Everything Doctor's & Hospitals are Afraid to Tell You: FDA Commissioner Dr. Marty Makary on How to Negotiate Your Medical Bills, Advocate For Yourself & Restore U.S. Healthcare

25:16And so they've just said, hey, we're going to redesign insurance so that you pay the first five or$10 ,000. So if I go to the hospital with a pneumonia, insurance won't pay for that. And by the way, I don't have insurance, so I have no idea. So insurance. One of these friends are going to call me when you get sick saying, look, I don't have insurance. Look, so here's how it works. So the first, the bill, you're gonna have to pay that bill up to five or$10 ,000 if your deductible is five or$10 ,000. Are they that high for like something as simple as the cold or pneumonia? Yeah, it's for any healthcare spend.

25:50It's an annual deductible. So now the average deductible in the United States is around$2 ,000. For basic care? Basic, but let's say you make$40 ,000 a year. You're not buying the gold-plated Cadillac health plans. You're buying the ones with the high deductibles. And so when you get that bill, when you take your kid in for asthma treatments, a mom is coming to me saying, hey, I was just worried they had an asthma attack and I got a$6 ,000 bill. I have to cover it even though I have insurance because my deductible is 10 ,000. So everyday Americans are getting hammered and that's why the phone is ringing off the hook in Congress right now.

26:28And healthcare is positioned to be the number one issue in the next presidential election. So, I mean, I guess I'm trying to think the last time I had insurance might have been when I was like a college student and there was like a college plan and deductibles were like$20 or$50. Right. Is it that they've risen that much or that I just had a bad plan one way or the other? They've risen. So the health insurance companies say, oh, we're going to design you packages for you to buy health insurance. That's not real innovation. just by saying, okay, we're only gonna cover the amount over a certain point.

27:06That's not a breakthrough in healthcare. That's just spreading the cost around. Why are deductibles going up? Like, was it a bad business model for the insurance agencies to, like, were they losing money on, you know, what's called the float of the insurance company? So it's, you know, I think it's the two root causes I identify in the book, The Price We Pay, which is medical inflation that's been going up nonstop, a mass increase in the middlemen of healthcare with money games so sophisticated, they're designed so no one can understand them, but I expose them in very plain English so anybody can understand them, and then the pricing failures.

27:45So when you don't have to disclose a price, why not charge quadruple or 10 or 20 times? Our research started with a study of emergency room bills showing that they range from one and a half times higher than what Medicare would pay to 23 times higher with everything in between. To deliver a baby in this city, New York City, it can cost you$6 ,000 for a standard uncomplicated labor and delivery or 70 ,000, actually technically$66 ,000. So six versus$66 ,000. What's the difference in treatment? Like why is there that spread? There's no difference in quality. Matter of fact, it's the same doctors just going to different hospitals, but it's sometimes it's just the wild west.

28:31It's whatever people can get away with. And so there are these preset, why would you go to a$6 ,000 when, $66 ,000 house, when you can go to 6 ,000 if you don't, if you're not paying the bill. I see, because it's the same thing, almost like the student loan crisis. Like they can keep raising tuitions as long as they know the federal government is backing all the loans. Exactly, exactly. So employers have stepped in and here's the bright spot. And they said, hey, we want our employees to go to the$6 ,000 hospitals to deliver a baby. If you go there, we'll give you free diapers and wipes for a year because we want to, you can go anywhere and we'll pay for anywhere and we're not telling you where you can and can't go.

29:11But here's an incentive. There's a company called Healthcare Blue Book that will write you a check for 100 or 200 bucks if you go to the lower cost MRI center if the quality is otherwise equal. Is there, is there, so - That's an example of entrepreneurship given this problem. So given that there's this large spread, they can afford$100 if an insurance company pays them$1 ,000 to avoid sending the patient to the$66 ,000 place and send them to the$6 ,000 place instead. Is there other innovations? Can someone start a deductible insurance company? Like for a fee, I'll take care of all your deductibles.

29:54Yes, there's certainly a whole bunch of those. and I'm really excited about the entrepreneurs. I met a lot of them for the book. But ultimately, what sort of, I guess, breaks my heart about this whole situation is that hospitals were built by churches, by and large in the United States, to be a safe haven for the sick and injured. According to their charter, regardless of their race, ethnicity, or ability to pay, anybody would be welcome. So can people be turned away from ER if they clearly do not have the money and don't have insurance? Not for emergency care. There's a law that says hospitals are required to take care of anyone with an emergency.

30:36But if you have no insurance or you're out of a network and you have an elective situation, that is a non-urgent thing, good luck in America finding a hospital that will take you on for charity care. Charity care has become almost rare. What's a situation of elective care that you don't think is that elective? Well, let's say you have colon cancer. If you don't have insurance or your deductible is prohibitively high for your income, that's something where we as a society should take care of those people. But now healthcare is so unaffordable, these people are getting shut out of the system. So right now, many hospitals are saying, oh, we do$100 million in charity care a year.

31:21Be careful of that number. Just gouging somebody with a high price and then taking whatever you can get is not charity, right? That delta is artificial. It's based on how you've marked it up. And if we can use honest terms like markups and price gouging and predatory billing, we can call out the practices out there. I personally believe, and I've told this to the White House and the members of Congress and name it, Trump, Nancy Pelosi's office, the head of Medicare, that billing quality in medicine should be a part of hospital quality. When you look up a hospital's quality, you should look up their billing quality.

31:58What's their average markup? Can they, do they sue patients and garnish wages? Do they put liens on homes of low-income people?

32:22So again, and this is what you talk about in both books, Unaccountable and The Price We Pay, transparency is something that's lacking from the system. There's data and each hospital has data. Is the data easily available if I ask for it? So the, no, it's not. Because right now there's the sticker prices, which are already out there. The sticker prices were required in January of this year to be publicly reported, but they're so egregious and variable and nobody is really getting it. Those prices aren't really fair and they're confusing. That's not meaningful. What we need in America is true price transparency.

33:00The real prices that the insurance companies and the hospitals negotiate, what the hospital will offer as a fair price to anybody. And then you'd have employers and what we call proxy shoppers in health economics do the shopping for the rest of people. When you go to the grocery store, you don't look at the price of a lemon, do you? When you buy a lemon or an orange, you rely on proxy shoppers. They keep the market in check. 10 or 15 % of people like my mom, you know, shop by the penny and compare, you know, a lemon or an orange at every single grocery store in town. And they're proxy shoppers.

33:36But not really for grocery stores. There's nobody who, I mean, just like a lemon is a commodity. so people have a sense, oh, I can get lemons anywhere. And they get a sense of the price and they go to the cheapest place. Yeah, and you rely on the prices of the cereal and the milk to approximate the price of the lemons. And if they were to gouge people on lemons, the word we get out or the proxy shoppers would stop shopping there. Also, proxy shoppers are employers in the US. Most people get their insurance from their employer. Their employers are deciding who's in that network. Now, I've met many business CEOs that are saying, I don't want this hospital in my network because they price gouge like crazy.

34:22I want this other hospital in my network, but they can't get at the prices. They're only getting hearsay from individual bills and crazy stories. Is there ever kind of a payola situation where some chain of hospitals that price gouges will pay to a company like, hey, make us your hospital of choice and we'll pay you X amount of dollars. Yeah, the price gouging game and the network game is both the problem and the solution that they have created. It's all artificial. Creating a network is, the network is both the firefighter and the arsenic. A network of hospitals. Yes, it's the boogeyman and it's the savior, right?

35:01If you come and go to a hospital, oh, you're out of the network, shame on you, like you did something wrong. The solution they offer is you've got to be in our network. Well, it's all artificial. If we just had honest, fair, transparent pricing, we wouldn't have these network games. And people could shop, employers could shop, proxy shoppers could shop, and we'd have real competition. So again, it seems like figuring out a way to enforce transparency, like not only reveal prices, but there has to be some sense what the price should be. So like, what should the price of a birth be? You know, should it be 6 ,000?

35:40Should it be 10? You know, should it be 66? Like, because I don't know which one's too high and which one's too low. I want the best care too, because there's that factor. So people show me their egregious marked up bills and we look it up on healthcare blue book, what the reference base price should be, just like Kelly blue book. How do they determine what it should be? So they get access to certain databases, including employers that hand over all their bills and they identify what the average price is in a certain area for a certain service. So Healthcare Blue Book is one innovation and it's one thing out there.

36:16I think it's a great company. They're one of the disruptors I highlighted in the price we pay, but I would love it. You're friends with all these hitters in the United States. I would love it if Google put on their website when you Googled a hospital, the average markup of that hospital Is it two? Versus the healthcare blue book price. Yeah, you could use that. That's called the reference-based price as the reference. Or you could use the Medicare allowable amount, which is what we use in our research at Hopkins. What if Medicare is wrong? Well, we know Medicare is, well, first of all, we know Medicare is not perfect, but we know 70 plus percent of providers out there would gladly take Medicare patients or else they would turn down Medicare.

36:59So if they're accepting Medicare, reimbursed Medicare patients, and they like that money, then we know it's roughly approximate to the true cost of doing the service or profitable for them. But when I go into a hospital, I don't necessarily have the Medicare prices all in a menu right in front of me. I'm going in there in emergency. They could charge, I'm knocked out. They could charge whatever. And if I say to them, hey, Medicare was only charging 10 ,000. You just charged me 25. They won't do anything? Look, one tip for any viewer listening is every hospital bill is negotiable. Even every service before you pay for it or agree to that service is negotiable.

37:40You just have to get to the right person. We've seen bills slash down 90%. And that tells you if they have that much room to come down, that there's a game going on. And a lot of these revenue cycle people are embarrassed by the game. And that's why they're very quick to offer these discounts. You just have to get to the right person. So the main issues though are this price gouging, the out of network trick to sort of bill more, the inflation of deductibles. It seems also there's, and maybe this is in the next category, the treatment we get, but it seems also there's over prescription of services.

38:21So I get things that I didn't need or want. Yeah, too much medical care. Is this in the price part or is this in the over prescription? Oh, inappropriate care. Number two, root cause problems. So if number one root cause problem in healthcare is pricing failures, number two is inappropriate care, often too much care. By the way, just as a quick mention, there's nothing wrong with being out of network. If you're a doc and there's supply and demand and you don't want to be in network, that's fine. But disclose that if you're at an in-network hospital. There shouldn't be a bait and switch going on.

38:53You mean the doctor should disclose? Yeah, should disclose. Hey, look, you're going to get a separate bill from me because I don't participate in your insurance. And even though the hospital participates in your insurance, my care is separate from the hospital bill that insurance will pay. So here's a question. Why can't hospitals require every doctor working for them to accept the same insurance the hospital does? It's a great idea. Or why can't the hospitals cover the doctors somehow? Why can't they have some sort of umbrella policy? If you're a doctor working in our hospital, our insurance will cover your costs.

39:26Look, James, that logic is so simple. It's brilliant, and that's exactly what we need. And if you look at the bills in Congress right now, that's what they're proposing. And that's the kind of common sense thing that we need right now. I mean, people are getting hammered. But is it like hard for a doctor to get multiple insurance companies to accept his work? Yeah, but we can get our act together, right? If we're all working for a hospital, we can get our act together. We can have one master bill. We can have fair pricing. We don't have to price differently based on who you are. And these are the common sense reforms that we need, and they're circulating around Congress right now because people are pissed.

40:06And who's against these bills? Oh, you would, if you saw the amount of money spent by the stakeholders of healthcare, the fourth largest contributor to campaigns is the hospital association. But why wouldn't the hospital be in favor of these laws? Because life is good. Life is good right now. But wouldn't it be better for them if they're charging even more because they'll mark up the doctor that is working for them and they get guaranteed payment because insurance pays for it? I'd love for you to talk to them and tell them that because we've been telling them the same thing. But look, if you're charging$70 ,000 for non-complicated delivery of a baby for which the reference-based price is six or seven, if you've got a tenfold markup on your service, do you really want to support price transparency legislation?

41:01As a human being, the hospital leaders tell me, yes, we need this, this is important. As a trade association, the lobbyists are fighting for the interests of their... Okay, so to be fair, if I was a hospital in that case, I wouldn't want transparency, right? I want to make as much money as possible. And my argument would be, we do this so we could do charity care. I'll have all sorts of arguments. But it seems like to a hospital, let's say I'm a hospital, it makes sense for me that all the doctors working at the hospital are in the same network as me. I don't want any out-of-network doctors because I don't want to have problems.

41:36I don't want to have patients calling my customer service all confused and going bankrupt and so on. I'd rather the doctor have the same insurance company as me and then I just mark up the doctor a little bit and I'm guaranteed their insurance company will pay me. That's one of the reforms I detail in the book, The Price We Pay. It's one of the reforms that's in Congress right now, but inaction is the worst enemy right now in healthcare. And we're seeing people just enjoy the status quo, the stakeholders. But like on that thing specifically, why would any legislator be against that idea? Because the American Hospital Association is the fourth largest campaign contributor in the United States.

42:16But even then, like, again, you and I both worked out the math. it's better for the hospitals. Well, people aren't shopping though. You mean for them to accept these out of network doctors as in network? Or force the doctors to be in network. Forcing doctors to do anything is never easy, right? But then I won't hire them if they're not in network. Well, a lot of times the doctors have the leverage. I mean, you've got ER groups, GI groups, cardiology groups that staff every hospital in an entire region. Okay. And so who's calling the shot? Who's working for whom? And if there's one business model in healthcare that's been the defining business model of the last five years, it's that if you can pull something out of the hospital bill, if you can pull the lab cost or the x-ray or the air ambulance bill or the ambulance bill or the doctor's fee out of that master bill and bill separately out of network, you can collect a lot more.

43:10And we've seen this massive fragmentation. When you buy a car, you don't pay separately for the steering wheel. and the spark plug and the belts and the axle. But that's exactly what you have in healthcare. And people are getting hammered with these surprise bills. And do the hospitals make more because it's so separated out? Well, every piece, every stakeholder is making more because it's a money grab. Every group is taking more money out of the system. I see. And so you have people going in for a simple set of stitches and they're getting hit with four or five surprise bills that are out of network.

43:47Because this anesthesiology group is called in, this doctor is called in, this x-ray technician is called in, and then the hospital charges. Yeah, you deliver a baby, the obstetrician is out of your network that night that they're on call. The anesthesiologist that put the epidural in is out of network. The pediatrician who sees the baby is out of network. And if the hospital says to the doctor, well, you have to be in network, the doctor can just say, no, but what are you going to do on Thursday night when you have no other obstetricians on call? Well, that's one problem, but also we need to get our act together at hospitals and just do this because it's the right thing for patients.

44:22I mean, where's the spirit of altruism? Where's those bright medical students? Well, to your point, though, all these private equity firms are buying these hospital groups and doctors groups, so they're just about the bottom line. That's just their mentality. I'm not excusing them. Exactly. I agree with you. Why else would they be buying specifically doctors where you have almost no choice? they're buying emergency room, radiologists. Do you pick which radiologists read your x-ray? Anesthesiologists, neonatologists. I mean, who picks their neonatologists? Well, this, like take radiology. Will this get better as AI starts reading x-ray?

45:01So there's some areas where technology is gonna just sort of move the needle and that will solve part of the problem. So I wanna ask about the inappropriate care because it's all related, right? Because people get charged for inappropriate care too. Yeah, that's the ultimate sort of double whammy, right? You have inappropriate care, then you're price gouged for it. Yeah. You have a great example with the Shah in 1979. The doctor operated on him, was convinced he was brilliant, did a great job. The Shah was fine. And then a week later, he's practically dead because the doctor cut his pancreas and his doctor was in complete denial.

45:39Yeah, the United States sent over Michael DeBakey who's an amazing and famous heart surgeon, to operate on the Shaw, but the Shaw did not have a heart problem. The Shaw had a spleen problem. And DeBakey was not a surgeon for the spleen. Now he's got good hands, but I mean, he had a complication. There was a pancreatic fistula from injuring the tail of the pancreas when he removed the spleen. And that fluid built up, got infected. And it's a great example of how people are flying blind. They think some guy's the best or some woman's the best at this procedure or expertise. The reality is we're not great at humility in medicine.

46:23We're not great at, I don't know. We're not great at see my partner because they have more experience. Is that because of the legal ramifications also? No, I think it's the individualism that we promote in medical school. It's competitive. There's a bias towards competitiveness, individualism and performance. And so it's a referral business. Look, I'm a surgeon at Johns Hopkins. Even though I work at a hospital, it's a referral business. Medicine in New York is the classic referral business. Only in New York do I hear vascular surgeons telling me, you know, Marty, I did this procedure. The patient didn't need it done.

46:59But I know for a fact, 100%, if I didn't do it, they were going to go across the street to the other surgeon and they would do it unnecessarily. So I'd rather be the one doing it. Who's telling them to do it? The patients, well, they just see the opportunity to do it. And they see that the patient will get a second opinion because it's very common in New York City. And they figure if someone's going to get it done, I might as well. Now, this is not most surgeons. Most doctors do the right thing and always try to. But we see this sort of, we ask doctors in the United States, how common is the problem of unnecessary surgery?

47:31National study published from Johns Hopkins, 11 % of surgery is unnecessary. That's what the doctors say. And how much of that is mistaken unnecessary and how much of that is, let's call it malicious unnecessary? I think it's like we get that we as surgeons notoriously under recognize the risks and we overstate the benefits mentally. That's how we think. We think things are very safe. We tend to minimize the complications. We oversell things. I mean, that's how we think of it in our minds. So it's not that we're being malicious sometimes. So we've got these biases. But once again - Oh, and can I ask, is the bias fueled a little bit by, like, will malpractice err on no prescription or, oh, I did this surgery.

48:20Yes, there was a within range predictable accident. And it's like, are they more confident they won't be accused of malpractice if they do this surgery than if they don't and the patient needed it? So the malpractice fear goes both ways. It's people avoid, doctors avoid doing things because of malpractice fears just as much as they probably do too much. Now, malpractice is a tricky one. All the experts have suggested it's less than 1 % of medical costs. It's not the real driver. And where it is, doctors sometimes just need to take a stand. Now, certain areas of medicine are getting hammered, obstetrics, neurosurgery in rural communities.

48:59There we need real malpractice reform. But check out the movie Bleed Out And you'll see this story of how malpractice laws are not as liberal as people think. In other words, they tend to favor physicians. They put caps. They have committees review cases before they can go to court and depending on the state. And the idea of the frivolous lawsuit is really extremely rare. The largest lawsuit in US history for a malpractice case from our research was$75 million. So the idea that there's like a billion dollar lawsuit for doing an unnecessary MRI where somebody cleans out their psychic powers from the magnet.

49:41I mean, those are long, tall tales that are not their problem. That's interesting because I sort of like anytime someone dies, I always hear that some relative will say, there's malpractice, we're gonna sue. But you're saying it just doesn't happen that much in reality. No, I'm saying that medical care goes wrong a lot. But I'm saying the fear of malpractice, making doctors do the wrong thing, or too much care, is probably overstated in our minds. Now, there's individual cases. Of course, people are going to disagree. But the idea that—so let me just tell you. We asked doctors this question. When they answered that 11 % of surgery is unnecessary and 21 % of overall all medical care is unnecessary, This is the voice of doctors nationwide in the US study.

50:32We asked them why. And they said, number one, sort of a consumerist culture, people coming in demanding stuff, right? Moms coming in demanding an antibiotic for their kids with the viral sniffles. So yeah, what's an example of something where patients really think they need care, but they just don't, and it happens all the time? I'd say the pill culture. Look, 10 years ago, we doctors in the United States prescribed 2.4 billion prescriptions. Last year, it hit 5 billion. Did disease double in the last five years? No, we have a crisis of appropriateness. So, yeah, when, so, okay, this is, by the way, I'm getting free medical advice from you right now without having to pay for it.

51:17So like if someone gets a scratch and it becomes infected, do you need antibiotics always to cure it? So I was growing, I grew up thinking, my grandma's wisdom said, if you get an infection, you can only cure it with an antibiotic. So, you know, as a surgeon, I can tell you open wounds don't get infected when they're exposed to the open, generally speaking. Now there's exceptions where there's not good blood supply and you do need to give antibiotics or topical antibiotics. But the overuse of antibiotics in medicine is one of the most egregious areas of overuse. And it's creating resistant superbugs that are going to come back with a vengeance.

51:58So when should I not use antibiotics if someone says use antibiotics? General principle, and I should clarify, this does not constitute the practice of medicine and no doctor-patient relationship is formed. If something is red, antibiotics are probably appropriate. If something is burning, if something is warm, if something is worsening. So like a rash though, it seems like that is in pain a little bit, that's probably needs an antibiotic. Well, a lot of things can cause rashes that are not bacterial infections that respond to antibiotics. But generally if things are red, burning, increasing, warm, giving you a fever, those are antibiotic related.

52:46Those are bacteria related. And if you don't take the antibiotic, Will it just get worse and worse? Or will it ultimately get better? If it's a bacterial infection, it can get worse. So we take things very seriously like dental abscesses or infections after surgery. We take those very seriously in closed cavities. Open wounds, like I said, are usually open and they don't get infected. But - What about something like, and this is almost off topic, but what about something like Lyme disease? Like my kid had Lyme disease and I avoided for a year having her on antibiotics, but then finally the school made her go on antibiotics.

53:24Well, generally speaking, Lyme disease, you want to treat with antibiotics. It's a spirochete and it does respond to antibiotics, especially if you treat it early in the course of Lyme disease. The tricky thing with Lyme disease is diagnosing it. And so, you know, there's a series of tests out there and some people think they have Lyme disease and they don't and vice versa. And it's tricky. Okay, so back to inappropriate care. What are other kind of big red flags that you discovered on your quest around hospitals in America? Just to note, that's how you researched this book is you went all over the country.

54:01This is not just research-based. You went all over the country and had firsthand experience seeing these situations. Yeah, I really enjoyed doing the research for the book, The Price We Pay, traveling around America for two years, visited 22 cities, talked to women that had C-sections and their doctors, insurance executives, everyone in every level of healthcare. And I would say C-sections was a big one. We found hospitals where one doctor had a C-section rate of 100 % and the other doctors had C-section rates in the teens. And they all randomly took call nights. So it's not like they had their sicker patients.

54:39They're all on call on random nights where people just come in randomly. So was it just that this guy was very confident that if he did a C-section, it would result in a healthy baby and he wasn't confident otherwise? I think it was sloppy medicine. Look, C-sections are generally more profitable and they're easier and they provide, I wouldn't say easier, but they provide more certainty for your evening. They're better for planning, right? Do you want to wait all night being, you know, waking up all night, waiting for a woman in labor to get to that point where you're going to do a vaginal delivery?

55:11Or do you want to tell them at eight o 'clock or nine o 'clock at night, hey, maybe we should do a C-section. It might be safer for the baby. The second a doctor says that, guess what? A hundred percent of women in labor anywhere in the world are going to say, do the C-section. It reminds me of when a woman's pregnant, what's that thing where they get the amniocentesis? So every doctor says, oh, you have to get amniocentesis. I don't want to say every doctor, but every doctor I've encountered says you have to get the amniocentesis. And then if you say no, so this is what's happened to me with, not me personally, but the mother of my children.

55:51If you say no, they always find some test where, oh, there's double the possibility of this extremely rare disease. They don't mention it went from one in a million to two in a million. And it's, I've, you know, people cry. Like I have 100 % more chance of getting this disease. And they don't know any other statistics about it, but they go rush right into the amniocentesis. Yeah, exactly. We see a lot of that. We, you know, we see tests done where we ask, what are you going to do differently based on a test result? We asked this of the doctor who's sending us the patient. I'm a specialist myself.

56:29I'm a cancer surgeon. You know, you got this test. Why did you get it done? tell me how the result will change the treatment course. And if it's not, if it's just out of your curiosity, that's the waste in healthcare. That's the inappropriate care. So, so. So, how much... So, more inappropriate care. Like what's, how can I protect myself? And this is really going between both books now. So Unaccountable and the Price We Pay. What are hospitals not telling me that I should know to protect myself both on pricing and appropriate care? And then what's the role of nutrition and wellness in all of this?

57:08Yeah. I just asked you a pretty massive question. How do we fix the healthcare system? Write a third book. Well, we put a bunch of resources up on the website restoringmedicine.org on how to fight your medical bill, on guidance for employers and CEOs who want to save money because most businesses are getting ripped off on their healthcare benefits and their pharmacy benefit manager plans. In terms of too much medical care, which is an epidemic, we also have the problem of too little care and the rural access problem, but by far the problem of too much medical care dominates our cost crisis. Anytime you need something major done, a major elective operation, you're gonna start a new medication for the rest of your life, for example.

57:56Get a second opinion. Get a third opinion if it makes you feel better. Ask questions, Google the heck out of it, find out, educate yourself. And there's a lot of great resources out there that people don't realize. Why are we treating hypertension with medication when we could be treating it with yoga. Why are we, now certain cases it's too high and it's out of the range. You're not gonna lower blood pressure in half with yoga. But when people come in with these borderline conditions and we give them a medication, it's because we're on a treadmill. The docs have 10 minutes with the patient and it's this reflex and they're burnt out and they don't like it and the consumerist culture.

58:41So recognize that 21 % of medical care is unnecessary according to the voice of doctors in a national survey. How about diabetes cooking classes as a way to treat high blood sugars? How about meditation for hypertension? And for diabetes, or diabetes too, is there evidence that instead of prescribing all these insulin shots, what if they just eliminated sugar or as much sugar as possible from their diet? Does that help? Or is there holistic non-medicine alternatives in some cases? And I'm not talking about weird holistic stuff, but just like basic nutritional things that they can do to solve serious problems.

59:23The field of nutrition has been corrupted in healthcare for most of its history, most of its academic modern history. We've been given the food pyramid and we've had the food industry tell us things like breakfast is the most important meal of the day. Oh, really? Where'd that come from? That came from a General Mills marketing campaign, right? Pancakes and bacon, though, are really God's food. Well, you look pretty healthy, so I'd say whatever you're doing, keep doing it. I'm not doing pancakes, but I do do bacon. Well, if you look at it, the question, is fat bad for you? Medicine's never really had an answer for that.

59:58It turns out all the research shows that there's no association between saturated fat and heart disease. There is research and there's evidence of the best types of oils to cook with, but doctors don't know it. We don't teach it. This is not, it hasn't made the mainstream science literature because the journals don't want to hear from non-randomized trials. Coconut oil is what you should cook with. Oh, really? Coconut oil. So let me ask you this. So you're at 14 years in school or residency or whatever, and you're learning the Krebs cycle, or whatever you referred to before, how come they don't have one course on nutrition and wellness?

1:00:38And you mentioned a couple of things too. There's lots of like basic procedures that solve problems. Yeah. That instead of the complicated procedures. Well, the medical establishment, if you will, has created a curriculum and a testing system that tests on certain things. So it doesn't matter how creative you are as a dean of a medical school, you got to get your kids through that testing system. And as long as they're testing on these things, that's what the curriculums focus on. And if you go in there and talk to people about bedside manner or communication skills or how to break bad news, they're smart enough to know, okay, I'll just park that for a little bit.

1:01:22I got to get through this exam, right? These are smart kids. They know what they've got to do. They know what they've been told to do. And so just going in there and teaching kids that are under the gun to regurgitate all this information is a failed model. We've got to change fundamentally the core competencies that we teach in medical school. It also seems like depending on your specialty should adjust your education, even the time spent. So I just did a podcast recently with the producer of the movie, Ask for Jane. And it was about a group of women in 1970 who helped other women get abortions, which were then illegal.

1:02:05Now they ran out of doctors. So these women taught themselves how to do an abortion. They did something like 11 ,000 abortions without one fatality. And they taught themselves to be essentially doctors for abortion. Like I'm curious how many specialized skills could be taught in a matter of weeks instead of 14 years. Look, if we just let nurses and technicians practice at the top of their license, you know, for the stuff they're trained to do and the stuff they can do, we could harness this mass energy and talent and compassion to do a lot more in healthcare. At Johns Hopkins, our head of the GI department is having nurse practitioners and physician assistants do screening colonoscopy procedures.

1:02:53Why not? I can take a kid from high school and probably show them how to do half of the basic skills of wound care and surgery if I had enough time with them and if they were motivated and determined and had that empathy. Right, and you refer to that like almost moving back to more of an apprenticeship type system. Yeah. So is that possible? Because it seems like that would be great. It is. And I love the curriculum. I always try to have bright spots in the book, The Price We Pay. and Jefferson Medical School has the most innovative curriculum. This guy, Steve Clasco, is doing incredible work.

1:03:28He's basically accepting students based on empathy and self-awareness. And then he says, if you meet a certain benchmark grade point average, say a three, four or higher, I'm just gonna hire based on empathy and self-awareness and communication skills. He accepts those kids and he really just beautifully walks them down the art of medicine and how to do great bedside care and think about holistic care and everything out there. And you mentioned in Unaccountable kind of the statistics that essentially what determined, the statistic that most determined success in a surgery is how many times a doctor has conducted that surgery.

1:04:10And it resonated with me because I've always been writing about, the needs for different types of educational systems, whether it's college or law school or whatever, like how long does it take to really learn a skill? And I remember I was at a dinner once, somebody asked me and asked me kind of in this rude way, well, what would you prefer? A doctor operating on you who didn't go to school or a doctor, a brain surgeon who graduated from Harvard Medical School? And I said the answer, which is I'd rather have a doctor who's done a thousand brain surgeries. I don't care where they went to school.

1:04:51I just want like a really experienced doctor. And I was glad you made that point. Finally, 10 years later, I see someone who makes that point in your book. But that does seem to be the way to go. Like that would have solved the Shah's problem, for instance, the heart doctor operating on the spleen. Yeah, and the book Unaccountable, I basically try to help people decipher and navigate the healthcare system to get care for themselves, letting them know what goes on behind the scenes, how doctors find care for themselves, how we do it for ourselves. And what do you do? So basically you delineate, are we looking for a diagnostician that is someone who can figure out what's wrong with me?

1:05:29Or am I looking for a proceduralist, somebody who's just technically the best at what they do? So once you figure out that you definitely need something done, you wanna go to the person who has a lot of skill with that procedure, a lot of experience, what we call volume in the health economics literature, and also somebody who's responsive. The ER doctors will tell you which surgeons don't answer their call when somebody has a complication, or the ER nurses will tell you which doctors don't show up when one of their patients has a problem. So you want somebody who's got a lot of, volume and somebody who's responsive.

1:06:09For the diagnostic doctor, the doctor who's trying to figure things out, you want to look for humility and listening skills. What is a diagnostic doctor? Like I've never heard someone say I'm a diagnostician. They're usually like a liver doctor or a heart doctor. No one ever says I'm a diagnostic doctor. It's a category of doctors. So every doctor is in part one or the other. So, you know, I'm probably 80 % procedural, 20 % diagnostic. So if I went to you, would I say, would I ask, should the patient ask what, that was just your subjective view of what you are. How does the patient know if you're a diagnostician or a proceduralist?

1:06:53Yeah, so I try to give pathways based on the condition. For example, the Lyme disease example that you gave. you want to find somebody who's seen a lot of Lyme disease and maybe a primary care doctor who's referred a lot of patients with Lyme disease and has had that loop closed back to know what the outcome was. And they can help decide, did you get the right test or not? Or maybe there's more tests to do. I found in that one specific case, or actually another family member with Lyme disease, Lyme doctors think everything is Lyme. You know, it reminds me of another situation. We all kind of know that the dinosaurs died because an asteroid hit the earth.

1:07:34But if you ask a volcanologist, someone who's a specialist in volcanoes, they're all convinced, no, that's not true. There was some big volcano that wiped out the dinosaurs. So every doctor is going to, you know, it's their nail. I don't know what the expression is. This is their hammer, so they're going to use it. Yeah, well, you're always going to have different levels of, of, how shall I say, like doctors who really have a command of their field. So for example, cholesterol testing. If you go into a doctor's office in the United States, 90 plus percent of doctors for that annual checkup are going to say, oh, we need to get a cholesterol panel, total cholesterol, triglycerides, HDL, and LDL.

1:08:13Well, guess what? That's like 40 years old, and it's mostly not helpful. The LDL is a reasonable proxy of your cholesterol profile. But how about lipoprotein little a, which is a blood test every person in the United States should get at some point in their life. Turns out you only need it really tested for once. The New York Times had an article titled, and I thought it was a great title, the blood test that one in five Americans test positive for that predicts early heart disease, but few doctors have ever heard of. What about cancer type stuff? So you go in, you have some pains, they want to throw you right in some kind of, I don't know, x-ray tube for like hours.

1:08:57A CAT scan or an MRI. Yeah. I like your colloquial description of our medical procedures. Yeah, I mean, there's judgment to it, right? And this is where we're not taught in medical school how to manage that gray zone. What's the trigger point for doing something? What's the threshold for intervening or testing? You know, I talked to a neurosurgeon who basically told me, he's a really good neurosurgeon, great technical skills. I said, I have a friend who had a headache. How do you evaluate what headaches to get an MRI on? He says, I would just get an MRI. I said, no, I mean, I'm asking like, just so I learn what, how bad is the headache where you say we should go?

1:09:38He says, I just, like, I just get an MRI on everybody. And I realized, you know, he has incredible technical skills, but doesn't have that sense of what's the appropriate threshold. So, you know, these are all things to weigh and consider. Now, when you talk about cancer, you don't want to mess around. You want to be aggressive with evaluating cancer. But there's like 6 ,000 cancers. You can't test for them all. Well, we shouldn't be doing blanket screenings for cancer because you end up with unnecessary care. And yet many cancers are asymptomatic until it's too late. Well, certainly that's the case with the cancer I deal with, which is pancreas cancer.

1:10:1680 % is the mortality rate and few people really get through it. So we do want to, you know, when somebody has symptoms, we want to get to it quickly. We don't want to over screen everybody. We don't want to do routine CAT scans because CAT scans have radiation. And if you find something that's a normal variation and end up in the operating room, you're probably more likely to die of the complication than you are from that normal variation. So we have cancer guidelines. There's no blanket rules, but we have cancer guidelines that are specific to the condition. So for example, with prostate testing, there's guidelines.

1:10:58With mammograms, you know, I personally believe if you don't have risk factors, you start at age 50 instead of 40. That's where I think the data fall. Doctors will tell me, you know, some, the doctors will disagree Some think you should get mammograms in high school, which is crazy because there's normal fibrocystic disease that gives false positives. So there's guidelines that are specific. And this is where you want a really good doc. But if you want to know whether or not a doctor is good, ask him if they have heard of Peter Atiyah, who's got a great podcast on health. Oh, and you mentioned him in The Price We Pay.

1:11:34Yeah. And he had kind of mal, he was a doctor, but still had a bad, very bad treatment that caused disability. Yeah, he's, I think, fully recovered, but he had wrong site surgery. They operated on the wrong site. And he basically, I think at some point, got disillusioned with the facade of healthcare, right? With this, the establishment telling everybody, this is what we have to do on everyone. If your blood pressure is over this amount, we slap them with an antihypertensive medication. If your cholesterol is above this amount, we slap them with a cholesterol-lowering drug. And he's like, hey, wait a minute.

1:12:11What about food? What about lifestyle? What about the real data to support? Yeah, like I have a friend who's had high cholesterol and he's on some anti-cholesterol stuff for the rest of his life. Does he need it? So what the guidelines don't factor is your ethnicity, right? My family is Egyptian. maybe folks from the Near East are more designed for the starvation state and the high cholesterol can be okay and more in a bigger range of normal variation. And no one in my family has ever had heart disease. People live into their 90s with high cholesterol, untreated. So we need to factor ethnicity.

1:12:49We need to factor personal goals. And the data often are not doing this. The medical establishment has sort of given us the Framingham study, which is Anglo, Euro, Americans who have lived in New England. And those results have been extrapolated, by the way, to men and women, even though some of that original data was done in men. Peter Atiyah looks at the real, he's sort of a serial obsessionist of science. And he'll look at, why do we say hormone replacement therapy causes cancer when the data show it doesn't cause cancer? Let's go back and let's re-educate. And to this day, talk to half of primary care doctors or any doctor in the United States.

1:13:37If a woman comes in really struggling with symptoms of menopause, the doc could say, when you ask, what about hormone replacement therapy? More than half of doctors will say, well, it causes cancer. It doesn't cause cancer, right? The data are clear. It's in the article. The whole story of how it was broadcast as causing cancer was a story of individuals, largely men advancing their academic careers in this sort of, you know, in cahoots with the journalists and the media. And so it was a giant misservice. And of course, because it's women, you know, men in the medical establishment relegate this to as, oh, just tough it out.

1:14:18You know, this is not a real issue. Well, guess what? Everyone deals with menopause differently. Some women really struggle. It causes serious symptoms, physical symptoms, pain, sometimes depression, all kinds of problems. Some women go through it with a breeze. But for those that really struggle, these are medical symptoms. These are real feelings. These are real signs in medical conditions. Why can't we give them the treatment that they deserve, that the data show is appropriate for them? and it's because the medical establishment has decided that this horrible study called the Women's Health Initiative is the gold standard, even though the data doesn't even support what the authors proposed.

1:15:07Gosh, I have so many more questions, but no one's knocking on the door here. You're telling me to wrap, but no one's knocking on the door. Can we just keep going until they knock? Okay, go for five more minutes. That'd be great. it's five more because when they're knocked they probably just have to set up and have to break down too. All right. So are you okay? Yeah. So, okay, here's another question I have. I'm just going to keep asking questions that someone gets basic cancer. I know that doesn't mean anything. There's all sorts of cancers and it's stage one and the doctor automatically says chemotherapy.

1:15:41How often is chemotherapy overprescribed? Like would you do chemotherapy for most cancers you might be prescribed with? If it's highly curable, Yes. Chemotherapy is overprescribed. All you have to do is talk to oncologists, get a couple beers in them at the American Society of Clinical Oncology Conference. They'll tell you. And it's a cash cow chemotherapy. For the most part, it depends on the agent, of course. Is it overprescribed when there's no hope or is it overprescribed when you don't need it? Both, both. Look, I see patients with pancreatic cancer getting hammered with radiation and chemo after surgery.

1:16:20And I'm kind of like, there's never been a study showing that radiation improves survival after surgery. Why are we doing it? So, okay, so that's when they're too late almost or beyond. What about when someone first gets cancer? How often is it overprescribed then? Like, why can't I just go to the cancer drugs as opposed to doing chemotherapy first? um they will cancer drugs generally are considered in the domain of chemotherapy so you know that i think the treatment algorithms people trust their doctors look when patients come in to see me they have one emotion that's guiding all their decisions they're scared shitless right they're they're petrified they often latch on doc tell me what i should do and I'll do it.

1:17:12We do get the highly informed patient that comes in with Google printouts of all these, you know, what do you think about this experimental treatment? Do you get annoyed with them? No, I encourage it. I encourage it. Some doctors get annoyed. They call it Dr. Google. I get annoyed if the spouse of the patient will call me and ask me all the questions that I already answered. And I realized the spouse is not really asking. It's the patient pushing the spouse to call and ask the same questions. But no, I mean, look, people are scared. They're acting irrational. And they're allowed to be crazy when you get a diagnosis like that.

1:17:47With breast cancer, stage one breast cancer, if you have a certain type of breast cancer, we know now that you should get a gene test and the gene test will tell you whether or not chemo will even work. If the gene test comes out a certain way, the chemo won't even work and you shouldn't be getting it. So why aren't we getting that gene test in every patient that's a candidate for that gene test telling us whether or not the chemo will work? Well, if life is good, given everybody chemo and fill in the chemo chairs, then, you know, why do this new thing? People get set in their ways when, you know, life is good as is for the business.

1:18:27See, I feel like all of these things you're telling me, like, for instance, the hormone replacement therapy doesn't cause cancer. The high cholesterol doesn't cause, or fat doesn't cause heart disease. It's almost like there's another book needed. Like it's just a simple, almost like here's 101 things the medical industry got wrong and you need to know for your health. Yeah, so I tried to pack as many of those take-home tips in the last half of the price we pay where I get into inappropriate care. So people can be educated and go to their doctor and say, I learned about LP little a, lipoprotein little a, I'd like to get it checked.

1:19:14And can you also send an apoprotein B and a C-reactive protein? Those are the three tests that I think every American should be getting to figure out if you're at risk of heart disease. I've met doctors in doing the research for the price we pay who have done the right tests and followed patients. and for 30 plus years have never had a single patient have a heart attack in their practice or any major cardiac event. Why? Because they're testing the right stuff and they're recommending the right stuff. A new association called the Association for Lifestyle Medicine is now saying, hey, instead of just medicating the hell out of everybody, can we talk about things you can do differently in your day-to-day routine?

1:19:55It reminds me of like in psychiatry, somebody will go into a psychiatrist depressed and they get prescribed an antidepressant. Yeah. But maybe their parent just died and they're, of course, situationally depressed. An antidepressant probably won't do anything because they're not clinically depressed. I mean, I don't know how much of a difference there is, but it seems like there's some difference. Seems like the same thing. Like people are just throwing these medications around. Yeah, and I see patients come in and they sort of whispered to me almost routinely when I see somebody, we go over their medication list and they say, oh yeah, and I'm on so and such and such medication for depression, I have depression.

1:20:41And I tell them, it's okay. Everyone in the United States has depression. Okay, we all get depressed and there's an epidemic going on right now. It's called loneliness. In my opinion, one of the biggest public health crises in America, I talk about it in the book, The Price We Pay. How about treating that loneliness with community, right? How about these seniors that come in? The number one thing we see in seniors is this sense of isolation and loneliness. And guess what? It affects every physiological system in their body. Sure, I mean, have you ever read The Blue Zones by Dan Buettner? Yes. So, and he basically talks about this area in Aventura, California, where every other blue zone, so there's all these blue zones, people live to a high quality of life after the age of 100, so he studied them.

1:21:26They're all demographically the same, except Aventura, California has people from every demographic. And the common factor is Sunday, because it's made it mostly Seventh-day Adventists there. Sunday, they all spend the day together hiking. They have community and they all live to 100. And the community is powerful, right? You see it when there's a couple and one of the spouses dies and the other spouse dies soon after, right? That's affecting their physiological reserves. And I think modern medicine is great with certain things. replacing your heart valve, right? You want to be in the United States for that.

1:22:00When you come in with general inflammation and malaise and low energy, we don't know what to do with it sometimes. And what we're going to be talking about in five and 10 years, I believe firmly from all my research for the book, The Price We Pay, and everything I've been talking to with people I respect in the field, like Peter Atiyah and Tony Kalou and these folks, we're going to be talking about your inflammatory state as a marker of your health. and your human biome, right? We've got this equilibrium of bacteria that live in your GI system. We throw it out of whack with all kinds of stuff like antibiotics and bad food.

1:22:37And then we realize, hey, people are sick. We have ulcerative colitis and Crohn's disease that didn't exist before antibiotics. We've created some diseases. We've created all this poor health from things like bad food. We're gonna be talking about your biome health in 10 years, I think, as a medical profession and your inflammatory health. It's funny because I feel like non-doctors who are interested in the medical industry do talk about this stuff. So there's various podcasts and people who've done self-experimentation who focus on inflammation and then they've developed their anti-carb diets.

1:23:15And, you know, Naveen Jain is a billionaire. He's been on the podcast. He has a company focused on the human biome. I don't know what he does with it, but I've just heard him talk about it. Gene typing, yeah. Yeah, so I feel like non-doctors are talking about it, but I guess it hasn't infiltrated into medical school, so doctors don't talk about it as much. Yeah, non-doctors talk about it, some of which are spot on and some of which are quacks and way out there. And I think medicine didn't know what to do with that diversity of heterogeneous ideas. So they kind of just globally rejected with the mantra that there's no randomized controlled trial.

1:23:56Well, guess what? There doesn't have to be. We can learn from before and after studies. We can learn from observation. We can learn from clinical wisdom. Medical establishment does not like it when we talk like that as researchers. I've been trying to get Hopkins researchers to talk more like that because that's how we think. So first off, I want to again say everybody should get this book, The Price We Pay, What Broke American Healthcare and How to Fix It. Actually, Steve Forbes, who's been on the podcast, is your blurb on the top, a must read for every American and business leader. I like how he adds, and business leader.

1:24:36You know, logically, all the business leaders in America are Americans also. They're Americans as well. So he makes a logical fallacy, but that's fine. We'll forgive Steve Forbes. But it's so important. He says this is the most important thing in our lives is our health and then our financial health, which we're losing as we try to protect our health. I guess I still have questions. Okay, I'm 51, never been to a doctor. What should I do? So it would be good to get the cholesterol panel that I mentioned, LP little A, apoprotein B, and C-reactive protein, and an assessment of your ethnicity and family history of heart disease.

1:25:21Okay, that's one thing. Another thing is to go over sleep and food. Chronic bad sleep causes Alzheimer's, I'm convinced. Just talk to the head of the Berkeley Sleep Center. And so learning about all the things that maximize the quality of sleep and avoiding things that disrupt sleep is important for your health. I sleep great. Well, that's good. Keep going. You're one of few Americans that sleep great then. And the other thing is food. You want your body to be in a low inflammatory state. That means avoiding simple sugars over complex sugars are slower to absorb. So they're not as bad as the refined sugars.

1:26:06But generally speaking, you want a low carbohydrate load in your system. If you want to go mega healthy and try keto, I think it takes a lot of discipline. But certainly any of those diets, be it South Beach, keto, low carb, you name it, anything is going to be better than the standard American diet or what we call SAD, the SAD diet. So any of those, those are all pro-health things. Avoid the processed foods, avoid things that are pre-made and you sort of pull out of a can and cook. Generally speaking, things that you can cook are gonna be healthier than things that you can just buy and eat. Be careful about pesticides.

1:26:56Roundup, there's a report showing that it probably causes cancer. That's what the report said. They got to be careful, of course, with lawyers. I can just tell you right off the bat, I avoid it altogether. Roundup is a weed killer and it's on almost all these non-organic things that we eat, produce, fruit, vegetable, you name it. So a strawberry has been sprayed on average 15 times. So how do you avoid the pesticides? So you want to buy organic produce, when, especially when there's the peel, that you're going to be consuming the peel. When buying fish, you want to avoid fish that are farmed in closed environments because the heavy metals build up in the fish.

1:27:39Fish can be very healthy. Omega-3 fats are good. They balance out the omega-3, omega-6 imbalance that we have in our modern diet. But you want to avoid - If I eat in a sushi restaurant, how do I know? You have to ask, and I think more people are asking. and when all of us ask, they're responding to the demand. You wanna buy local foods. The farm to table movement is a great movement in America. Cooking with things like coconut oil, eating nuts, avoiding things that are processed and high in their sugar and carbohydrate load. What nuts are good? I don't know of any specific nuts that are more healthy than others, but I will tell you that some believe macadamia nuts have something in it that's healthier.

1:28:31I can only handle so many macadamia nuts or I want to vomit sometimes, but I like, you know, five or 10 and then I got to stop. You mentioned breakfast earlier. Do you kind of avoid breakfast or what's your breakfast? Yeah, I don't subscribe to the modern day phenomena of produced by the food industry that everyone has to eat a large breakfast in the morning. I don't think we were made like that. I don't think our biome was designed for it. I think that hunters and gatherers would get these large sums of food and then sort of eat large meals. And I think that's why you're seeing the micro and mini fasting movement grow in the United States.

1:29:12There was a small animal experiment that showed if you sort of segmentally fast the animals that they could have a better longevity. So it created a lot of interest. Of course, it was kind of a sloppy study, but maybe there's something to fasting. If you think about how we were designed, how we sort of changed over time, did we really have food in four and five hour increments, you know, all of our waking hours? No. So when the food industry puts these things out, like milk, right? We have to drink milk. Why are we drinking milk? Were we really meant to drink so much cow's milk? Is that how, all right, this is messing up the human biome.

1:29:56And so I like either macadamia milk, I like almond milk or a mix of different types of milk. I don't love coconut milk that much, although anything with coconut is generally very healthy. You can put it on your skin, use a suntan lotion, cook with it. It's great. Anything coconut's great. How many, I know I'm asking bulleting these questions, but how many hours before you sleep should you have your last meal? So you'll hear different things about that. It's important to avoid alcohol, I think in the evening for quality sleep. Your body is digesting in that sort of rested state as you sleep. So you don't wanna overeat.

1:30:34And I think that's how people misinterpret this advice, but I think it's okay to be eating large meals in the evening or regular meals in the evening. The interesting thing is if you avoid the carbs, you'll see this with the people on keto, they don't need as much food to feel full. And that's one of the reasons they probably are able to eat healthier. Supplements, good or bad. So a big study on supplements show that those who, they don't live longer. There's no health benefits to the multivitamin once a day. So it's funny, you have guys like Peter Diamandis, you know, from, I don't know, he's done all sorts of things about modern technology.

1:31:10he has like 150 supplements a day or some outrageous number. Does he sell them? I don't know. I don't think so actually, but I don't know. Yeah, big randomized trial in the journal, the American Medical Association, looked at those on daily multivitamins versus those without long-term follow-up, no difference in health outcomes. Now, if you're deficient in something, certainly you need to, you know, a supplement could help. But where do we get these guidelines from? Where do we get these rules that say everyone's cholesterol has to be in this range? It's different for every person. It's different for every ethnicity.

1:31:44Well, Dr. Marty McCary, thank you so much for coming on the podcast. The Price We Pay, What Broke American Healthcare and How to Fix It. And then your other book, Unaccountable, What Hospitals Won't Tell You and How Transparency Can Revolutionize Healthcare. And I just want to mention the price we pay. You went all over the country meeting hospitals, meeting people. So much work went into this and so much insight. And I really appreciate this conversation. Will you come back on the podcast again? Because I still have probably 50 questions to ask. Asking for a friend, right? Asking for a friend, right.

1:32:23Great to be with you, James. Great to get to know you. Thanks for having me. Thanks, appreciate it.

1:32:39Thank you.