the biggest problem is that the patient has no ownership of their information meaning that they cannot decide if the data is used or be compensated if it is. The possibilities of the block chain allow for patients to control their information and dictate those to companies - not the other way around.

Additionally, patients owning and securing their own data would allow for more accurate and safer transfer of their personal medical information when traveling between medical systems, EHRs, or even health providers within the same system. In essence, a patient could only transfer the information they want and deem important to a particular provider and no more. A quick example would be to just provide personal demographic information to an imaging center and not all their health history.

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There's no shortage of an alphabet soup of government agencies but the same exists within the nebulous public-private sphere of medical education and credentialing. These non-profit organizations were created to ensure a baseline within medical education institutions across the entire country for medical students, foreign medical graduates and residencies. However old and established these institutions are, they are still staffed by people who make decisions and are charged with maintaining the organizations financial stability.

But, since they don't have any real competition, they can make financial decisions that are not always the best for the long term viability of the organization which can lead to problems in the future. Sometimes those futures become the present and people paying for their services, ie, medical students, residents, and foreign medical graduates take the brunt of their poor fiduciary planning.

The real financial risk to many of these organizations is similar to what threatens governments at the local, state, and federal level: pensions.

Charles Kroll is a forensic accountant which means he is adept at parsing financial reports and determining where money is flowing and where the inherent financial risks are to organizations. With the help of analyst Elizabeth Tremblay, they have analyzed the financial data from the National Board of Medical Examiners (NBME) - which conducts the testing for medical students - and have found troubling signs. Foremost is that the NBME has a retirement fund that is worth almost $300 million which is twice the value of the organization. On top of this, the retirement fund is still underfunded which means it is at some risk for default with an organization that clearly could not meet those extra payments since it is dwarfed by the size of the retirement fund.

Of course, the great risk is to medical students which would probably be on the hook to make up for the financial offset if the retirement fund becomes grossly underfunded. The only real source of revenue for the NBME is its examination fees. And for medical students, they are forced to pay whatever fee the NBME comes up with since there is no competition and alternative testing organization in the United States. The financial mismanagement of this and other organizations will fall hardest on those with no choice and the least ability to pay.

Retirement benefits are usually of two main types, defined benefits and define contributions. It effectively shifts the risk either on the employer or the employee. In the private sector, defined benefits (guaranteed payouts over the length of your retirement) haven't really existed for 35 to 40 years. Nowadays, private companies and most non-profit organizations offer 401Ks which are specified contributions but do not guarantee your future payouts - they are whatever they returns are.

What is so unusual is that all of these medical education boards use defined benefits as their retirement structure which puts their organizations and, by definition, their clients at risk for covering the gap of underfunding their benefits. According to Kroll, unless the organizations kill their defined benefits plans they will be at increasing risk for insolvency or at a minimum, jacking up fees to students.

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It's easy to become despondent about controlling spending or eliminating waste through reform on government expenditures. We've all seen the headlines about the $1 million hammer or toilet seat and governments losing track of money. Also, with all the people who have been elected on the platform of 'transforming' government or making it efficient, there has been almost nothing but the exact opposite happen. It's why the joke about death and taxes not only funny but very true.

To make matters worse, imagine government getting involved in the purchase of a product that is incredibly expensive and wasteful - US health care. This is a recipe for budget overruns, poor health outcomes, and a bottomless pit of spending. The opportunities for wasteful spending is so great and the lobbyists to keep the gravy train of spending so powerful that tackling it at the state level seems hopeless.

Yet that is exactly what Christin Deacon did.

Reforming New Jersey's Health and Benefits Plan

Maybe it's because Christin Deacon didn't know any better but she looked at the amount of money being spent on New Jersey's health and benefits and actually thought she could find some meaningful savings for taxpayers. To her credit, she asked the questions that no one had asked and pursued solutions that no one had seriously tried before. Through her persistence, Deacon helped save New Jersey citizens over $500 million per year for years. Those billions of dollars have been used to fill other gaps in the state budget and most importantly, haven't been thrown away on poor contracts or inflated pricing.

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A rite of passage for doctors is completing a residency in a specialty. Sometimes, they complete multiple specialty trainings but ultimately sit at the end of their years of training for board certification. At one time, once a physician got board certified, they were considered a specialist for life and no further testing or training was necessary. That all changed in the 1990s as the governing board for all the specialties, the American Board of Medical Specialties (ABMS) began to require that new trainees only receive time limited certification. This meant they would have to undergo new testing or requirements in order to maintain their board certification.

Initially, this expiration was every ten years and usually just involved an exam. Physicians grumbled about retesting within their discipline which required time, money, and travel usually. Eventually, over the years, the testing and continuing education modules grew and expanded requiring more and more time and expense. Now, a physician who is triple board certified, like a hematologist-oncologist, would have to do testing every 2-3 years with almost continuous rounds of studying parts of medicine that he/she no longer practices. This can cost the doctor upwards of $40,000 every ten years!

As the onerous and expensive requirements for ABMS recertification continued to pile up, doctors from prestigious medical institutions from around the country decided that it was time for another choice for board recertification. The concern was not in the initial training and certification process but simply in the verification of continued mastery in the doctor's field of practice. Therefore, they set out to create a board certification that recognized prior training but focused continued medical education that the physician felt best helped them in their day to day practice.

This allowed the new all volunteer board to decrease the annual certification price to only 30% of the ABMS price while also drastically eliminating all of the mind-numbing busywork that doctors say contributes nothing to their practice but grows their burnout. Doctors were upset over the perceived exploitation and lack of response to their concerns over the recertification process so another choice through the NBPAS is a welcome addition.

One of the main limitations in the acceptance of NBPAS by hospital credentialing committees is the fact that private insurance carriers couldn't get credentialed by their credentialing bodies if they didn't use ABMS credentialed physicians only. Hospitals were very hesitant to allow medical staff who were not qualified to get paid by insurance carriers as they feel that this puts their patients at risk for surprise bills. Fortunately, NBPAS has now obtained acceptance by NCQA and URAC which are the main credentialing services for insurance carriers. This paves the way for physicians to have a choice between the ABMS certification or NBPAS and still get paid.

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The COVID pandemic has created a lot of interesting surprising and challenging political dynamics in countries all over the world. In the United States, we have a clear divide between those who declare themselves Democrats and Republicans in whether they support mandates and vaccine passports. The treatment of children remains a subject of a tremendous amount of strife. However, our neighbors to the North in Canada are having the same political tension growing as exhibited by the Freedom Convoy.

The Freedom Convoy began January 22nd as a decentralized protest movement in Canada led by truck drivers entering the nation's capitol, Ottawa. According to my guest today, Warren Speyers, the convoy is seeking to end the vaccine mandates for traveling and generally moving into businesses. Speyers says the truckers are not looking to fight vaccination, rather, just the mandates and edicts which they feel are restricting their freedoms and businesses.

The convoy consists of not just truckers but also many other Canadians who share those same goals and values. Speyers says that there are all sorts of trucks, tractors, and even personal vehicles which line the streets around Canada's Parliament. From Speyers' description, the convoy has been met with lots of support from citizens in Ottawa. The protests have been largely festive celebrations with people packing saunas, hot tubs, and even their hockey skates along with their families. The truckers have been showered with food, meals, valentines, money, hot showers, and offers of diesel gas from well wishers.

Although the protests have been peaceful, the Canadian government has sought to end the movement without pulling its restrictions and mandates. On the day we recorded, February 14th, Prime Minister Trudeau and the federal government invoked the Emergencies Act which is essentially grants the federal government extraordinary powers to prevent massive violence, threats to Canadian sovereignty or a threat to public safety and health. In practice, the government has threatened to freeze and seize the financial accounts of anyone who financially supports or participates in the protest since most of those involved are owner-operators and not actually parts of large corporations.

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If there is one thing that seems obvious throughout the pandemic, public discourse on just about everything seems to have broken our brains. We are incapable of having discussions without vitriol and there appears to be a real desire to not simply win arguments but destroy our ideological enemies. This leads to all sorts of strange behavior like fracturing previously solid personal relationships between family members, friends, colleagues, and, in today's example, patients and their doctors.

It began with a surprising email in her gmail account in the fall of 2021 for Dr. Meg Edison. A man identified himself as an investigator for the Michigan State Medical Board and was following up on a patient complaint for 'misinformation.' After a google search to feel comfortable that the individual was an actual state employee investigator, Dr. Edison gave him a call to find out what the nature of the complaint was against her.

It turns out that one of her long standing patients had lodged a complaint with the state board of medicine claiming that she was pushing misinformation at their child's last visit. The claim consisted of the 3 allegations:

As one can see, all those statements are correct and were true by government authorities even back in the fall of 2021. Fortunately, the story has a happy ending and the Board of Medicine found the complaint to lack merit and was summarily dismissed without any action taken against Dr. Edison.

Organized medicine can be an extremely challenging and aggravating landscape for physicians to navigate sometimes. However, when it comes to standing up for doctors, there aren't many organizations that will do it. And when it comes to taking on the licensing boards, state regulatory bodies, or hospitals the only groups that have doctors' backs are the professional groups. Dr. Edison made the point that it is important to find your niche in organized medicine and run with it to help foster relationships with other physicians and learn more about the state of medicine and different ways to practice.

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Dr. Graham is the most frequent guest on the Paradocs Podcast and has appeared 5 previous times to discuss COVID (they can be found here, here, here, here, and here). Today, we talk a lot of COVID but also what it takes to retire amidst a pandemic. Do you need extra financial security during these times? What strategies work best? But mostly, we discuss Graham's optimistic feeling on where we are with the pandemic.

Dr. Graham's very optimistic that we are in the final stages of the pandemic. Both from a scientific, social, and political aspect. Scientifically, we are closely approaching the point where nearly everyone in America has been infected or acquired immunity to COVID from vaccination., This will significantly reduce the chances of mortality and move future infections to less severe. Socially and politically we are definitely seeing a shift away from shaming and hysterical calls for zero-COVID towards a more rational approach of accepting the virus' endemicity and learning to live with its presence without extreme mitigation measures.

There also seems to be a real reckoning that most of what we did to prevent transmission was largely ineffective even within the ruling class. This is an important point that makes it less likely that these measures will be broadly pushed in the future. Of course, there are still further calls to now push vaccine passports and mandates but the utility of them is crumbling as we see that vaccination is hardly effective at preventing the spread of the virus. Pushes to continue mask mandates except to N95s are present in some communities (especially schools) has occurred but are being met with even more hostility from the lay public.

As for N95s, it is clear that they are fairly protective for individuals and all other masks have limited utility. This means that if you are an individual who wants extra protection from others, you can simply don the N95 yourself. This also means, that others can operate in their lives in a pretty normal capacity without worrying about others. Since vaccinations and boosters are widely available, anyone can get the protection they want without having to worry about others and what their 'status' is. This is a huge leap forward and Graham argues is the way forward with schools and businesses as it allows those who want extra protection to protect themselves and those who choose not to to live a fairly normal life. It is probably the only politically feasible path forward for our schools and everyday life.

Finally, Dr. Graham spoke a little in that he is more optimistic because Paxlovid, the novel protease inhibitor, is now approved and has had amazing therapeutic results for those at risk of serious complications with COVID. It also may serve as a platform or basis for future therapeutics in other respiratory viruses. Yet another reason to be optimistic on the future of the pandemic. You can listen to my latest discussion with Dr. Monica Gandhi to get her explanation of Paxlovid in episode 154.

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(The following is a speech I would give if I were allowed to replace the current head of the Presidential task force on COVID-19, Dr. Anthony Fauci. We have had a huge loss of trust in our public health institutions and a change must be made. This is the speech someone needs to make as they replace the current regime which has had a run through two presidential administrations.)

My fellow Americans, it is a great honor to receive this appointment to head the US task force on COVID-19. I want you to realize that I approach this position with great humility recognizing that I can never have enough knowledge and must rely on others to gather the most complete picture on this virus. The fact that this is a new pathogen means that our knowledge is ever-evolving and we must be nimble in our course of action. 

It has been a long and dark 22 months that we have been dealing with this pandemic. SARS-CoV-2, the virus that causes COVID-19, has killed hundreds of thousands of Americans and millions world wide. Make no mistake, this virus can be deadly.

Unfortunately, throughout the pandemic’s response, the American people’s trust in public health, modern medicine, and government authorities has eroded significantly. Large swaths of our population no longer trust voices whom they deemed trustworthy just two years ago. This is mostly the fault of those in charge of public health and I seek to reestablish that trust.

Of course, regaining lost trust is not easy. It requires those who were in authority to accept their missteps. It requires a whole profession to admit it was wrong.....

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