In a thought-provoking episode of our podcast, we had the pleasure of talking with Dr. Bernard Evenhuis, a newly minted physician with a unique perspective on the shortcomings of modern medical education and healthcare. His journey from being a successful software engineer to pursuing a medical career is fascinating, but it’s his insights into the problems of the healthcare system that make this episode a must-listen. Here’s a breakdown of the key discussion points from our conversation with Dr. Evenhuis:
Dr. Evenhuis shared how he transitioned from a career in software engineering to medicine, driven by a desire to help people in their most vulnerable moments. He discussed his passion for integrating technology and healthcare, but ultimately, it was the ability to meet people in moments of crisis and bring healing that inspired him to become a doctor. His journey serves as a testament to following your passion, even when it leads you down unexpected paths.
One of the central issues Dr. Evenhuis discussed was the concept of the "chief complaint" in medical training. Medical students are taught to focus on the primary symptom that brings a patient to a doctor, but this narrow focus often overlooks the root causes of illness. This method trains physicians to treat symptoms rather than addressing the bigger picture of a patient’s health. As Dr. Evenhuis explains, "Physicians aren't incentivized or trained to keep people healthy, but rather once a person becomes sick, that's when a physician's role takes place."
The episode also dives into the problem of hyper-specialization in medicine. As Dr. Evenhuis noted, many physicians become so specialized in one area that they lose sight of the patient as a whole. He shared a powerful story of a patient who was only being treated for a hernia, while the larger issues of post-traumatic stress disorder, depression, and poor lifestyle choices were ignored. This hyper-focus on specific issues leaves many underlying health problems unaddressed.
One of the most eye-opening discussions was about the financial impact of the current healthcare system on patients. Dr. Evenhuis talked about how many doctors are unaware of the cost of treatments they prescribe, which can financially devastate patients. He gave an example of a drug that cost a patient $30,000 a month, a decision made with just a few clicks in the system. The lack of cost-awareness in medical training contributes to the growing problem of expensive healthcare with questionable long-term benefits.
Dr. Evenhuis advocates for a change in how medical students are trained, pushing for a model that focuses on preventative care and health guardianship rather than the current reactive approach. He believes that future physicians should be trained to look beyond the chief complaint and work to keep patients healthy before problems arise. This shift, he argues, would lead to better patient outcomes and lower healthcare costs.
Dr. Bernard Evenhuis’s insights challenge the traditional ways we think about medicine and healthcare. His experiences shed light on the need for reform in medical education and the healthcare system as a whole. If you’re interested in how the future of medicine could be reshaped by passionate, forward-thinking doctors like Dr. Evenhuis, this is an episode you won’t want to miss.
Click here to listen to the full episode and explore the future of healthcare.
Episode Transcript:
Firouz D.: [00:00:00] Good day, everyone. It's a, uh, absolute honor and pleasure to, for me to introduce our guest of our podcast today. And frankly, Bernard is more than a guest. He's a part house owner. I've had the pleasure and honor of knowing Dr. Evenhuis for the past six to seven years. Um, the first couple of years as a experienced software engineer who joined our team to convert our In person physical direct primary care to a virtual model before COVID, before telemedicine became hot and sexy.
And then the second phase of my interaction with, uh, Bernard was when he became the medical student at, uh, at Case Western Reserve University, one of the top medical schools in the country. And, uh, uh, through that, [00:01:00] uh, physical interaction. Four years of medical school, we had numerous interactions, and as we were working together, I actually authored a book that's called Health Guardianship, The Remedy to the Sick Care System.
And during those interactions, my eyes opened through Bernard's, uh, observations of some of the root causes of the issues we have in the current healthcare system, as we call it a sick care system. Until, and recently, Bernard, uh, a newly minted physician. Now Dr. Evenhuis is completing his residency in Georgia.
Bernard, being one of the smartest people I've ever met, he is intending to become a health guardianship physician and spreading that concept among the newly minted physicians and so forth. Bernard, he's been exposed to the internship and residency. At the same time, he's going to be exposed to To the goods and bads and uglies of the current system.
[00:02:00] So, with that introduction, I want to open the discussion for my co host, uh, Josh and myself to ask Bernard, Can you tell us about what interested you in going to medical school after rather being successful as a software engineer? So, tell us a little bit about your journey.
Bernard Evenhuis: Uh, I love to say, uh, Dr. Daneshgari, FD as we call you.
Um, it's an honor to be on this podcast, uh, and talk about some of my experiences throughout medical school as well as, uh, my medical training overall. Um, so if I were to answer, uh, what inspired me to go to medical school, it's really been quite the journey. Uh, I, I started off, uh, with a career in software engineering, uh, throughout high school, um, and throughout undergraduates, uh, I worked as a software engineer, um, often full time.
Uh, and eventually I figured, um, well, uh, instead of working [00:03:00] for a software contracting company, uh, maybe I would be able to help more people and build, uh, some fantastic, uh, uh, inventions, um, by going out and starting my own software contracting company. So I really like building educational software. Um, and then there was the type of software that really didn't help a whole lot of people.
And so I thought to myself, If I'm going to spend the rest of my life chasing some career path or trying to be competent in some way, I'd like to be able to help people in the greatest way that I can. And as I thought to myself even further as I went through, uh, through my undergraduate degree, um, as a, uh, double major in computer science as well as, uh, Cell and molecular biology.
I realized that the most visceral and intimate way that I could help other people was actually through medicine. So that inspired me towards trying to integrate medicine as well as [00:04:00] computer science. Um, I did some research over at the Cleveland Clinic under some of our, our, uh, co colleagues, some of your mentees, uh, Dr.
Daneshgari, and that's ultimately how, how I met you. Uh, what ultimately inspired me to go to medical school is, uh, I realized that if I were to truly help people, um, in the best way that I can channel my talents. It's to meet people in the darkest moments of their lives, where they're experiencing illness or some insult that threatens the very core of their wellbeing, and to assist them in those moments, to channel my knowledge and whatever talents and training I have in order to bring order from that chaos and bring healing from that illness.
And so that's, that's ultimately what inspired me to go to medical school.
Firouz D.: Bernard is, uh, when you started the medical school. [00:05:00] There was a discussion between us and that was that what we call the, the health care as a sick care during because it's really both systematically and financially waits until people have a symptom.
And as you know, now, as a physician, that when the symptoms develop, is really the tip of the iceberg. But the concept that you opened my eyes to was when you started your medical school training it starts with the, what is called the chief complaint, which is basically what is your number one problem?
What is your number one symptom has brought you to me? Could you elaborate on that impact of that concept, why that has basically ossified the Uh, the, uh, the training of the physicians, frankly, just look at after the tip of the iceberg rather than the, uh, the bottom of it or the root
Bernard Evenhuis: causes. That's a, that is a really good point.
To [00:06:00] touch on the points of the chief complaint, uh, and its role in medicine. I think you're alluding to a conversation that we had when I was a first year. Medical student actually, uh, and back then, uh, we were just learning the ropes of the medical equation, how to, uh, introduce ourselves to patients, how to, um, dissect out a history and, and differentiate a problem and then ultimately solve it.
Uh, and what I realized is, uh, at the heart. And at the start of every single medical encounter is this chief complaint. If a patient gets admitted to a hospital, um, and, for example, you go up to the hospital and say, Hey, there's this 57 year old male that just got admitted. They're gonna look at you like you have three heads because, okay, admitted for what?
What is the complaint that we're addressing here? Uh, and in, in medical terminology, we, we say, state that, that specific complaint they came to the healthcare, uh, facility for, [00:07:00] that's the chief complaint. And that's core to this medical education, because in medical education, really, the, the entire goal is to internalize all this academic knowledge we have in trying to take a chief complaint and dissect out more information in order to differentiate that chief complaint.
Thank you. And then once we have it differentiated to the point where we can apply a specific label, then we can order some diagnostic tests to further differentiate. We can order some therapeutics to possibly treat that specific label, but it all starts with that chief complaint.
Josh Taylor: I would like to ask, though, you were mentioning the chief complaint with one of the first and a principle measure.
How did that counter your perception going into med school? A shift for you from what you were expecting?
Bernard Evenhuis: Yeah, absolutely. That was a shift. Um, I see, I think this is the general view of physicians [00:08:00] by large society. Um, at least what's, what's shown on TV, but, uh, I think we all like to see physicians as guardians of health, people that, that keep patients healthy and, and prevent them from becoming ill.
I think the reason why, uh, the, the centrality of the chief complaint was such a shock to me is because it made me realize that physicians aren't incentivized or trained to keep people healthy, but rather, once a person becomes sick, that's when a physician's role takes place. It's only after somebody has something to complain about that we have something to do.
Josh Taylor: Yeah, and you're trying to categorize against the CPT codes, you're trying to diagnose and then get them into these channels of treatment. The doctors are trained.
Firouz D.: To only look at the tip of the iceberg and with all the other constraints that comes with their work time wise, you know how much time they haven't spread and so forth.
Then they take the chief complaint as Bernard explained, [00:09:00] they took, we take you through a differential diagnosis because the faster we can take that chief complaint and basically zoom it into one of the, one of the cells that has an ICD code. There we can apply the. Diagnostic and treatment and go from there.
Josh Taylor: Uh, you actually shared a story, Bernard, about the very thing that FD was just talking about, how when you were, when you was in one of your rotations and you saw that one patient where, again, everything was being addressed about the chief complaint, like her actual issue, I think it was a surgery clinic you were a part of, but you started asking all these questions that other people didn't seem to be asking.
Bernard Evenhuis: Yeah, absolutely. Absolutely. Um, And, uh, this definitely touches on the, the heart of, uh, the reason why, uh, everything, everything in the medical equation, starting with the chief complaint, is so problematic, uh, and [00:10:00] flawed. Um, this was actually back when I was a third year medical student. I was, uh, rotating in a surgery clinic.
Um, and really the goal of a surgery clinic is to identify people that, uh, would benefit from surgery or have some reason to, to have a surgery. Um, and, uh, so, uh, we really only had a small piece of the entire pie of, of all potential issues that could happen to a person that, uh, that requires medical care.
Um, and so, um, one of the patients that, that I, um, had the opportunity to care for, Uh, was a woman, she was in her late forties or early fifties, she had significant peripheral artery disease to require some procedures to clear out the disease because she was having, uh, severe pain when she was walking related to her atherosclerosis and, and narrowed arteries, uh, and so she needed the attention of a [00:11:00] vascular surgeon, another very specialized, uh, Uh, type of physician, and as a, uh, a side point, actually the life expectancy of a patient upon meeting a vascular surgeon, usually they have such significant disease that the average life expectancy of a patient talking to a, uh, a vascular surgeon for the first time is about, uh, By the time a person sees a vascular surgeon, this disease has already been going on for years, maybe decades.
And when something goes on for years and decades and the root cause isn't addressed, well, we can deal with the secondary effects of that cause. But it's still going to happen, it's still going to cause damage if that initial cause isn't removed. And, uh, so in this case, um, uh, actually in the surgery clinic, I wasn't even dealing with the vascular disease.
But actually, a complication of the surgery that she had to undergo in order to treat the vascular disease. So, [00:12:00] she underwent some clearing of one of her femoral arteries, and While she was waking up from the surgery, she coughed, and as she coughed, popped a hernia in her abdomen. Um, hernias are very, they're usually very benign, it won't affect somebody's life.
Uh, often times they're not even very painful, you can kind of just tuck them back in. Um, and they really, um, Oftentimes don't need surgery, but she was referred to the general surgery clinic, and, uh, uh, she came to me, and so my role as a medical student was to evaluate this person. Do they want surgery, and would they be a good candidate for surgery?
Well, she would be a great candidate for hernia repair, because hernia repairs are very, uh, very low risk surgeries, but Uh, when I walked into the room with a patient, um, I saw a very interesting picture. I saw, um, first in her chart, I saw that she wasn't falling with any primary care provider, uh, [00:13:00] really only falling with a vascular surgeon.
So that's really her only interaction with healthcare, uh, dealing with this secondary issue, um, to some root cause. And when I walked into the room, I saw this woman. She was wound up. She had kind of like a depressed, uh, affect. Um, and I thought to myself, huh, there must, there must be something, uh, deeper going on here.
Uh, and so I went over the history of her, her vascular disease, the difficulty that she was having walking. Uh, and I'd asked her about this, this, uh, hernia, it was a benign hernia, it wasn't strangulated, there were no overlying skin changes or drainage or rashes or fevers or chills that, uh, uh, would make a person worried that this could be life threatening.
And, and really, with everything else going on, she could have surgery, but It really wouldn't be the best use of her time. And so, I started to ask her other questions. Uh, why is she having such significant vascular disease? I started to ask about her habits. [00:14:00] As it would turn out, um, something that was really not documented in her chart.
Uh, nobody had even asked throughout all these surgeries that she required, all these interactions with healthcare providers, uh, what's really going on. And as it would turn out, she had significant post traumatic stress disorder. And significant, uh, major depressive disorder. Uh, there are standard sets of, uh, questions that we ask people with these sort of conditions.
And, uh, the, all the flags were going off like, uh, waving red flags. Um, and I asked her how she was managing all this because it was clear that she wasn't following up with a psychiatrist. He didn't have a primary care physician, uh, prescribing her any medications to help with these conditions or to, to provide her any therapy.
Um, and so she told me her, uh, her management technique, which was about three packs per day of cigarettes and about 12 beers a day. And so these are from a physician's perspective. Um, alcohol use disorder, [00:15:00] tobacco use disorder, PTSD, major depressive disorder. These are very, um, Simple to treat conditions, oftentimes, for the general outpatient
Josh Taylor: population.
It's got to be infuriating to hear, especially when you see the condition so far, and then you're thinking, wait a second, this poor woman has basically not had any interventions at the primary care level. No one has, as a generalist, come to her and said, Hey, let's help treat the actual emotional harm that's been done and what you're struggling with, so that you can actually get treatment.
help without it really affecting your body.
Firouz D.: This was a, uh, case where Bernard called me and actually he was crying on the phone because emotionally the, the, um, the impact of this experience with this human being, this woman in her forties and fifties, you know, if you look at the life expectancy, she should have another good 30, 35, 40 years of life [00:16:00] expectancy.
Uh, the sick care system is basically looking simply at the tip of the iceberg. In this case, she had a hernia, had come to general surgery clinic. The reason the hernia was picked up because she was on the surgical procedure when she coughed, the hernia popped out. And now when we come to this, basically the, the mode of operation of the sick care system that basically has 10 or 15 minutes at the most, five minutes, the majority of cases to spend with this person.
Address the hernia and then move her out. And if it wasn't for Bernard's pre exposition to this issue and his fresh look into spending time, frankly, this whole issue of what are the root causes of this person's massive atherosclerosis, vascular disease, his PTSD, and eating, alcohol disorders, and so forth, would be gone, uh, totally, uh, you know, unnoticed.
And this brings us to the next point that The kind of the [00:17:00] evolution of the sick care system over the past hundred years, we started from where the primary care was, the good old family doctor in Rockwell's, you know, drawing, you know, we have that picture that there's a doctor there who is the guardian of your health, they attend your needs.
Because of the demand of the science and expansion of the knowledge, currently we have developed over 100 subspecialities. The more subspecialized you are, the more prestigious you have in the career, the more money frankly you make, but that the result what we have forgotten is, as Bernard explained this, at the root of this there is a human being that one basically Issue leads to the next one, leads to the next one, and so forth.
And if he don't have time to spend to discover this, leave alone intercept it. This is, and then the system is rewarding this hundred super [00:18:00] sub specialists to do more and more and more. So if I take you through the process, a hernia surgeon, that probably supervising Bernard in that clinic. He is rewarded financially, not by discovering what is the root causes of this person's problem.
He's financially rewarded how many hernia surgeries he can do per day, per week, per month.
Bernard Evenhuis: I think the issue here with that, um, most people that are going through, Training. As physicians see the benefits of specialization, you deal with a specific set of medical conditions. Things are a little bit more clear, less ambiguous.
You get paid more, you get a better light. This also kind of ties back to the chief complaint when everybody is so hyper specialized and they all have that very tiny piece of the pie. They fail to see the forest through the trees, they see the patient through the one organ system or one subset of diseases that they're very, very highly trained and highly efficacious at the treating, but they fail [00:19:00] to see all the other root causes that that might be contributing to this patient's presentation.
And I think, I think that's, uh, um, that kind of reveals the issue with, with medical training or the, the goal of medical training is to, Learn how to differentiate a chief complaint. So if somebody has shortness of breath, for example, and it gets worse. And, uh, when they exert themselves, the goal is to figure out, okay, is this a.
blood problem? Is this a lung problem? Or is this a heart problem? And we have specific tests that enable us to distinguish that. Uh, and if it becomes a heart problem, then we refer them to a cardiologist who has their own specific, uh, specialized training to, to treat heart problems. If it's a lung problem, then we refer them to a pulmonologist.
And then even there, once, once they're at the level of a specialist, uh, there, there is further differentiation.
Josh Taylor: You said back in. Your school though, all of this referral [00:20:00] to referral to specialist to specialist is racking up costs for the patient and that there really isn't, um, training on the connection between this system of referral to specialist after specialist and the fact that it's actually impacting the financial well being of the patient, right?
Bernard Evenhuis: Oh, absolutely. Uh, I mean, the fact of the matter is that you get billed for every, every visit. In fact, um, at this point in trading, or at least my experience as a, as a medical student at the, when rotating through primary care clinics. Uh, when diseases reach a certain complexity, um, the knee jerk was to refer to a specialist.
As, as a physician becomes hyper specialized, they actually lose that general medical knowledge. And this is, even occurs within spe uh, specialties. So, for example, I recently had this one patient that had very severe COPD, and inhalers weren't working for her, and Um, and [00:21:00] this patient, uh, um, uh, had been on maximal medical therapy and needed some experimental treatments at the level of interventional pulmonology, so the normal lung doctors couldn't help.
And, uh, so the interventional pulmonologists planned this, uh, this new procedure, the endobronchial valve placement, where they actually cut off air supply to the most vulnerable Uh, the most diseased parts of the lung, so we prevent those parts from inflating and therefore all the air gets redirected to, uh, all the healthy lungs.
So this, this woman was really an interventional pulmonology patient that, Um, I had the opportunity to, to coordinate the, the health care while she was in the hospital. And it became apparent to us that after these endobronchial valves failed and, uh, they had to be removed, well, she actually, that actually, that procedure at the level of interventional pulmonology triggered a COPD exacerbation, which is something very simple that all pulmonologists should know how to treat because it's one of the bread and butter [00:22:00] of pulmonology.
And so I figure, okay, this woman's, uh, um, on maximal medical therapy and I call up the, uh, the interventional pulmonologist and I'm like, hey, you know, this, this person's in a COPD exacerbation. How can, how do you think we should approach treatment for this? They said, I'm an interventional pulmonologist.
Just call regular pulmonology. I don't deal with that. And so this shows that, uh, that's even within a specialty, even if, as you get hyper specialized, you actually lose the training, the general medical training that you once gained through a medical school
Firouz D.: or lose the incentive to deal with, it's not that training is, uh, my time is much.
better incentivized if I do what I'm basically as an intervention pulmonologist. Don't waste my time asking me general pulmonology issues. Bernard is exploring the evolution of the subspecialization and what we're seeing is, I think at the system level, what is, this is working for the Doctors and for the hospitals [00:23:00] because it creates more incentive and revenue and compensation for them.
What has been left behind here is the patient.
Bernard Evenhuis: Uh, we have an eroding structure of primary care. A. emaciated structure, a skeletonized structure, of primary care, where primary care physicians really don't guard people's health. But rather, fulfill this role of surveillance. It used to be the case that primary care physicians, by and large, had their own practices, but As we've kind of written in our book, the healthcare system has been consolidated into about 5, 000 major hospital systems, and now the 5, 000 major hospital systems employ those primary care physicians.
And the role of those primary care physicians in the hospital system is really to see patients, identify chief complaints, and then direct those patients to the appropriate specialist. It used to be the case the primary care physicians did a significant amount of [00:24:00] work up at the primary care level, uh, and a significant amount of treatment.
Um, but in this system, the incentives are to actually, uh, decrease the amount of time that a primary care physician can spend with, with a patient.
Josh Taylor: With your experience in med school and, and recently graduating and becoming a doctor, Um, does this change the way that you talk to patients about what they should be doing proactively when they are inside of the healthcare system?
Does it, did, uh, this kind of change the way that you even maybe give guidance to people inside your family about how they should be accessing and working within their, their health systems?
Bernard Evenhuis: Yeah, absolutely. Um, actually, it's a common, uh, discussion at the dinner table these days to kind of forewarn people about.
Uh, incentives, the incentive structure of the healthcare system. But, uh, also in my discussion, in my discussions with patients these days, understanding, you know, [00:25:00] this hyper specialization of positions and everybody having their piece of the pie, um, I think this knowledge helps to consolidate it into the perspective of a patient when, when things go awry, so for example, um, I had a patient recently, this person had a, uh, a very severe case of, uh, kidney disease called focal segmental glomerulosclerosis.
I know it's very difficult to pronounce. FSGS, we call it just to save years of time over, over the course of training. This person, as a result of their kidney disease, they had too much fluid in their body, and we had to take out a significant amount. We did so By giving him some very potent diuretics, diuretics that, um, are so powerful, again, a generalist are told not to prescribe a certain intensity of medications without consult, consultation with the specialist.
And so we brought the nephrologist, the kidney specialist on board, um, and with three different [00:26:00] diuretic agents at pretty high doses, uh. Um, diuresis person very, uh, very potently. Um, and the person, they were, uh, uh, very, very swollen all over their body. And after a little bit of diuresis, they became less swollen, less swollen.
Their legs started to shrink, and they previously had these large blisters, boule, we call them, weeping boule, because he had so much fluid. And his, his, uh, legs started to shrink, and the, listening to the nephrologist, uh, they said, diaries away, actually, we need to give more and more diuretics, more diuretics, more diuretics.
They were looking at the kidney function, as the kidney function was improving, what, uh, was removing fluid. The issue is that they weren't necessarily looking at this patient's legs. And as we saw a lot of this fluid come out, the legs turned from, uh, uh, little, uh, water balloons to normal looking legs to kind of shriveled up looking like raisin.
And so this patient actually at the, um, had an episode where he attempted to walk [00:27:00] around, but he had such little volume in his blood vessels that he ended up passing out, uh, in the hospital. And so each person has their own roles, and the people that we're in charge of is diuretics. We're looking at his kidney function, which was improving.
The issue is that there's a whole lot more to his body, a whole lot more to his health than just his kidneys.
Firouz D.: As we mentioned earlier, over the past seven, eight years that Bernard and I have worked together, we kind of started looking at the tip of the iceberg of the problem. The problem was Why we are spending two to three times more than the Europeans and Japanese and we are getting worse results. Worse results meaning between five to six to seven out of every ten Americans have chronic conditions.
So our longevity is falling behind other developed countries. So we [00:28:00] have a very expensive and mispriced services here. And we. Kind of put our efforts in understanding what are the misalignments and then how we can reverse, uh, these misalignments and really redirect this largest industry in the country, again, four and a half trillion dollars, uh, and through this redirection, uh, we would save somewhere about two trillion dollars.
We would actually create more incentive for keeping people healthy, so forth. But as we are discussing this whole, uh, process of how we can re align the relationship between primary care and the consumers. So primary care, rather than being a treadmill of seeing 30, 40, 50 patients a day, see 10 or 12 patients so they have time to spend with the patient, become the problem solvers rather than referral machines.
And [00:29:00] how they can be the guardian of the person.
Bernard Evenhuis: You're absolutely correct. The American healthcare system being the most expensive in the world, but trailing in outcomes. Uh, a lot of this has to do with how medical students are actually taught this dogma. Um, so in many cases, for example, we're taught dogma, or we're taught how to treat certain illnesses, and these diagnostic and treatment algorithms don't actually have any education on how much they cost, or in some cases, um, The outcomes that they create for patients specifically.
So let me give you an example. Uh, I had a patient recently, um, to kind of similar situation. There was a root cause dealing with some of the secondary or tertiary effects of that root cause. In this case, the, uh, the root cause was the, uh, There's this chronic urinary attention. He had a UTI, a transient bacteremia, and then eventually had a [00:30:00] pyogenic liver abscess, and only after all those events happened, well, his sodium levels and his blood got a little bit low, and we worked it up.
We identified him to have, uh, what's called syndrome of inappropriate ADH secretion. Uh, and as medical students, we're taught all the, uh, all the traditional ways of managing SIADH. We start off with some fluid restriction. If that doesn't work, we give them some salt. Giving them salt never works, um, at least salt tablets or urea tablets.
And then we go to the, uh, the third line, which is, um, uh, ADH receptor antagonists, um, like Conivaptan and Tolvaptan. Now, uh, these medications actually had a, a pretty effective uh, advertisement campaign recently. Um, if somebody, uh, is, the whole point of them is, uh, the whole point of these medications is to have people pee out more water so their sodium levels go, go up because the [00:31:00] concentration, uh, increases.
And so the, the advertisement for these medications was to have the, a salt shaker, like the salt shakers you see in restaurants, but coming out of the salt shaker was a, uh, kind of a heavy stream of water. That's generally how these things work, and it seemed like a good idea for this patient because nothing else seemed to be working.
And then, well, as it would turn out, um, as I'm getting ready to put in the orders, I just typed in into the EHR, CONI VAPDAN, hit enter, then this patient starts getting CONI VAPDAN. It's as simple as that. It's actually fantastic. Very convenient for the, uh, the position. Only takes a few seconds. The issue is that a month's supply of CONI VAPDAN costs this patient 30, And at no point during medical education were we ever taught how much these drugs cost.
And, uh, you ask yourself, why is healthcare so expensive? And then you're met with the phenomenon that a physician within a couple of seconds can cost a patient 30, 000 a month. That might explain a [00:32:00] little bit, uh, a little bit of that, that, uh, excess cost. I mean, it's not just INTOLVAPT. I mean, uh, the cost of some of these immunologic, uh, um, agents are, are absolutely mind boggling.
Firouz D.: Bernard, I'm glad you brought up the issue of basically disconnection of the medical education from the realities that are practiced. You brought up the issue of the total ignorance of education, medical education on the cost. And whereas the physicians, they have the authority to basically cause significant financial damage to their patients because they have no clue what their insurance is, how much deductible they have, and so forth.
Where I have the pen, they have the authority to issue tens or hundreds of thousands of per month for a basically the patient. The second part that we have discussed in the past is this basically pen that can write the most [00:33:00] expensive treatments for this person is totally free and independent and irresponsible toward the outcome.
That is basically this pen is writing. Absolutely.
Bernard Evenhuis: Absolutely. Um, uh, and, uh, this kind of. touches upon again, the structure of medical education, right? We, we learned that there's, there's a specific algorithm of how to, how to work things up and treat things like a series of steps that you should do. And if you don't do these series of steps, well, you're a bad doctor.
Um, and, uh, and so what I realized as I, as I started to meet and, and, uh, help diagnose and treat patients is that oftentimes we're taught things that Actually don't do much for moving the dial on patient outcomes. So, for example, even today, I was seeing a patient, uh, Uh, she had diabetes, she had hypertension, all these cardiovascular, uh, risk factors.
And every physician worth their salt that, uh, manages hypertension, diabetes, uh, wants to avoid heart attacks in their [00:34:00] patient, they, they, uh, um, they'll use this, uh, ASCVDE, uh, risk, uh, scoring to calculate their 10 year risk of, uh, of a heart attack or a stroke, um, you know, given, given their cholesterol and hypertension.
And really the decision to make there is to, whether or not to put this person on a statin, a medication that, uh, so many Americans take that, uh, intends to lower the cholesterol risk. And today I was wondering to myself, okay, say I put this woman who wasn't previously on a statin, let's say we started on a statin, I was wondering how many, Years of life am I actually giving this patient, or, or helping this patient obtain by putting them on a statin and telling them to take it every day?
So I did a little bit of digging into the medical literature, and there hasn't been many studies that actually have as a primary outcome the life prolongation effect of statins. But there's enough studies to get a statistically significant review, [00:35:00] meta analysis, some evidence on how much statins actually prolong life.
And so, in the current literature, our best estimate of, uh, having a person take a statin every day as prescribed for five years. Does anybody want to take a guess at how long this will prolong a patient's life? I'm going to go with months.
Firouz D.: Okay, what about you, FD? If someone tells me that I have to take this for so many years and anything less than a year or a couple of years, uh, I would
Josh Taylor: throw that away.
I was going to say, and I want to add that I'm saying months because I'm cynical.
Bernard Evenhuis: Sure, so while some researchers in Western Europe, many in, uh, in Denmark actually did a review of the current literature, All the randomized clinical trials and all the data that we have on this subject. And after this intense review of the, the literature, they found that the immediate, the expected time of taking a statin for 5 years, um, the [00:36:00] expected additional time of life is actually 10.
6 days, given one approach, uh, of, of computing, and then 8. 9 days. Uh, with a different approach. So, um,
Firouz D.: and what is the total cost of five years of taking the statin?
Bernard Evenhuis: Uh, so, so the average monthly cost of, uh, one of the premier statins, the Cadillac statins, we use it all the time, a tour of a stat called Lipitor is about 430 per month.
So if we multiply that by, uh, 60, that's 25, 800 and a whole lot of dedication, um, and, and keeping up with taking it every day. So. Those, uh, those 10 days of light, uh, 2, 500 a day,
Josh Taylor: kind of expense. Not to mention the fact that I would assume that that study is only specializing, looking at did it prevent heart attack, right?
Like that's the actual thing that it's [00:37:00] measuring, not all the other systems that may be affected by the fact that they're taking the statin for five years.
Bernard Evenhuis: So a lot of, a lot of the studies that I've looked at this subject look at specific measures like whether or not people had a stroke or whether or not people had a heart attack or looked at specific numbers like how high is somebody's LDL before and after taking statin.
What many don't report on is actually how much light does being a statin, uh, being on a statin give. And so this is some often, uh, not discussed. Uh, evidence, um, within cardiology circles, um, because the, the evidence suggests that, um, perhaps we're not really doing much to prolong people's life by using these medications.
And it's not just statins that follow this pattern. Actually, um, and this is something that we've discussed before, uh, uh, FD, but, uh, there are a whole lot of things, quote unquote, things [00:38:00] we do for no reason, uh, within medicine, whether inheriting a specific tradition or just being told that this is how we do things.
So, for example, correcting calcium for people with hypoalbuminemia or doing abdominal x rays for constipation in children or, Putting, uh, people on specific types of antibiotics with specific types of infection. In fact, the practice of medicine is just riddled with, uh, with all these practices that actually have no basis in medical research.
And that medical research has not demonstrated positive patient outcomes. I think this touches on the root of the problem. We spend four years in medical school. It's a very difficult field to study. And if you put enough effort, you can, uh, um, become very good at internalizing all this medical knowledge.
And you can apply it to people's presentations in order to differentiate them and then hopefully treat them. But the issue is that all that information that we learned doesn't actually, often doesn't actually have any correlation [00:39:00] with how much treatment costs or any positive effects on patient outcomes.
I want
Firouz D.: to kind of bring this home and we wanted to Look at the, really the root causes of, uh, this, uh, sick care. And as you could see, the, the current medical education, it's really more than 90 percent of the curriculum in the Air Force is on the post event, post, uh, uh, health event training, uh, to train the physicians, really train the physician to be sick care specialist.
And in that process, the primary care is the feeder into the specialist, the specialist Basically, the more they do, the more incentive they have to make more money. And in this process, the whole person and their medical condition root causes have been totally ignored. There's no place in the system to pay attention to that.
And that part also now has played the role that this medical [00:40:00] education is completely devoid of the costs and the burden that these subspecialization and technology costs for the, for the member. That is the kind of the dark side. The bright side is the new generation people like Bernard, who really has taken this upon himself to go and shed light on the fact that we do need to go back to the roots of what the medicine was caused of, helping people do no harms.
And really the new generation of the guardians, not only, The guardians will be the guardians of the health of individuals, but as you could see, the guardians of a wealth of people. The historical time has arrived for us to look critically as how we need to shift and the direction of the medical education towards health.
The guardianship of health by the time being the sick care specialist.
Josh Taylor: Bernard, thank you so much for sharing your experience in med school. I think it's [00:41:00] very revealing where some of this stuff is stemming from. I think when we see some of the situations that are going on inside of our healthcare system, we can forget that every doctor has gone through med school, and so that the training is there someplace.
And to see, to furthest point, a physician that's gone through med school but is asking the questions is actually very encouraging. So thank you for, uh, being in the fight and being a part of the rebel camp.
Bernard Evenhuis: Yeah, absolutely. And, um, you know, I hope that sharing my experiences has shed some light on, uh, issues with the structure of medical education.
Not, not in a way to criticize needlessly the, the concept of medical school, but to demonstrate that, There is the possibility of creating a type of medical education that equips people to guard health, that equips people to prevent others from developing chief complaints rather than [00:42:00] waiting for the chief complaints to happen in the first place.
But it was an honor to be on the show, uh, uh, tonight, and I really appreciate the opportunity.
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