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Apologies, Money and the Medical Movers & Shakers, 500k Q&A

This is rather embarrassing. I created a newsletter called The Medlife Monthly(ish) (see, I knew even from the start to build in some wiggle-room, I just didn’t realise quite how bad I’d be) and when I went to interrogate my previous posting record, it went July, August, September..December…and now we’re in June. I better not admit that I started writing this in early May. Better late than never eh? Well in this case, maybe not. You be the judge. Apologies for my period being so unimpressive. Period in the 1/frequency sense of the word, obviously.

Truth be told, life has been busy but enjoyable. I’ve embraced living outside the big city and ticking off dad clichés like gardening, DIY, and barbecuing. I hope you have been able to enjoy whatever has been happening in your respective lives.

If I found myself with some free time and was in the mood for writing, I wrote a video script rather than this, so I haven’t been neglecting you (that is gaslighting, I have), simply prioritising the channel. But no more! (not legally binding)

In Issue 4 of the Medlife Monthly(ish)

- Waffle

- Don’t forget to like and prescribe (essay)

- Channel updates – doubling down

- Send me your questions!

I realised that most of the newsletters I subscribe to are penned by masters of their craft. Writers and journalists. Hence subconsciously I felt I should not be issuing forth an ill-constructed missive, but a carefully produced work of gravitas – and this is the excuse I will hang my ineptitude upon. Yet, is that what a newsletter needs to be? I not known for me prose innit?

Truth is, I still haven’t quite ironed out what direction nor form I want this newsletter to take. I imagine most of you have signed up perhaps due to interest in one or more of the topics I’ve covered on twitter or youtube, so I will aim to use it to relay tidbits that might’ve ended on the cutting room floor. I also subscribe to a few newsletters that are weekly and with a handful of exceptions, I find a relentless publication schedule results in emails full of filler, leading me to reflexively delete them unread.

The upside of a long gap is that I’ve posted nine videos since my last newsletter, eight of which came in 2022, taking the channel past 100 videos overall and creeping towards the half milly (more on that later). Huzzah!

The last three videos have had a cohesive theme, rather coincidentally as opposed to any plan (on one of those Myers-Briggs-type personality tests, I achieved the lowest possible score for ‘tendency to plan things'. Wing it. That’s my motto in life. And that’s what I tell every patient when I consent them before their procedure. “Other doctors might look at your notes like the blinkered allopathic traditionalists that they are, or even look at your X-rays. Hello? The 19th century is calling and wants its paternalism back! No no, I like to get into your heart, take a look around, get a feel for the place and wait for inspiration to strike. You know who likes doctors that plan? Big Pharma”).

What a run-on, nonsensical paragraph. No one would guess I started in print after seeing how comfortable I am butchering English grammar. Rather like my handwriting, once upon a time I was rather proud of how I wrote. Those days are distant memories. Lost in time, like tears on a page.

Side note: I hope I am not reinforcing that old gag about doctors’ handwriting. It’s a personal bugbear of mine that it’s regarded as a big joke. People laugh off doctors’ handwriting like it’s just a fact of life. Haha look at the funny meme about a doctor’s scrawl. I actually think it’s negligent. If you’re unable to write legibly, you should be reprimanded or made to use an alternative form of documentation until you can master a skill my three year old has already got under his belt. Doctors are only writing potentially life-saving or life-ending sentences. Nothing important! I frequently have to spend five minutes unsuccessfully attempting to decipher someone’s entry in the notes, only to give up and call them, wasting everyone’s time. Stop laughing about this, make it into a disciplinary offence. If some people are genuinely unable, offer an alternative.

This will sound very anachronistic to medics in many countries who have abandoned paper notes long ago. I too have worked in hospitals where everything is computerised, but the majority of hospitals in the UK remain paper note-based. Mind you, these stresses are simply replaced by hatred of EHRs (electronic health records) in countries like the US, oft cited as a major contributor to burnout.

Don’t forget to like and prescribe

Back to the thematically linked last three videos. They were on the Silicon Valley mentality in medicine and how our worship of tech, and the way it has completely changed our world, often is exactly the wrong approach to medicine; a more light-hearted one about a confusing NFT project run by some social media doctors which just ticked so many boxes of things I find morbidly fascinating, and turned out to spark off some coverage in the mainstream press; and the most recent video is a look at how our tendency to elevate scientists and doctors to the level of superstar can facilitate the most serious of fraud.

To me, these feel linked by a common thread. That of a sometimes misplaced faith in technology and innovation, coupled with a desire for personal gain. A capitalist naïveté. In each case, an outside observer might question how people are taken in by the fairly apparent scams. How can smart people believe that they should shell out for expensive medical tests that have not been shown to offer any survival benefit, or turn a blind eye to glaring holes in a research record, or hand over their hard-earned cash for a line of code ostensibly linked to a comically-bad work of digital art? Because in each case, the gullible feel that they stand to gain, either monetarily or otherwise. This entirely understandable desire can blind us to the truth.

Okay, humans are driven by greed, big news you say. No great revelations so far – but when medicine and money collide, an array of problems arise. I won’t rehash the content of the videos but I couldn’t help but notice a similar phenomenon at a huge cardiology conference in France that I recently returned from (indeed the first draft of this newsletter began with “I’m on the train to Paris” but you’ve already heard how bad I am at completing this letter).

I shot a hastily put-together little ode to one of my favourite chapters in medical history while I was there (coming soon), so had my tiny DJI Osmo Pocket camera with me, and received a few comments from friends and acquaintances about being the resident YouTuber. Some less complimentary than others (and that was just my friends). I do find my unusual position, as a senior (in terms of rank) specialist doctor and an even more senior (in terms of advanced age) YouTuber, offers an interesting perspective. In both of my guises I am viewed essentially the same way, by different industries. Medical companies want access to my patients; companies that advertise on social media want access to my subscribers. Surely it’s only a matter of time before a medical multinational asks me to make a tiktok about their latest stent. Make the #MegatronChallenge go viral! (Megatron is an actual brand name of stent. Don’t ask).

It’s a common joke amongst content creators that the most frequent question normies ask is “how much do you make from YouTube/TikTok etc?” It is no different for part-time hobby YouTubers like me, I still get asked that all the time. And yet, no one asks speakers after their conference session on ‘Why every patient should get treated with the Coronary Rinsing System (CRiSys)’ how much they make from Medlyfe CRiSys Medical Devices Inc. I couldn’t help but crack a wry smile when considering how numerous conflicts of interest must be.

Now please don’t misinterpret me, the vast majority of clinicians in attendance were people who care about doing the best possible job for their patients. We discussed countless ways we feel we can improve operations, devices, medications and so on. But the whole venture is floating on industry money. Certain specialties in particular are awash with money from pharmaceutical and device companies, such as oncology, orthopaedic surgery, dermatology, and almost certainly above them all, cardiology.

No matter how noble and honest a human being is, if the very things you can do, and want to do, are shaped by industry funding, and your whole career structure is dependent on you doing certain activities, you end up placing faith in grand institutions to do the right thing. For that is a truth far more palatable than profit ultimately being the underlying motivation.

Again, you might infer from what I’m saying that this is all bad. But that is to ignore the reality of how medical research and innovation takes place. Doctors are not paid to directly promote a drug or device, but paid for their expertise in developing it or running a trial. However, clearly that introduces a bias. As a registrar (fellow), my job was to learn as much as possible. If a new device comes onto the market and is taken up by hospitals, I have to know how to use it. Fellows’ pay is meagre and debt often high, but the device company offers training for free, perhaps even taking us out to their HQ in France, the USA or Ireland. The teaching is delivered by respected doctors so it’s a fantastic opportunity to learn from the masters in a small, informal setting. And even though no one at any time says “you must use this device”, obviously if you train using a particular kit, you’ll feel more comfortable asking for that one next time you’re in the operating theatre. These companies are smart. A friend asked why drug reps bought even the lowly junior doctor some lunch and, if I haven’t already laboured the medicine-youtube metaphor too much already, it’s all down to brand loyalty. Don’t forget to like and prescribe.

Social media influencers have to conform to certain regulations, such as the Advertising Standards Authority’s guidelines for endorsements in the UK. This is why you see #ad under your favourite insta fitness model’s post about supplements. Or at least, you should. But this at least partial transparency is absent from medical events. Yes, we are supposed to put up a slide at the beginning of our talks with our financial conflicts of interest but – I kid you not – it’s normally up for less time than it takes to click away when you accidentally find yourself on an American news channel.

These are ‘KOLs’ (key opinion leader, no I hadn’t heard of it until recently either), respected and supremely knowledgeable, experienced clinicians. We all value their opinions and experience. But having been conditioned by the impetus to make creators declare their sponsorship payments, I found this widespread acceptance that we’re just going to ignore how much doctors are paid by different companies…rather odd. When I’ve said this to colleagues, I’ve got reactions of strong agreement, to a smile and shrug that indicates they will not think of it, nor me, ever again, to frank annoyance that I would suggest that an honorarium for doing work (such as giving a presentation) would affect decisions made in patient care.

Full disclosure – my ticket to the otherwise prohibitively expensive conference was paid for. Two of my friends who have also recently been appointed as consultants came as well, our hospital thought it important for us to attend the world-leading conference in our field so that we could bring new knowledge (and to be clear, there is an incredible wealth of brilliant information to learn at these events, I don’t want to portray it as a knees-up. And the lectures themselves are not sponsored nor do the companies have any editorial control over what speakers say). The fund to send us there is contributed to by industry. Now, I don’t know which companies paid so I can convince myself that I am not conflicted. But clearly they do this so that physicians will attend and (hopefully) visit one of their stands to hear some sales patter. A common tactic is offering free coffee. However in France the rules on accepting even a cup of coffee are stricter, leading to this amusing sign next to the barista:

Someone once proposed that speakers should wear Formula 1 style overalls with AstraZeneca, Abbott, Medtronic or whatever displayed prominently. Actually was that in Scrubs? Almost everything in medicine was either in Scrubs or ER. The medical equivalent of ‘The Simpsons Did It First’.

I have benefitted from industry money, because in some capacity it is essentially unavoidable (FYI ‘industry’ is a catch-all term we use to describe pharmaceutical companies, device companies, medtech companies and so on). Part of my PhD funding indirectly came from industry money. Most of our training days as junior doctors were sponsored by industry (although their contact with us was significantly limited). I’ve attended training courses partially funded by industry, and of course last month’s conference as described above.

There are several initiatives such as Who Pays This Doctor and Disclosure UK, where doctors’ financial payments are listed (although the lists are incomplete). Even that information is difficult to interpret. Let’s say a company wishes to learn from one of the best cardiologists in the UK. They come to watch her perform cases, ask her what problems she has noticed with the kit she uses. They make notes to help guide their product development. She allocates a fair amount of time to talking to them, meaning she has to take a day of leave. They offer her £2000 (I have no idea if that’s realistic, but let’s assume it is). Another company wants to promote their latest drug. They pay a different cardiologist £2000 to give a seminar in a fancy restaurant to local GPs (family physicians) explaining why Medlyfe’s Crisicillin is a game changer, with specific talking points and all the slides prepared for him. They never tell him to say the drug is great, but we’re all imperfect humans and if a company is plying you with wine and envelopes of cash, almost all of us would subconsciously look upon them favourably.

Both cardiologists go down as having received £2000, but I am sure you would agree they are not equivalent.

I am not sure what your take-home message from that rambling essay will be. But I hope I’ve conveyed that there is far more complexity than one might initially imagine. I don’t take money from industry, but I cannot claim to have avoided industry money entirely because it’s not possible, especially in a field like interventional cardiology where we use SO much kit and are responsible for large chunks of each hospital’s budget. You would be entitled to think that’s an apologist position, and I hate the fact that because of the actions of a few who do genuinely enrich themselves unscrupulously, the whole profession is tarnished. I also wonder if me making money from YouTube (Google) is a source of some financial conflict of interest? Next week I will be chairing a session at a large NHS conference in Liverpool, and I am going as a guest of Google. Incidentally, there I will meet the global head of health for Google and the medical lead for Fitbit (Google Fit) – who are both cardiologists! The collective noun for a group of cardiologists is a bundle. But is accepting a train fare from a tech company involved in health fundamentally any different to accepting a train fare from a pharmaceutical company? If only I was a British politician, I wouldn’t agonise so much over expenses like these would I?

Well if you ever catch me making a YouTube video telling people that yes they SHOULD google their symptoms, you can assume Sundar Pichai has sent me a manila envelope stuffed with unmarked US dollars.

Channel updates

I’ll keep this snappy as good lord I’ve wittered on already but I’m really trying to double down on my channel efforts. This is as much a reaction to the chaos in the NHS at the moment, with every day pushing the hospital and my colleagues to breaking point. I have been more conscious than ever that I value YouTube and Nebula so much as a creative outlet, a hobby, something to keep me sane.

I am spinning way too many video plates at the moment though, with hours of footage I need to turn into various finished products. To that end I have hired an editor at long last, who is called Tanmay. Hello Tanmay! I bet he doesn’t subscribe to this newsletter. And last week I put out an advert for a researcher to help with a video (but the intention was to keep them on if it worked out). I didn’t realise something had gone wrong with my forwarding email address that I listed in the post (on youtube community tab and twitter) and I went to bed. The next morning I realised something was wrong when I had no emails (surely at least ONE person was interested?), so amended the post and went to work.

I had to take the advert offline after lunch as I had received 252 applications! I was not prepared for that at all. I have been through them and am blown away by how many super smart and motivated people are out there. Truly overwhelmed by the response and I thank everyone who entered. I replied to each and every one (I think!) and have made a list of many I hope to work with. So that was an amazing experience and I imagine I will do something similar next time I need help with something specific. It also reinforced to me that times are tough for a lot of people right now, which perhaps explained why so many jumped at a paid gig for which almost all were overqualified. Just sorry I can only pick one (for now). I say “almost all” because I got a few school kids applying. Heck, they’re probably still overqualified for helping some dude look up info for a youtube video! But damn do I salute their enthusiasm and ambition, at that age I doubt I would’ve thought to apply for something like that, although in my defence the Internet consisted of a series of wooden tubes in those days.

I have started writing my first Nebula Class and plan to film it in New York later this year, if all goes smoothly. With me, that’s not always guaranteed. Remember my podcast? Exactly. Nebula has grown so much in the last couple of years and it’s been so exciting to see and be part of. My only regret is that I’ve not been able to engage with it directly as much as I’d have liked (as a creator), but I keep hoping that I will be able to rectify this.

And finally I have started work on the Crisis Cave. The Medlife Mansion. The Temple of Rohinduism. Or as some know it, my garage. I’m attempting to convert the whole thing myself into a studio/gym/workshop/bike garage. Where else did I turn to learn about insulation, plastering, flooring, electrics…YouTube of course. The strange thing is that while DIYing away and having a whale of a time in between mortally injuring myself, I kept feeling this nagging sensation that I should be turning the whole thing into cOnTeNt. Should I set up a timelapse? Make a little montage? The perils of being online – even someone like me, who is not a vlogger (not a vlogger) and runs a mile from anything parasocial, can fall into the content trap. I’ll never miss an opportunity to warn of the downsides of oversharing on social media, so consider this today’s sermon. Plus, deep down I know literally no one would give a sh*t about me doing up my garage.

500k Q&A - send me your questions!

And finally, in spite of languishing for what has seemed like an eternity in the late 400s, the channel is finally knocking on a half milly. So as has become custom, send me your questions. I will be prioritising mailing list questions because I really do appreciate that you’ve taken the time to sign up. And I’m aghast (in a good way) that you’ve read this far! So surely you deserve first dibs on questions. But – please keep them short!

Reply to this email with your question. I won’t reply as they’ll all go into a folder, so that the first time I read them will be on-camera. And I’m going to release part of the Q&A exclusively on Nebula so I can answer as many as possible. Remember, the way to sign up for Nebula is by visiting CuriosityStream.com/medlife and use the code ‘crisis’ which will alllow you to get a year of both CuriosityStream and Nebula for under $15.

Until next time (which I’m assuming will be around 2024), toodle pip.