Vascular Surgeon on Plaque, LDL, and Metabolic Disease – Lily Johnston MD

I made it. I'm here. This sucks. What? What? What the hell? Like, I did not think it was going to be like this. Like, no, no, no. It's It was the moment for me. I was like, "I this has to change." Like, "Something has to be different." I have to have a practice that in some way helps with this problem because I cannot just keep being the person who takes these people's legs off. Like, that is going to crush my soul forever and I will never recover if that is all that I offer these people in this world. I feel like in 2026, if I had typed my symptoms into Chad GPT or Perplexity or any of these things, I probably could have gotten a diagnosis in under 10 minutes.

"Yeah."

"And you know..."

"that's a big deal."

"It's a really big deal."

"Tell me who you are and what you do."

"My name is Lily Johnston. My day job is as a vascular surgeon, or, um, maybe just a fancy plumber. But I think that you and I know each other because I have now a very vested interest in what I am calling cardio-abolic prevention. People have lots of different names for it. It's a bunch of different things, but it's metabolic health in a nutshell."

"So, you've watched me do this a few times now. Uh, I usually ask this with guests and to be sure, I like to go deep into the background of the guest. You have a, I have a special reason to want to get into it with you, which gets back to your book. Um, then I usually get into, you know, this situates who you are. And then lastly, we've got from the desk question. So, these are questions that uh other users write in. Uh, if anyone's interested, go to ownerlabs.comesk. Uh, we are our own uh sponsor, so you know, the obligatory, please get your uh private blood work through on your labs. Okay."

"Let's get started. Uh, you have a book, the, but it's not out out yet that we're recording this."

"No, we are, we are just going to press and uh, hopefully, we'll have copies in hand by the summer and formal release in maybe October is the..."

"okay"

"official launch date."

"So, I, I've quit trying to speculate as to when these episodes drop, but I may work it out to drop this close to when your book is released or whatever. We'll, we'll see what we can work out."

"Makes no never mind to me. You do it when it works for you."

"Gotcha. Um, but I was myself thinking, 'Oh, great. We're going to get an advanced copy of the book,' except that it's right in the midst of my roll out with the documentary. And I, like, this week alone, I'm recording for uh Feldman Protocols. Uh, you know, I have Arthur, I get on tomorrow."

"Yeah, I know."

"I'm like, 'Okay.'"

"Um, but uh, I was fortunate in that Sharon was able to do a little bit of forward reading for me to highlight a lot of things. And then she kept telling me about these passages and then I just kept getting more frustrated that I didn't have the time because the passages uh I could relate to. So I don't want to spoil it too much. I just want to say that I have a feeling that even though I didn't get a chance to get too much into it, I'm gonna love this book. Tell us about it."

"The book is an exploration of my frustration with medicine and the practice of medicine and the culture of medicine in the 2020s. This was a surprise to me because I am the daughter of two physicians. If anybody should have known what they were getting into, it was me. And yet, I found myself slogging my way through my training, which is not a surprise, right? Nobody expects medical school and especially not residency and especially not surgical residency followed by a surgical fellowship to be a cakewalk, right? Nobody thinks that that's going to be fun. But you keep telling yourself like, 'It's going to get better when it's going to get better when I'm in residency and I'm doing what I want to do and I don't have to master all of this other stuff in medicine that I'm not really interested in.' And then you're in residency and you're like, 'Okay, but I'm going to do a fellowship. It's going to get better when I do my fellowship and then I get to focus on what I really want to do.' And then you're in fellowship and you're like, 'Oh gosh, it's going to get better when I'm in charge.' Uh, that's must, this must be the problem. And finally, after let's call it, oh, approximately 17 years from sort of undergrad through the end of my training, you arrive, you get your office. It's got a little window. It's got room for your plants and your degrees. Many very fancy, expensive pieces of paper on the wall. And you're like, 'I've made it. I made it. I'm here. This one sucks. What? What? What the hell? Like, I did not think it was going to be like this. Like, no, no, no. It's just the first year. Okay, it's going to get better when it's going to get bad. Just give it a year, right? The first year is really hard, steep learning curve. You're not done with training just because they give you your piece of paper. Just wait it out one more year.' Like, 'Okay. All right. Gave it a year. Actually gave it a year and a half. I was like, 'Nope, no, this isn't it.' And I had two best friends from my training who were in different areas of surgical practice, different parts of the country. And we would be on these calls with each other and like everybody was miserable. And we're talking to, you know, second order friends and acquaintances, other people in training and so and so dropped out and so and so left their residency and is now doing something else. And it just felt like nobody was happy and fulfilled in her career path. And then we looked around at our teachers, our attending physicians, the faculty at all of these places where we trained. We're like, 'Okay, who is happy? Like, who are we looking up to? Who is running a life, living a life that looks like what I want?' Crickets. Crickets. Like nobody. Nobody. And so then you force yourself to look around and say, 'Okay, this is my life. I get one short and precious life. And if you learn nothing else in vascular surgery training, it is that life is short and precious and you are not guaranteed anything. So is this what you want? Is this going to be your next several decades?' Meanwhile, my father has surgery related to degeneration of his spine, which was in some part the result of a career spent hunched over operating on people, saving their lives, doing this very noble, brilliant work. And..."

"Can I pause you there?"

"Yeah."

"Because what I want to do is I feel like you've given us a great teaser foundation. Um, I'm going to add to what you just said in that actually, while it may sound like the book is kind of outlining, hey, this was, you know, this long slog and you just should have figured it out earlier. You explain exquisitely throughout how you're in the process of learning it and why it's so difficult to learn until you're further along in the path. But now, let's go all the way back."

"All the way. So you said you're the daughter of two physicians. When was the first point in which you knew that you wanted to get into medicine?"

"I don't remember a time when medicine wasn't the plan. And to some extent, I am concerned that that's actually just a failure of imagination that I just never spent a lot of time questioning whether perhaps there might be an alternative that would be more interesting or different. But the truth is, my parents adored and were in love with their careers and in many ways still are. My mom is still working full-time in a different version of practice than what she had uh in her prime clinical years as a business owner and and private practice, OBGYN. And my father is a cardiac surgeon. He is now retired, but he has such beautiful fond memories of his career. And I looked at these two people who truly lived and breathed the medicine and the surgery and the care of other humans in the world and thought, 'Who doesn't want this?' Like, they were the ones where I looked at that and was like, 'Sure, that's a life that seems amazing.' Right? They were really happy and they had a lot of autonomy in the way that they practiced that was challenged, especially in the later years of their career. I didn't appreciate much of that at the time as a young adult, but looking back on it now, I see how things were evolving in modern medicine to create more friction as they were later in their in their careers. But..."

"But importantly, when you're at that younger, impressionable age, they're in an era of medicine that's very different from the one you would enter."

"Yes."

"And that's a big part of your book."

"It's a huge part of the book. And and I think the transition happened, I don't know that it was slow, but it certainly didn't seem like I was watching it devolve in real time. It felt like some of that happened like while I was in training, while I was in school and suddenly I show up and it's a whole new game, totally different environment."

"So, you're, you're not just think of this as the family business. You literally have two, you know, parents. Are you an olding child, right?"

"I have an older sister."

"Oh, you do have an older sister also in the business."

"No, she's the smart one. She's a teacher."

"What does she teach?"

"She teaches social studies uh in Albuquerque, New Mexico."

"Gotcha."

"Yeah."

"But for you, this just seemed like the way, right?"

"I loved science. I loved especially the biological sciences. I was always curious and I always liked problem-solving and it seemed like the most concrete application of that was to like help individuals. I thought for a brief period of time about being a research scientist and spent some time in a lab and thought, rightly so, that that was a very important skill set for me no matter what I did in science and life. It turns out my brain is not quite logical and linear enough to stay in the basic science realm and do things like literally one step at a time and go from A to B to C to D and create a..."

"boring engineers are into..."

"Oh, but thank god somebody does it, right? Because my poor brain just does not want to do that. And I find it amazing when two different brains get together and like actually make sense of the whole mess. Now, importantly, um, just to jump ahead, when you're getting into college, I'd gotten a little bit of a preview from Sharon. It isn't straight medicine from, you know, day one to where you're at now. You had a little bit of a kind of detour. Would that be fair to say?"

"Yeah. I had always known I needed one year between undergrad and med school. That was always something that seemed important to me, this concept of a gap year. For me, originally, it started as a time to grow up a little bit. I was a, you know, nine months young for my grade in school, so I was always a little bit younger than everybody else. But more than that, it seemed important to me to have a just a little bit of life experience, right? Our training pathway is so long to suddenly end up in your 30s telling people how to live their lives and never having paid a bill or like lived in your own apartment and having to figure out how to get the plumber to fix your clogged up sink when you're at work, right? I mean, just the stuff of living."

"So, how old were you at this time?"

"So, I was uh 21 when I graduated from college. And so at 21, you're saying, 'No, I, I am going to ultimately be a doctor, but I do want to get in this little gap year. It's just the one time I can fit this in.'"

"Yeah. I built it into the application process. So, I just decided I was going to apply a year late to medical school, meaning I built in that year. That way, the applications would come in and I would have my, you know, admission rolling and I would just have this one year. My my first plan was to go be a ski instructor in uh Colorado. I grew up skiing with my granddad, my mom's dad, and I wasn't gifted by any stretch of the imagination, but I figured I could probably figure out how to get a few, you know, three-year-olds down the mountain without dying. And it would be a great time to just do something totally different and be outside and have again, like something of a less nerdy, more normal life for just, just a taste, just a little bit. And I walked into my premed advisor's office and was like, 'I'm going to take a gap year.' She's like, 'That's amazing. I so support that. Just one little thing. Uh, you can do anything you want except go be a ski instructor or go be a surf instructor.'"

"She literally said this."

"Yeah. And I like, totally unprompted, and I was like, 'Okay.'"

"Where did that come from? What's the reason why?"

"The, the better question is, is it really true? Right? I mean, did, would it have mattered? And nobody knows. But uh, the idea, of course, is right. You're supposed to be this martyr. And that indoctrination starts so early. It starts before you get into medicine. But it's this idea that you are committed, right? Don't you want to be making yourself bigger and better and stronger for this dedicated service, this life of service that you are about to embark on, right? This is going to be a monastic endeavor. So, by all means, like make yourself..."

"So, it was kind of like a, um, don't, don't pursue something that's not intellectual, that's not high-minded, academic, something to that effect."

"Yeah. Don't be, don't be a trivial, frivolous, yeah."

"person, right?"

"Don't let your brain rest too much."

"No, no, no. We can't have that."

"So, where'd you go? I thought I was going to be a, a consultant for, you know, some kind of uh con, you know, firm that does science consulting or medicine consulting, right? You go and you show up somewhere and you tell them how inefficient they are and they're like, 'Oh, thank you so much for that valuable information. Please put that in a 300-page report nobody will ever read.' And I was like, 'Well, maybe I'll do pharma for a year or maybe I'll do this or maybe I'll do that.' And I went to a science fair, a career fair that was for science and tech people. And I thought I was a science and tech person because I had been in a biology lab for a couple of summers. I like almost had a publication out. I was really proud of myself at that point. And everybody took one look at my resume which said psychology on the top. We can talk about that in a second if you wish. Uh, because I decided to be a psych major instead of a biology major, even though my focus was in neuroscience and the intersection of those two things. And I'm like, 'You're not a scientist. We don't have anything for you. Go away. Like, go be, go. Like, we have serious people who want real jobs. Like, you don't belong here.' Okay. Well, my friend was also at this career fair with me and she, as a chemistry major, had lots of uh business to to be had. So, I was waiting for her and I was, you know, dejected and rejected and needing to kill some time. And there was this government uh table down the hall and I thought, 'Well, it won't be a total waste of a morning if I leave here with a really cool pen.' I just want a pen, but I'm a really good psych major, right? I know how this works. You don't just steal a pen and leave. That's lame. You need reciprocity."

"Hang around for the pitch."

"Yeah. Right. Like,"

"Okay."

"And and I know how this is going to go because I've just done it four times. Right. You're, we're going to have a nice chat. You're going to be tentatively interested and then I'm going to show you my resume. The face will fall, the shoulders will sag, and you'll say, 'Oh, I'm so sorry. We just don't have any position where, you know, appropriate for a psychology major.' And you have to have that little sneer and that um disdain in your voice as you say it. So, I think, 'Okay, fine. I, this is like 30 seconds. I got this down. It's fine. I will send them my resume. They'll say no thank you and I'll walk away with my pen and we will have, you know, fulfilled the social contract. Everybody is is fine.' So I go over there and we have the little chitchat like, 'Well, what do you do? My focus is in neuroscience and the brain and I'm very excited about new developments in this and uh, but you know, I am a psych major.' And I'm like, grabbing for the pen, waiting for the, waiting for the, and they're like, 'Oh, you should talk to Mike. Sorry. Say what? No, no, no. Uh, don't go anywhere. We need you to talk to Mike. He's on, he's on a break right now, but he'll be right back. Just, just hang out and wait for Mike.' Okay, sure. Well, I can wait for somebody else to say that they're not interested in the skills that I have to bring to the table. So, I wait."

"Making you work for that pen."

"I know, right? Um, it was a good pen, to be fair. So, I wait for Mike and Mike shows up and, you know, he sort of flips through the resume and there's a lot of and uh, you know, frowning and looking and and really making me wait and sweat this out. I'm like, 'I just need to leave with the pen. We, you can just say what you got to say. I get it by now. It's fine. I'm really over it.' And he, he takes a look at everything and he looks up at me and says, 'I'll be back next month for interviews. Would Tuesday the 3rd or Wednesday the 4th work better for you?' And I thought, 'Uh, well, I guess Tuesday.' And at this point, I'm thinking, 'This is practice for that consulting gig that I'm really going to get.' Like, 'I don't, nobody's going to hire me to work for the US government for a few years. Like, that's ridiculous. Like, what am I going to do there?' And but this is a practice. It is really early in the recruiting season and interview practice is a great idea and you shouldn't turn that down. So, okay, I sign up for an interview and we go through this process and then sure enough, four months later, I have zero consulting interviews and the government still wants to hire me to be a science and technology analyst. And I think, 'Me? I mean, that could be a fun adventure. You never know.' And then I spent three years being a science and technology analyst."

"Wow."

"For the government."

"Okay. So, let's get into that. You, first of all, where is it at? Is it..."

"Northern Virginia. It's in Northern V."

"Okay. So, pretty close to the, the heart of it all, right?"

"Uh, you get hired in. You still anticipate that you're going to just do this for a year."

"I, I wasn't quite sure. I knew that they had a four-month training program, but I thought, 'Eh, I mean, it's just a job.'"

"Yeah. You feel like it's an investment."

"But now it's kind of like you're on a track."

"Right."

"Right. But hey, see where this goes. So, this is such a great story because had it been the first place you went, you might not have even taken them seriously in trying to set an interview in a month from now, you'd be like, 'Well, I kind of want to go to the other tables or something.'"

"Right."

"Exactly. But because this was like the very last, the, the end of the road, if you will, and you had already kind of put up with a bit more like from the setting that you're telling me, it makes it sound as if you might have just been coming out uh with such a sense of, you know, accomplishment behind you that you were expecting the job fair would just be a bunch of people swooning for your attention and you'd be just trying to select between them, right?"

"I knew I had fierce competition. Right. You're, you're in the Ivy League with all of these other people, most of whom are actually much smarter than I was. And so you're, I, I wasn't necessarily assuming that I would be the cream of the crop or the pick of the litter. But I did think that I had something to offer and would, you know, have at least some engagement at the science and tech career fair. And that was my mistake. But that's what's fascinating is a lot of times a series of things that don't turn out the way you expect opens this door in a unique way towards something you might actually find you really like."

"Yeah."

"So you go through this four-month training program. Can you tell us anything about that?"

"The four-month training program was perhaps the best brain training I have ever done for life. And the reason for this was the WMD intelligence failure had happened fairly recently. I was a freshman in college when the planes hit the Twin Towers and the Pentagon and the um WMD thing ensued thereafter. So by the time I graduate from college, this is very fresh recent memory. The intelligence community is a gasast at the fact that they have just had this colossal miss. Just whiffed it completely. And they have done their own sort of root cause analysis to understand why that happened, how they failed, and how we are not ever going to let this happen again. The training was designed to systematize our thinking. And I got to say, just like college, I was surrounded by a bunch of very, very bright people. We all thought we were fairly rigorous thinkers to begin with. I mean, yes, we were young, but we had all excelled in whatever last educational stint we had just completed and we were actually at that point kind of the cream of the crop, at least to a first approximation. So, we were like, 'Okay, you're going to teach us how to think and write and talk. Like, we've, we kind of got this. Like, it's not going to be that hard, right? Like, this will be not.' And it was a complete 90-degree turn from what academia asks of us, right? Academia asks for you to have the big build, right? Start from first principle and what has been done in the past and what we know, what the gaps are, what we have done now. And you sort of walk through this very long intellectual argument and somewhere four to eight pages or hours or years down the road, you end up with some conclusion. And great, but nobody in the world who works for a living has time for this. They want your conclusion. They want your level of certainty and they want to know what else you might have missed. So the whole concept for the intelligence community was to figure out what you know, figure out what you don't know or where your gaps are. Have some process by which you have actually tested this and then declare with an appropriate level of certainty or uncertainty, as the case may be, what people need to know to make the next decision."

"Yeah, that's, um, this is not only a theme that I know was coming up a lot in your book from a lot of the quotes that were shared. It's a theme that actually kind of maddening to me in this space, particularly within research. It, research of all places, there should be a level of comfort with acknowledging a lack of certainty and, you know, that kind of Bayesian thinking where you get towards saying, 'Okay, I'm about this sure.' I like, for example, throwing out 10 scales just in day-to-day practice because people get it where I can say something like..."

"Okay, on a scale of 1 to 10, where one is you have no idea and 10 is you are completely certain, like you are, the earth is round, where do you land on this?"

"Yep."

"Granted, it's totally arbitrary, but it's at least opening the door."

"It's saying, 'I don't expect you to to give me an answer that's that has a level of certainty like the earth is round.' I'm already expecting it's going to be on a spectrum. But that I found coming into this space and working with doctors, um, I don't know another way of putting it. It's almost like I have to approach gingerly with saying, 'It's not a boolean. It's not either I'm completely uncertain or I am certain.' It's just that I want to fit into the language, the degree of certainty. Yeah. And that's a larger hurdle, weirdly, in research than I thought it would be, particularly when it comes to things like heart disease. And so, not to get off on that tangent yet, I do, I wouldn't be surprised if when you ultimately enter medicine, it's what I would, my own, um, preconceived notions are given my own process and working with doctors and scientists up until this point, that it's going to be vastly different. And I think your book gets into that."

"But at this moment in time, you haven't actually, you haven't had any medical training yet, right?"

"Okay. So, you may think this is just the way of the world for all higher education as far as you know, right?"

"Yeah. I mean, I recognized it was very different than academics and that if I ever went back to an academic environment, it would probably, I would need to kind of relearn that sense of prioritization and decorum and, you know, how, how an academic talk goes versus how you brief somebody in the government space or in in the corporate world. Those are very different tasks. You can ask, maybe why, maybe they shouldn't be, but they are, for better or worse. So, at that point, yes, I think this is very cool and I'm thinking, 'Well, this is, you know, very interesting for this one application, but probably it won't serve me that well later down the road.'"

"So, you get through the four months of training, then you're actually practicing, right?"

"Yep. Doing the, doing the analysis thing. And do you, so you're doing it, you're doing the job. You talk a little bit about the job in the book, right?"

"Very little, but yes."

"But you mainly, you're talking about what the thinking is and especially how it contrasts with what would be ahead of you."

"Exactly."

"For medicine, um, you're at that time that you're past the training and you're now fully into it. Were you starting to think ahead to when you would leave to then become a doctor or were you already kind of struggling at that?"

"It didn't take me long to recognize that I wanted more time in this role. So I deferred first for a year and then for a second year. So that's how I deferred."

"Deferred my admission. So I, you know, I was applying to medical schools. I interviewed, I did all the things, I got into, you know, a certain number and then I asked of those, you know, how many of you would allow me to spend an extra year doing what I'm already doing now? And here is why I think this would be valuable for my, you know, career as a physician. Uh, and, you know, a proportion said, 'Okay, we would let you defer for a year.' It was probably most, um, when I was having a blast still in year two, I was like, 'Can I have another year? Could I have a second year?' Only one school was like, 'Sure, you can have one more year.' Uh, by the time I asked for a third year, they're like, 'Yeah, no. You were either serious about this or you're not, and if you want more time off, you're just going to have to reapply, which means taking the MCAT again.' That I was not going to do."

"Wow. So, you really are facing down the barrel."

"Yeah."

"Of, are you really serious about becoming a doctor or not?"

"Did you consider not becoming a doctor?"

"No. And the reason for that is my perception of why I was valuable to the job that I had doing science and tech. So, what was I doing? I was reading literature and translating it for a more lay audience that had investment interests or research interests in this space. So, people who wanted to know what was neuroscience going to look like in 20 years. How do we invest our own resources in the United States to make sure that we are keeping up with this technology? Is it relevant for government and military applications? If so, how and how do we make sure that we are going to stay or are we on the on the cutting edge and and how do we stay there? So, it was a, it was a communication role in many ways. It was a interpretation of the literature and translation and communication and I was able to go to conferences as a civilian because I had just come from like a training program in neuroscience and I had the ability to say, 'I did a thesis and I was in a lab and here are my credentials,' and people would still talk to me. That was going to expire, right? There's a shelf life, but at which point you've been out of academia for a certain period of time and now you're nobody and now you have no reason to engage in an academic or a scientific meeting anymore. Like, what do you say you do? You work for the government. Like, that's weird and creepy. Nobody wants to talk to you about applications in the brain. Like, that's like actually kind of scary. Nobody. So it was clear to me that my utility had a shelf life and I did not have a PhD at that point. And I had my undergraduate degree. I was hired by a bunch of engineers. And so the pathway in engineering was much more focused at the undergraduate and master's level. Like, they're not super concerned, many of them, about sort of terminal PhD level degrees. And so they didn't see it as a huge shortcoming that I did not have a PhD. They absolutely should have hired a PhD to do what they had me doing. And I'm so glad they didn't. Um, I met a few of them along the way who were great, but uh, they didn't know any better because they were a bunch of engineers who were interested in other areas of technology. And I got this like golden ticket to wander amongst academicians and scientists and go through all these places. But it was very clear that that was not going to be a long-term strategy. Like, I was going to top out very quickly and then I was going to be sad that I did not have a chance to go still be and in a scientific role and getting curious about new developments and new exciting things. So I knew I had to go back to do something and medicine was such a big prior, like it was already built in. Um, and as much as I loved the science of the brain, I was actually also quite sure that I did not want to do the medicine of the brain because the, the delta between those two spaces, at least in my opinion, was so great at that time that it was never interesting to me to be a neurosurgeon or a neurologist. And so I, I was actually quite sure I was not going to do medicine of the brain, but I knew I had to go do something. And I didn't think I, like I said, I didn't think it, it was really my calling to be a basic scientist or even a translational scientist. So medicine still seemed like the right choice, even though I was deeply reluctant to go back because I was having the time of my life when I left."

"But you still kind of felt like that was your ultimate life track, is what it sounds like."

"Yeah. So, okay, time to grow up, right? I guess. Yeah."

"And you then decide to go back. Did you know by that point, uh, what specialty you were likely going to head into? Did you, for example, think you were going to become a surgeon?"

"Again, thinking about, um, Bayesian prior, both my parents are surgeons and it was always the hypothesis to disprove. I was, I had scrubbed operations with both of my parents. I had been in other parts of the hospital with friends of theirs and tooling around and trying to kind of try on different jobs or or, you know, specialties in the hospital and I was pretty sure that surgery was going to be the right choice. There were a couple of other like interventional cardiology, maybe interventional radiology. There were a few other things that I thought might have been interesting to me. Uh, my mom's an OBGYN. I thought maybe, I wasn't really sold on that, which is ironic now that I have such a passion for women's health. And she and I laugh about that, but I was pretty sure it was going to be surgery. I didn't exactly know what kind of surgery, but I loved what my dad did. I thought it was probably going to be heart surgery."

"I find in the, the world of doctors, surgeons kind of, kind of feel they're in this kind of, you know, when you're really serious, now, you're heading towards surgery. Surgery is where the best of the best end up. I feel like there's a, a sense of that sometimes. Um, there's of course this other component which is, I, I think it's hard to convey to somebody who doesn't realize, I mean, having both your parents have that level of expertise has got to feel like this, you know, layup of mentorship capability, right?"

"Yeah. It's also a total setback in other ways that I did not appreciate until I was in college or even like a true adult much later in life about what people do outside of medicine, like, and having a life outside of medicine and having community outside of medicine. My parents were both doctors and what we talked about at home was mostly science. Now, my sister, when she was home, she's my half-sister and 13 years older than I am. So, there were many years where she was in college or or out in the real world and I was left just with my parents. But while she was home, she did not ever really want to talk about medicine and that was fine. She just had to watch the news or read the newspaper and come up with something else to talk about at dinner because my parents inevitably would default to doctor mode and talking about stuff because..."

"She was the rebellious child who was like..."

"She was the Peter Pan. Yes. And in so many ways for our whole lives and uh, she always was very afraid that I was not rebellious enough. And uh, in the acknowledgements of my book, I say, 'You can now say that you told me so.' I think that, um, because I've had a lot of doctors sit across from me, of course, work with a lot of doctors for the research we're doing. I myself have come to really appreciate, in a positive but also negative way, in a large negative way, how it really is almost like a tunnel. It's like you're placed on it and if you want to become a doctor, anybody who's in your life who understands what it takes is like, 'You need to just focus your entire life on this. You need to be working much more than other people, you know, who are trying to have a life outside of what they're doing. Even if they're in the process of, you know, going through college and so forth, you have to work more hours. You have to work harder. And you have to realize you're competing with a whole bunch of other people. You have to out-compete all of them. You are going to be on this track for a very, very, very, very long time. You need to acknowledge it now to be the best of the best.' And that's just what it takes, right? You know, in the military, when they bring in new recruits, this process is very transparent. They very intentionally take you away from everything you've known and all of your own personal structure and routines and they demolish it. And this is, of course, on purpose, right? They break you down to build you back up and mold you into the soldier and the team player. Medicine does the exact same thing, but nobody talks about it and nobody acknowledges that this is actually being done on purpose. This is the very intentional indoctrination and disconnection. And I don't think anybody sat down and wrote it out one day and was like, 'You know what, we really need to make sure that these people have no lives and no connection outside of themselves.' But it has become part of the ethos and part of the martyrdom culture of medicine and part of the, you know, 'What's the only bad thing about being on call every other night? You miss half the good cases, right?' Like this is an old joke from my dad's generation of of physicians and it is this very insidious process and it is sold to us as what is absolutely necessary to achieve greatness in this very serious life or death. And it is, I get it, right? Right? Called in last night in the middle of the night to help somebody, right? Life or death, life or limb situation. And it is true, it does require dedication. What they don't tell you is that when you go down this tunnel and you slowly give up pieces of who you were as a whole human being to become this attempt at a machine, that this attempt at a robot that they want you to become, you become a shitty doctor."

"Yeah."

"Right. And I, partly why I write this book is, yes, it's for my colleagues and everybody in medicine who is disillusioned and trying to figure out what the heck happened and why are we all here suddenly? Like, why are more people leaving their jobs in the first year of a new career in medicine than ever before? Why are we all unhappy? Yes, it's partly for that, but it is also perhaps more importantly for everybody who's had a terrible experience in medicine. And that, based on comments, based on interactions I have with patients, is a vast majority of the people who are currently interacting with the US healthcare system, perhaps maybe internationally as well, but certainly in the United States. And trying to help you as a consumer of healthcare understand why the experience is so miserable. Why your doctor is a jerk, and it's not because they're a bad person. It is because this has happened to us over many, many years and we didn't really understand it or recognize it and realize it and what is going on behind the scenes. It is not to excuse it. It is not to give us all permission to continue to be jerks. It is to say, 'Here is what has happened behind the scenes and here is how I think you as a patient or you as a family member or somebody navigating this system on the consumption side can help your clinician remember who they are and engage with you as a human being in that like soul-to-soul way that is actually why the most of us got into medicine in the first place. None of us got into this to be a jerk and fill out paperwork and not make eye contact in the room and like clickety-clack on our keyboards while we document your visit in the two minutes that we have to see you before the next person comes in. None of us wanted that, right? But how do you get past that? How do you actually engage with the human side of this to get where you need to go and get well?"

"Well, and that's why I think we, I wanted to set the stage of like, in the 90s, for example, um, and I've talked about this on the podcast here before, my dad's dad would explain he was watching in real time his doctor, who is his age, by the way, they'd been in the same class, um, was retiring and then he got a young doctor, young doctor by in his 40s at the time, uh, who, you know, just didn't think as highly of nutrition or or exercise or at least would state it in a kind of glossy, you know."

"Oh, yes. And of course, also get, you know, good exercise and um, and be sure to eat better. But it was, it was like a one-sentence conversation. There would, there was the shortening of the time. He was like, 'I used to have my doctor visit me, literally visit with the bag, right?'"

"Yeah. House calls."

"And now, yeah. Now I'm supposed to go in and the pill box, he'd keep bringing up the pill box that this was a new thing. And his doctor, you, you'd have, he'd have to be in screaming, howling pain to be prescribed something. His doctor was anxious to get him back off it."

"It's like, 'I don't want you to get stuck on this.' Instead of saying addicted, he would just say, 'Don't get stuck. Don't get stuck on this drug or that drug.'"

"And and that was such a contrast that he was remarking to me long before I was into this space, right?"

"But these things are changing over time. You're in this education, right? As the shortening, the thing that you just set up, this 15-minute visit. Like, if we were to go back to the 80s or 90s and be like, 'Yeah, in the future doctors will be walking in the door with your blood work in hand, they'll be doing, I like to call it boldface type medicine, which is they're looking at the blood work and they're scanning down to where the boldface type is and they're like, 'Oh, this is out of range.' Well, there's this kind of medicine that helps with this thing. I saw it at the most recent conference and some of my patients are doing well on it.' That can get more and more shortened. One of the, um, things I'm going to paraphrase from your book was how, uh, efficiency was becoming more and more the order of the day in medicine, which might sound good when you hear that in the abstract, efficiency. Well, good. We want efficiency."

"Right?"

"Do we though? Because efficiency suggests a, an effort towards a unit direction, right? Towards a particular outcome, such as achieving those 15 minutes. Like, what if there really is just in the 16th or 17th or 18th minute that additional information that actually makes all the difference for the patient? Do you have that latitude as a caring physician to provide that to the patient who you think you need that extra time for?"

"Right."

"Yes. Hand. I do in my current practice at uh Scripps in in La Hoya. I have a metabolic clinic which I am starting and I penciled it out. It costs me, but my initial visits are an hour. My follow-up visits are half an hour and for me, that's actually a sacrifice. What I had when I was uh only doing this privately was a 2-hour initial visit or at least 90 minutes depending on whether I was also doing an ultrasound and hour-long or 45-minute long follow-ups that I actually cannot make pencil and still approximate a reasonable living uh in an insurance-based model. In an insurance-based model, I can do an hour and a half an hour and like it's a small cut, but it's worth it because my satisfaction as a provider is worth whatever extra dollars I'm leaving on the table to not see a patient every 15 minutes. I don't ever want that. And um, I know my, my schedule looks cush compared to my my partners just down the hall who see patients every 15 minutes for their surgical things. And it's a very different conversation, right? Anytime somebody brings up, 'Do I have to take this medicine or what should I eat?' they immediately are referred to me. Um, which is perfect and, but it's a different deal. It takes a long time and I see people back much more frequently because we have to have a high-touch relationship to check in with these things. Also, we talk about nutrition and movement and sleep and stress and social connection and supplements and medications and all these other things."

"This is good. We, we know it's coming to a happy ending, or at least you're feeling very optimistic, right?"

As to where your practice is going. Let's jump back to you're entering medical school. When is the when is the first sign for you that this might not be what you were expecting?

I want to go back to this idea of what my training was like for the government versus what the experience is in medicine. And I knew it was going to be a challenge to have been in an environment that was very much a meritocracy. I was young for my job. I told you they should have hired a PhD and they didn't. And for all of that, if people would give me 10 seconds, I could show that I knew what I was talking about. I had enough credentials to be taken seriously and I had done the work. And once people saw that, my age was not relevant. My lack of a PhD was actually not that relevant. As long as I provided information, the level of certainty and the evidence for my conclusions, people were happy to take my work on on face value.

In medicine it is hierarchical. There is no meritocracy. And I was in a lecture. So part of what I had done working with the government was a portfolio in human performance. So we were looking at what compounds what things make people perform better. And this was mostly for the purpose of special forces type operators. And it applied to pilots and anybody who has a high performance job. maybe even surgeons. So, I thought about sleep and I thought about supplementation and I had actually gone through some of the literature on this. We had a pharmacology lecture my first year of medical school and the professor who was going to give the lecture came out and said, "You know, supplements are garbage. This is a waste of your time. This is a waste of my time." And he sat down and started to strum a guitar on stage. And he said, "You know, there are a couple things in the syllabus. I'll talk a bit about them, but like we're actually just going to chill and listen to music." And I could feel my heart start to pound cuz I actually had read the chapter that we were supposed to read or the syllabus or whatever it was. And I had questions. I actually thought this was a great lecture. I was super excited because it actually had some relevance to stuff I had been studying when I was working. And I wanted to know like what the leader in pharmacology at UC San Diego had to say about this. I was really like stoked for this lecture.

Wow. And so I like started to like put my hand up.

That voice in your head wasn't uh getting through to you. It was like no.

Yeah. Well, I mean there was a blaring alarm, but I just decided I was going to ignore it and see what happened. And long story short, uh, I was put in my place and said, "Silly girl, sit down. Don't worry your pretty little head about any of this. Trust me when I tell you this is a waste of your time and mine and we are going to enjoy some music." And that was really when it sunk in like I was not in Kansas anymore. We were not in a meritocracy anymore. I needed to suck it back up and like recognize my place at the very bottom of this very long ladder and it was going to be years before I could have thoughts of my own or express uncertainty and doubt.

And the irony of this is there is a ritual in medicine. The first day when you show up as a brand new brighteyed and bushy tailed medical student, they give you this white coat. There is a white coat ceremony. And it's a short white coat to distinguish you from the real doctors with longer white coats and whatever. Uh, and

it's a real thing, by the way. People should look into this because there literally is a kind of

like in the military, you know how you have stripes? It's entirely analogous to the length of the white coat that doctors have. It's Anyway, go ahead.

And it's different if you're in Boston. Nick might have something to say about that. In any case, it is a ritual almost across the country that you get your short white coat and you get a speech and it is designed to be inspiring and welcome you into the fold and you know here begins your indoctrination. They don't quite say that, but inevitably inevitably, and I've listened to many of these, there is a line that gets thrown out in your white coat ceremony speech and it says, "Half of what you are going to learn in the next four years is wrong. We just don't know which half." And everybody chuckles and says, "Haha, isn't that funny? Isn't it great that we're in a discovery period and we are so fortunate to live and work in this environment where we're learning and discovering new things and it's going to be this intellectual experience for all of us to learn and grow and be curious?" And like nobody nobody laughs anymore when the next time you're like, "Well, what if this one's wrong?" Like, "It's not wrong. I just told you this is the truth, capital T truth." Like they forget that they said that the second it's out of their mouth.

like to to really drive it home. Nobody could, for example, bring up that statement after the fact and be like, "What if this is maybe part of the half?"

That's on the wrong side. Wouldn't we want to get to the to the other half? The challenge, the actual challenging of authority. It's something that you'd been comfortable with in your prior job. Because in intelligence, nobody wanted to not hear what might be other insights, even if they're insights as to why they could be less certain about some course of action that was in the room. Would that be fair to say?

It is. And again, this is where there's a lot of um bait and switch because in the modern medical safety culture, we talk about challenging authority. And this comes out of the um flight safety literature, right? The how do you prevent a plane from crashing? They did studies and they've asked flight crews like how why did this event happen? How many people knew that something was wrong and didn't say anything? And it turns out that the culture of safety in an air crew is critically important. And this has come down and there was an Institute of Medicine report that was all about, you know, the number of medical errors and this is equivalent to 737s crashing every day, the number of people that are injured for a medical error and um all this conversation about what in fact is our culture in medicine. And it is not a safe place to question or to raise a concern to somebody who is very senior to you. And uh because that is perceived as a personal affront, right? And I think you may have experienced this as well as you have gently asked questions in this realm.

I had to I had to go through some relationships first when I thought I had the Hollywoodized version of science in my mind and that ultimately doctors are scientists. You know, I was watching ER. I was watching House MD. I loved House MD even though it gets a bit fantastic.

There was a lot of arguing and a lot of debate and eventually there, you know, House turns out to be right every single time. Spoiler alert for people watch the show. But he has the other doctors in there to challenge him and to debate back and forth on what, you know, may be the issue with this diagnostic that always turns out to be very esoteric and combinatorial, right? But importantly, Hollywood's teaching me, oh yes, the the proverbial, you know, giant classroom where there's the guy in the back and he goes, "But professor, did you think of this? Is it possible that it's this?" And the professor's like,

"That's a great idea, Ted." You know, and he starts working on it. Then it cuts the montage of they're working together. And then all of a sudden the professor is up in front of his colleagues and he's going, "Oh, actually, you know, my I I really appreciate Ted's suggestion and now we've worked out that it's this." And then everyone's clapping. You know, there's this sense, well, that is very common in engineering. We are living and dying by what the best ideas are in the room. And it is not uncommon at all for a very established team to be trying to hire in new talent. and you just you have no idea what their scale of capability is. But we usually have things like code reviews, tests, code tests, things like that. But we often want to see their work. And they could have any kind of background. They could be 18, they could be 48, they could be any of that. We're already looking at the code. We're looking at patterns. We're looking at um ways by which they handle things. A lot of times you can give them a code review in whatever their favorite you know language is. We learn a lot about how they do things then but then if given new technology how will they adapt

and how much they can thoughtfully uh take that in has very very little to do with their education has more to do with abstract mechanics and a lot of the things that that we already know as programmers. Right? And I I'm not kidding when I say this. As somebody who started a bunch of technology companies and one of my most successful ones I sold that was here, which gave me the nest egg to do this research, that company, we hired 30 engineers. And it was legitimately a red flag. If somebody came in touting their credentials, they're like, "Oh yeah, no, I just went and got my degree with computer science." Like, "Okay, okay, but can we see the, you know, the work that you've done?" "Well, I have two group projects. Here's the code from that." Now we're like, "Okay, like we're already starting to get concerned because it feels as though they feel, you know, their degrees are the equivalent to competence. And we know all too well a lot of times it's the person way outside the box who comes in with really fresh ideas that make a huge difference. Not always, but a lot of times.

The the other example I like to bring up is junior engineers in a room with a senior engineer where a senior engineer makes a statement that's just flatly wrong. That doesn't go very long unless you've got a very toxic environment where they actually are in fear of their jobs. But a lot of times you just like the company can't afford to be wrong. a company can't and let senior engineers just lord over juniors with bad ideas for very long before it goes out of business. And that's the culture I came from. So I had to spend some time in those first few years where I was

I actually upset a a good friend who's a doctor. I won't say who this doctor is, but I will say that um they were very helpful in connecting me early on to some cardiologists and lipidologists. And I thought that I could have these interesting academic what I thought were academic discussions and debates on what might be understood by the field that could be wrong in the context of like lean mass hyperresponders. And looking back, I now know better. I my approach was perceived by them to be too aggressive, too forwarding. And I've I've learned, let's just call it etiquette. I've learned etiquette and a lot of that has to be um putting forth my degree of respect and acknowledgement for all they've accomplished which is genuine right? It's just that I I understand better now to prioritize it and that's going to be just a slow process to bring forward a challenging idea. I can't just like jump in a meeting and start discussing things that could be paradigm shifting, right?

um and I'm Sorry. I find the higher up the doctors are where you'd think the experience might make a difference in that regard, the more challenging it actually ends up being, the more hierarchical it ends up being. Because there's this kind of sense that, hey, I've earned this place. You can't just speak to me like some guy off the street, you know, if I'm going to work with you. Um, you need to, you know, understand where you're at, right? And I think you have to go back to this idea that these tenured professors have been told and their own sense of identity and worth is based off the corpus of literature that they've generated. It's not that they're just a great clinician and a good brain and if everything they've ever done before turns out to be wrong, but they could embrace that and do something different, everybody would say, "Oh, well, that's just how science works, right?" No, it is deeply threatening to the entirety of their career basis and their advancement basis if you come in and say, "Hey, uh, I get what you've studied, but like is it possible that there is some other alternative here that might explain some portion of the variability or that could be relevant to a population that you haven't studied before?" And it's it's as if they are not in like as a human they are not independent of everything they've done before. And so we are not we are stuck in this credential-based sense of achievement and worth and and nobody actually rewards the fact that your brain actually works well and you could have this code review and you could bring something new and fresh to the table and generate new stuff and prove yourself wrong, right? The the Finemans of the world are not in medicine.

Yeah. I I have a hypothesis on this. I think part of what entrenches this are these long time cycles. So when it takes a long time to do a study and it's like a big portion of your work, you feel certainly a lot of attachment to how that study is being graded by everybody else. And I mean, and I can speak with some experience on this, right? But by the same token um there are things that I learn in the course of doing it that may be limitations that I also want to discuss after I've learned them but for which when I'm surrounded by other people who are research partners with me it's impacting their you know their careers in a meaningful way.

Um, I'm going to give you a salient example because we're going to be publishing on this fairly soon, which is that within our own study within keto. We're measuring plaque, right? And we're doing with CT angiograms. Yep.

You're going to be pretty familiar with this.

There is a catch though. The catch is that the heart surprise is a moving target.

What?

Yes. Lots of people think that you can just get a snapshot here and then another time here and then just kind of like look closely. And no, there is it's changing. It's conforming. It's a muscle that's constantly moving and you're doing your best to catch it when it's slow enough and uh these CT machines are so advanced now. But that said, if you have a population like ours that has a large proportion of it with very low levels of plaque, it's going to be more difficult to measure both the plaque as it's presented the first time and to measure its change in a follow-up scan. That's not the worst thing in the world. That's first of all, it's already a big deal that so many of these folks have showed up with sky-high levels of LDL and did not have the expected levels of high of plaque for like being nearly half a decade average on this, right? But also that it's difficult to measure their change because there's also not that likewise change in plaque that would be expected for their levels of LDL at least at the you know the edges. Okay. Well, a number there's a there's this term noise floor which I really like for lay people. It's you know, what we're getting into is something called minimal detectable change. That's what the paper will get into. But the the lay person way I try to explain this is a bathroom scale. So if you go if you step on and off bathroom scale um and you find it's going up and down by like a tenth of a pound, did you really change that much in weight? No. Probably that is the noise floor or at least the point at which you know how much it's off. Much of our participants are below that noise floor

and therefore there's this scatter and we cannot draw strong conclusions on how much of a change in plaque it was if it's below that noise floor. But if I'm one of those patients, I'm pretty happy to know that my plaque is low enough that it's difficult to measure it in the first place. And it's even more difficult to measure its change.

Mhm.

But the field of imaging, they don't often report minimal detectable change, MDC. I want them to, right? But even what I'm telling you right now, Lily, could get me in trouble. I may have to like edit this out of the episode at some point later if I, you know, if I run this by the colleagues, but

it still is a pursuit of truth, right?

And it has changed how I think about imaging, right? This this issue with your study has changed how I approach CTNIO in my patient population because

it's not a bad thing. No, I think it's a great thing because it has really grounded for me the idea that a CTA is a very helpful study at least at a one time and point in time, but our ability to track overtime and I'm actually really excited that you're sitting down with Dr. Dr. Aguguston soon because um he was great on Bokeh. I think you'll have a really fun conversation and he's maybe somebody who's been doing this clinically in his own practice for a while. I know he is using the overlay tools uh in his CTAs. My concern is that not only is there minimal detectable change noise at the level of the scan itself, there is probably also what Dr. Ali described as algorithmic drift or a change in how change is detected by the AI overlays, whether that's heart flow or clearly or any of the other tools that may come to market. And I don't know, we we don't have reported data for what that is and how much change is actual clinically relevant change. So I don't know how to interpret somebody's clearly scanned from year 1 to year three with a 3% change in non-calcified plaque volume. I I just someday I'd love to say that we have that level of precision, but I don't know what that means right now. It's and this is where I would just say it's fine to get back to the 10 scale, right? Okay. So, there's um minimal detectable change. If you're going by the strict definition of it, then you are trying to figure out amongst an existing uh normal distribution, what you would say you're 95% or greater sure has been a detectable change.

Right? So what do I mean by that? I mean that there's been enough of a difference between this baseline and this followup in either direction going up or going down that you can say I know there was a change because it got to be enough, right? So getting back to the bathroom scale, okay, some things are maybe, you know, uh 20 uh 20% of a pound, right? So 0.02 or something like that. My confidence level might not be now that I've stepped on and off it enough times, I know that that doesn't come up very often. So, my confidence level may not be at a 95%. It might be that I need to be closer to like half a pound to have a 95%. And you know why? Because I know when I have gained weight and I step on and off it, it gets up enough. That's when um, you know, if we had a if we had a computer here, I'd show. But you could probably imagine this if I'm if you're looking at a normal distribution, you know, hill and you're moving another normal distribution hill to the other side, it's how much of a difference between the two there are such that you can feel confident at a population level there's been a change, right?

Yeah. And I think that's much harder if you don't have a standard against what you're measuring. Right. And so this is another issue. we can measure against the you know intravascular ultrasound or some other imaging tools but those are very invasive and we're not going to have enough of a population level to really norm this. So, you know, the the analogous um extension would be, you know, if you do water displacement testing of yourself and your body and then you're checking your scale, you actually may feel more confident that you could get down to the tenth of a pound rather than a half a pound depending on what you think is even a more precise and validated tool that's that's more accurate, right? But what we're not sure whether we have that yet for this kind of imaging data on on a population broad scale with plaque changing over time.

Right. Right. I and this is this is part of the challenge is that um when I was stepping into this and I don't I don't regret this part of it all doing CT imaging I think is the exact right thing to do with this population. the the key finding of there not being a baseline higher level of plaque not even just with AI guided analysis but just even with um semi-quantitative analysis

sure

is a major finding because that is the expectation per the present-day lipid hypothesis. The present-day lipid hypothesis is if we had for example, we had six participants with an LDL of 400 or higher, it is the present-day lipid hypothesis that they should have at least uh some substantial detectable levels of plaque and that probably would associate with the uh change in the year-over-year relevant towards another high-risk population. So that's that's the tricky part is whether or not to identify and it's by the way why we want to get the five-year scans. So I don't know if you heard about this as well.

Five-year scans for this population would just be gold. Um,

for sure.

But that said, as you know, it's not been a smooth ride. There's been, and this kind of correlates with your story to some degree, there's been some moments of uh trust consideration with the system that we're trusting to give us the answers, right? Which we can get into a little bit later. But I want to I want to get back to your story again real quick and then we'll jump back to I I do want to get to Dr. Nadir Ali's discussion and segmentation drift because I really want to jump into that. Um I want to close the gap at least with you ultimately then going into surgery and uh I had Philip Ovati on here before who's a cardiothoracic surgeon but you're close but not the same exact kind of surgeon.

Yeah. So Phil and I know each other and we we've had this chat. My dad is a cardiac surgeon. I thought I was going to be a cardiac surgeon. I did a cardiac sub internship when I was in medical school and I picked my general surgery residency program based on their cardiac surgery fellowship and was planning to have sort of a you know extra six months doing cardiac and was going to do it there and it was a whole plan. I have all these plans and I didn't actually know much at all about vascular. It had not really been on my radar as a student. I didn't rotate on it and I had to rotate as a resident on the vascular service my intern and again my second year of residency and a couple of the surgeons took me under their wing and said, "You don't want to be a cardiac surgeon. That's that's 1990 stuff. That's 1980s stuff. Like that's old. Um, they're still doing the same operations they did then. Look at all the stuff we can do. We have all this cool stuff. And if you have just a little bit of the ADHD nerd spicy brain then you can be in the leg one day, you can be in the arm the next day and on Friday you can be up in the neck. One day you can be doing open surgery, the next day you can be doing minimally invasive things with wires and catheters and stents. And if you want to have a super intense very sick practice, you can be, you know, the aortic person. And if you want to dial it back a notch, you can do, you know, more venous work that doesn't tend to have quite as many emergencies and super sick patients. Or you can do more hemodialysis work which does have very sick patients and can be very technically complex but is more bounded. And so there are all these ways to titrate or tailor your practice as a vascular surgeon that I did not see happening as a cardiac surgeon. The other piece of this is vascular surgeons work for everybody in a hospital, right? I got called by trauma surgery last night. Some days it's the OB/GYNs who are operating in the pelvis with a tumor stuck to a blood vessel. Some days it's, you know, the orthopedic surgeons who had a little whoopsie. Uh, but everybody wants our help. We are, um, usually it's a bad day if you call us, but like you're happy to see us. And we don't necessarily have a referral pattern that is beholden to a specialty who does stuff we would want to do. Cardiac surgeons, sadly, are beholden to cardiologists. So the way that you get a patient in cardiac surgery is that the cardiologist says, "This person is now too old and too sick for me to do the stents or the transcatheter valves or any of the really latest and greatest techniques that are evolving in interventional cardiology. Uh, could you crack their chest open and rearrange their anatomy open surgically?" There are some cardiac surgeons who are doing endovascular work and that's a very real but niche thing and many of the jobs are not um organized in a way that that referral pattern is given to them because the cardiologists want to do that. That's what they trained to do. And so you get the like day old leftovers if you're a cardiac surgeon. You don't have another pathway to referral. Like they all come through cardiology. So,

and it's and to to your point it is a very appropriately to some extent it's a very fixed theater if you will within the body right so it needs to be done in a very reproducible way for the benefit of the operation success right

sure yeah

so to to that extent exact even just what you were talking about right now I can imagine why that would be so appealing because or why it'd be so appealing to go with a vascular surgeon across all these other places because it sounds so much more adventurous, right? You you yourself don't know what your day is going to look like. There might be some commonalities, but even then there might be all kinds of mysterious things that you get called into that require some more on the spot problem solving.

Indeed.

So, yeah, I I I could see the appeal for that. And it sounds like by this point in your career or at least in, you know, as you're coming up in on the educational side, you're already kind of working through um this isn't exactly what you thought it might be and you're almost looking for some ways to channel what sounded like was a more creative endeavor from your earlier job, right?

Yeah. You know, I still in residency was sure that I was just going to do surgery. it. If you had told me then that I would be doing what I'm doing now, I would have laughed you out of the room. I had no inkling that that was going to be the path. And to to get where I was, you really have to appreciate and perhaps as an engineer you might that surgery is super problem focused and it is immediate feedback and often it is pretty gratifying, right? there is a problem, you fix the problem, you rearrange the anatomy or you take the thing out that is causing problems and you're done and it's great. It's immediate and people feel better and they walk out with a, you know, better situation than they walked in with versus the, you know, quote unquote internal medicine slog where you're like micromanaging their blood pressure medicine every and and this is the perception. It is not like helping people through their lifestyle changes. It is not helping people get well. that is micromanaging their chronic disease every 6 to 12 months and like, "Well, sir, I'm sorry that you had swollen legs with your amlodipine blood pressure medicine, number one. Let's try blood pressure medicine number two and see if that does anything better." And you're like, like, and I have to wait six months before I find out. And then they haven't even checked their blood pressure at home. And I'm relying on this crappy blood pressure we got in the office when the patient was late and running up the stairs and we should be so lucky um running up the elevator and like, you know, not relaxed and not seated and still for 5 minutes before we check their blood pressure. Do I even trust the number? We don't know. And so you're thinking, I why do I want to do that? That's lame. And I was looking at my mom who has this amazing career and a beautiful private practice where she was longitudinally involved in the lives of all these women, but I was like, "GH clinic and like telling these people what to eat and then they don't do it." And no, like that is not for me. I want to have a problem, go fix it, send the patient out, and this is going to be my thing. it's going to be perfect. I'm going to love this. But I didn't.

You didn't. So, what happened?

I discovered that in fact what seems like a very simple solution anatomically in that moment. And if you have appendicitis, it is right. If you have appendicitis and you come in and somebody takes your appendix out, yes, you in fact are measurably better than you were when you got to the hospital. and you probably go on your merry way and don't think about a doctor again for hopefully years. The heart and vascular space is a systemic disease. It is not a local phenomenon. So sure, I can bypass the artery in the leg that is blocked or I can put a stent across the thing in your neck that's causing you a stroke, but you still have the disease. I actually have not fixed your problem. I mean, I fixed one part of a very big problem. Um, but it's like whack-a-mole, right? I fix your carotid and then you come back because you had a heart attack during the general anesthesia for the procedure that I did for your neck and then your blood pressure goes really low while we're managing your heart attack and then you clot off a blood vessel in your leg and now your toe is black. And so, it's just this progressive problem. And now, by the way, it's been a year and now there's, you know, new plaque that's building up in the stent that I just put in a year ago. Now I have to go back and decide, are we going to blow up the stent some more? Are we going to replace the stent? Are we going to do a different operation? And it just doesn't end, right? These are patients for life. And while yes, I love the ability to have a long-term relationship with my patients. I don't want it because they're not getting better. Like, no, that's not what we're here for. We got into this job, again, to be helpful, to help people feel well. Very little of what I do as a vascular surgeon with the surgery piece lets people leave and be like, "You know what, I feel amazing. I am going to go uh on this international safari for like four or five years. I'll see you maybe never." That does not happen, right? I'm like, "Well, I'm going to see you in 3 months and we're going to get another ultrasound and maybe it's going to be okay and maybe it's not." And like I'm awake at night thinking about, "Should I go treat that little stenosis there? I don't know. Are they going to stop smoking? Are they going to do this? Are we going to do that?" I didn't. D. So it became this perpetual frustration. And then in my first job as a vascular surgeon, not only did I have all the vascular disease for historic reasons in this particular practice that I joined, all of the amputations in the hospital were done by vascular surgery. And the historical reason behind that is of course if the circulation in your legs is so poor for so long and we have done everything we can to fix it and it still fails then the tissue in the leg dies and amputation is the sad but inevitable consequence of that process. And so yes vascular surgeons have always been involved in amputations related to poor circulation. But it turns out there are a lot of other reasons that people end up with amputations. And perhaps the most troubling now is a diabetic foot ulcer that becomes so badly infected that it is a life or limb situation where the or so much tissue in the foot has been destroyed by the infection that it's no longer a useful organ for this patient and it has to go or they will die of this infection. And so we did all of the diabetic amputations in the hospital and I had at this point had you know we had come through the other side of COVID during COVID while we were a little clinically light. This is when I had started looking for myself because I was not sure that I was a beacon or paragon of health and I wasn't sure I was going to stand up in front of any of my patients and be taken seriously when I said, "You should do this better. Like you should have these lifestyle things." And so I worked on my own stuff for a while and I found this idea about carbohydrate reduction and could that be a therapeutic intervention for our patients and especially my patients who have diabetes?

And what year was this?

So this was 2020, 2019. So would it so would it be fair to say that you diabetic complications like literally having to lose limbs became kind of a strong seed for you to work your way towards okay we got to deal with this root cause because

it's huge

because I just whenever whenever I'm talking to any doctor who has to be involved with it it sounds like it's one of like the most disturbing things that you have to be doing is to coordinate on cutting a piece of somebody off, right? Like it's just and I just like even hearing it, thinking about it, and not even seeing who these people are who are having to face this and then ultimately come to that conclusion that I've I've um diabetes has been a major disease in our family, but I've not actually, at least in my adult life, had to observe this with a family member of mine. But again, hearing about it, yeah,

just gives me shivers.

And that's not me being a doctor actually there. So, I can't even imagine what it's got to be like for you guys.

Yeah. It was a patient I had done an amputation for and I had seen he was supposed to come see me in clinic, I think, as a follow-up. And I saw that he canceled his appointment because he was in the hospital again. And I looked him up uh because I wanted to see how he was doing and check on him. And you know, he had healed his amputation on the left side. He was back in the hospital for an infection in his foot on the right side. And I took a look at the pictures that were in the chart of his foot and thought, "He's going to get a second amput." And he was not old. He was in his 40s or 50s, maybe.

Wow. And I remember, you know, his spouse, I remember them talking about like their cats and their dogs and like their very active life, uh, or things that they wanted to be doing, right? The it was the moment for me I was like, "I this has to change. Like something has to be different. I have to have a practice that in some way helps with this problem because I cannot just keep being the person who takes these people's legs off. like that is gonna crush my soul forever and I will never recover if that is all that I offer these people in this world."

So what was your first introduction? What was the entry point for you to start looking at carbohydrate reduction?

in terms of like my education in the space or like how I started doing it?

Who did you first read? Who did you first watch?

Uh Low Carb MD podcast. So yeah, Brian and Tro and

Oh yeah, sorry. Brian and Tro that's right. Yeah, Brian intro and um a Brian Sanders actually was also in there in the mix. Um and the the food lies situation.

Is this also based near you, right? Is he in San Diego?

at the time? I was still like Virginia and then uh Minnesota based. I was not actually back here yet or back in San Diego yet. Um so it was not a geography thing. It was just like a podcast that I happened to tune into during COVID times that had a huge catalog because I really just went down the rabbit hole and wanted to like listen to the whole opus and really get into it. And it was important to go that rabbit hole because I started to see like not only it started about me, right? It started with my mom showing me a paper on intermittent fasting that had been in the New England Journal and I was early in my fellowship and I was overweight and not feeling myself and not feeling well at all and really unhappy and was like, "I need to be I need to do better. Like I need to feel better first of all and second of all this is not a place from which I can be a healer. Like that's I'm not walking the walk. Like I'm sorry." And that's true of a lot of my colleagues and I get it, right? Our lifestyle is not conducive to health. And that is something maybe we should dive into as well because it's certainly part of the book.

And I was going to say you discuss this in the book,

but I don't understand how we can be asking our health care teams, our clinicians to be doing all of these things, being up all night, having terrible food in the hospital, giving up their lunch breaks to go make rounds or write their notes or do whatever and not have health as their central core tenant. I mean, I just it's so backwards. It's it gets only more mind-boggling the deeper I've been in the space because you have what should be the institutions if you're going if you're going somewhere to get healed, right? At a at a minimum, the food served there should be that you know, a decent rate. So the the other issue is how much money is involved. That's the part that drives me crazy because what usually what I usually hear in response is, "Well, yeah, but good food costs a lot of money." I'm like, "Huh, what does disease cost, right? Why wouldn't hospitals of all places have some of the best food?" Because part of it is that you want to show in the place of health, of healing. You want to demonstrate as well as improve the recovery of your patients. And as I understand, there are studies that exist on the quality of the food with patient recovery. What more did we need? But then on top of that, you have the doctors themselves, right? You have medical professionals who have conditioned themselves on bad diets. And I don't mean to be callous here, but I kind of don't want surgery from somebody who's not on the best diet. Knowing what I've known about my own personal experience on how I operate with code, with research, and so forth, when I've done these diet experiments, I've seen how much it affects me.

Right.

So, this just to me seems like a no-brainer is no-brainer. Why why in your opinion is it so hard to fix this? I wish I had a better answer for this. I was thinking about this coming here on the plane ride and this goes back to the human performance world. Every other major high performance field has a whole ecosystem around optimizing that performance. Right? Pilots have mandatory rest time between their legs and the amount of hours that they fly is very carefully regulated and they have their evaluations and their fitness and their this and their that. Uh athletes, right? You tell some athletes, you are going to go do, you know, a tournament and half the games are going to be in the middle of the night. Some of them are going to be eight hours. Some of them are going to be four hours. You're not going to know ahead of time how that's going to go. Uh you may get woken up all night long with phone calls and then have to do, you know, press conferences all day long and then, you know, squeeze in a tournament game in between some of that stuff. And you don't really get like a meal time. You just get to like go to the nearest convenience store or a cafeteria and like fend for yourself at whatever time that might be. So like I don't know, 8:00 p.m. 9:00 p.m. What are you going to get? And uh how do we think that would go? Right. Right.

And this is what we are asking our especially our surgeons and our proceduralists who are called in in the middle of the night to do. It's bananas. And the only way I have been able to make this pencil for myself is to go down to a part-time surgical schedule. I mean, I I couldn't figure out another way because I was burning my weekends rotting on the couch trying to recover both mentally and physically from days on end of doing this. But were you there yet in 2020 when you're adopting a low carb diet? It sounds like that may have come later.

That came later.

That came later. So you you

I was still thinking it would get better when Yeah.

Yeah. You were still in the hope of the We were still in hope the great finish line. So you go down the rabbit hole. You I take it adopted the low carb diet then. It did in 2020, right? And

now I'm guessing you're going this might be a good option for my patients. Um, you're you're a vascular surgeon though so it must be asked obviously I'm biased to be asking this but the question of cholesterol, right?

sure

By this point in time in 2020 has the topic of cholesterol floated up enough in your your learnings that you're starting to wonder with regard to this?

it it crossed my mind in the sense that just like that very first approximation, right? Atkins diet, all the bacon, all the butter, all the this, all the that, like surely that's not a good thing. And then, you know, the the sort of again first approximation answer from the low carb community, which is, "Well, but we're fixing the insulin resistance and that actually means so much more than whatever happens on the lipid side." I was not yet deep into the lipid space yet. I was not particularly facile with any of the interventions. I was not aware of the pros and cons in particular of these medicines that we are prescribing like candy to our patients. And to let me be very clear, all of my patients on the surgical side have plaque. So that is a different conversation than what we are talking about in a primary prevention space, which I now also have a have a role in. But and I I have been so conflicted. I sat on a committee that wrote guidelines for the American Heart Association regarding the use of medications for patients with peripheral hero disease. And I have to say like it was weird, but the general idea that we are just not recognizing the enormity of the contribution of insulin resistance and diabetes to the formation and progression of plaque should by itself be enough.

Uh 100%. Right? Like if we we agree on more than we disagree on in in even if you want to take the actual extremes of your 10-point scale and where you sit on lipid heart um and diet heart is a little different actually than lipid heart and and they're related but a little separate. And regardless, like we all agree heart

Attacks and strokes are bad. We all agree that we would like to prevent that. We all agree, I think, I'm I'm actually assuming this, but I think we could all agree that the standard American disaster diet is a poor choice to lead to that outcome.

But if you look at the recent epidemiology, smoking's fading away. And yet, cardiac surgeons and vascular surgeons are busier than ever.

Yes.

So, why would that be? Like, we all thought, hey, we're just going to go golfing. And I don't golf, but like we're all going to hang out and do other things because we're going to have no more business now that all the people have stopped smoking. And it's not the vaping. I mean, that's not good for you. I'm not recommending that by any stretch. However, I mean, it's not like that is what's accounting for the majority of patients with vascular disease that I treat. It's just not.

And you know, I believe personally that lipids are part and parcel of the many, many things that result in the formation of plaque decades later. I am not under any illusion that they are the only thing.

Um, they are an easy thing to move the needle on with risks and benefits associated with that, and we can happily have that conversation because I have it every day in my clinic.

Right?

Uh, and it's a great one, right? It means something.

But importantly, and and just like to clear the air on this, you are um, there's no wrong answer to this. You are pro lipid hypothesis per se, and that you would want to treat LDL levels in your patients, right?

So generally, yes. I agree with the idea that the preponderance of evidence at a population level supports the idea that particularly for patients with established plaque, established disease, particularly who've already had an event, heart attack, stroke, limb event, there is evidence to support the use of these medications to reduce the likelihood of another event. In patients that have not had an event, who have a, and we can talk about what reasonable is, but some evidence of plaque formation already based on an imaging test, I also believe that monitoring and perhaps reducing lipids is one of several strategies that should be employed to potentially stabilize and/or reduce plaque burden going forward. And the reason to be thoughtful about that with early stage disease is because the degree of intervention can be so much lower.

Right? If we if we posit, and this is an assumption, but it's one that is mainstream now in the lipid hypothesis, that it is an integral over time, area under the curve.

Then I can make very small interventions very early with large changes over time and not have to break out my big guns, big doses, big stuff later when it finally manifests as an event. And so this is why I push back just a little on the CAC is zero, ten-year risk is low, we don't have to do anything right now. Um, I, I, it is an appropriate one of several appropriate answers to that scenario, and I'm happy to offer that to patients. I think that is their choice. It is absolutely their choice. And also, I do think that if you want to make smaller changes early, and there is some evidence of disease, and CAC zero is a unique situation. Let's say it's a CAC of 30, right? That's not a lot of disease. You're still very unlikely to have an event in the next 10 years if you have a CAC under 100.

Yeah. Even then, it's it's very age-considered, right?

I'm a first person to talk about the age component of that as well, 100%.

Right.

But like, let's just talk about generalized statistics. If your CAC is 30, you don't have that much disease, and your 10-year risk from that particular score is pretty low, all other things considered.

Right?

So.

But, but yes, there's a safe space. Believe me, I have had plenty of pro-lipid hypothesis, very, again, it's a range, right? It's a spectrum.

To many of your colleagues, what you just said sounds like an ultra-LDL skeptic position, right? To to many of the people in the low-carb space, you know, I'll eventually have David Diamond on here. He'll be like, "Yet again." Right?

Right. Yeah. Yeah. I'm such a disappointment to everybody that I feel like I'm actually right in the perfect place.

Exactly. That's that's that's always where you want to. So, okay, where I was going with this was because you were kind of bringing this in, is back to the spectrum. I think I can make a strong case that wherever you stand with the lipid hypothesis, save a very small number of people, diabetes is not even a close call, right? Like there's so much discussion that can be had on lipids. Cool. There's a lot of range for how much you believe or don't believe in the lipid hypothesis. Fine. I'm happy to host any kind of debate with anyone as to whether or not severe diabetes comes anywhere close to even the most fervent pro-lipid hypothesis position. And this isn't, this is often when I'm bringing this up, many people are pro-lipid hypothesis are going, "Now, wait a sec. You can you can address both." I'm like, "Please address both if you believe in both." But my one big consideration when it comes to LDL and um, and I'm probably more fervent about this because this comes up with certain family members, is that a number of people are like, "Ah, but my LDL is great. I'm not really worried about a heart attack." And I'll be like, "But you have four of the five criteria for metabolic syndrome, and you definitely have very severe insulin resistance." And when I'm looking at a fasting insulin of 40, I'm scared for your heart. I don't care what LDL number you tell me you have.

Right?

It doesn't matter to me. You have to understand why it is that these, you know, these type 1 diabetics were dying so early from exogenous insulin levels. Right? It's because insul, you know, hyperinsulinemia, pathological insulin resistance, and definitely all of these diabetic complications. There are serious, not just all-cause mortality concerns, cardiovascular disease concerns, they have to be addressed. And that, and so that's my biggest complaint about LDL is not where people stand on the lipid hypothesis, it's that it sucks all the oxygen out of the room.

Right.

And that too often doctors are like, "Well, I'm going to think in terms of heart disease from this one particular metric, and oh, good, it's low. I'm not worried about you getting a heart attack." You know, we should be monitoring these other things. But that's that's a problem.

It's also a little bit of of a silo problem and an abdication of responsibility. Right? As the vascular surgeon, my job is the vascular system. And I'm being ironic here. I don't actually mean that anymore. But aspirin, statin, those are those are my guidelines, and that's that. Your diabetes is your endocrinologist's problem or your primary care doctor's problem. I can send them a message that says, like, "Please, you know, address the A1C of 11." Uh, but I'll I'll happily put them on a on a medication that might actually make that worse, but I can make the LDL better. So, great, I did my job, right? Pat myself on the back, right? And part of my evolution as a physician and part of reclaiming the joy in medicine for me has been to recognize that A, none of my interventions on that, like just check the box, follow the guidelines, front ever made anybody feel better. And B, it was wholly inadequate because yes, while cardiovascular disease is the leading cause of death in men and women worldwide, uh, it's disability, it's dysfunction. And if we improve your cardiovascular mortality, but you die of something else at the same time anyway, is that actually moving the needle at all? Like, do we just feel better because I've had you die of an immune disease or of cancer or of something else that was equally disabling than because you didn't have a heart attack and not on my watch? So, my evolution has been to realize that in fact, fixing people's insulin resistance tends to make them feel better, like in miraculous and meaningful ways, uh, in a way that treating their lab panel does not. But it takes a person who wants to do that. And part of my frustration as a clinician in the trenches every day is that that's a minority of my patients. I have people that I will go blue in the face talking to them about the need to work on their nutrition and try to manage this using lifestyle tools and techniques, and I will spend as much time with them as they need for me to do that. They're like, "I'm doing everything I can do."

Do you have colleagues who occasionally don't love that you're giving nutrition advice?

Uh, I don't know that I have any immediate colleagues who don't love this. I did have somebody leave a comment on my channel recently who, um, told me to stay in my lane.

Yes.

I've definitely, uh, I've had many of those "stay in my lane" comments because, after all, this is not my usual lane. Uh, I do want to get to some questions from the desk. This seems like a good spot. Uh, should men and women eat differently or approach health differently, or can they eat the exact same and get the same health results? I don't know that we can answer this from a data standpoint. I think that we can't say men and women or old people and young people or people in red shirts versus people in blue shirts can eat the same thing or different things. What I struggle with a lot is the macro to the micro. So we talk about, and the lipid hypothesis is perhaps maybe the best example of this for us, the lipid hypothesis as a population finding. Right? The patient in front of me is an individual human, and this is where there's a huge disconnect because I have LMHRs who come to my practice who know they've seen me on other people's podcasts and they want me to be their doctor, and I'm happy to do that. And I end up saying, "I don't know." So much in those patient visits, and I feel badly about that because it's, I feel like they want me to give them an answer and say, "You can do this and it'll be fine," or "We're not going to do this and we're going to feel right about it." I don't know what the answer is, particularly if you have plaque. And all I can tell you is what the risks and the benefits are, and I can offer you a trial of something, whether that is observation, repeat imaging in a year, whether that is, uh, a lifestyle intervention, whether that is pharmacology, whether that is supplementation. We can do any number of things. I do not know for you in front of me today what is going to happen. And that is a beautiful and amazing thing, actually. And it is why my job is fun. If everybody just got the same thing all the time, you don't even need me. There's a bot for that.

Right?

That's why I joke with the whole boldface type medicine. I'm like, "I could just write a program."

It wouldn't even take many lines of code.

Well, and and big health systems do this. They actually have, you know, sort of like pharmacy-directed medication pathways where you get a lab result, and your doctor gets it, sort of, but it actually goes to a pharmacy team, and the pharmacist picks your new medicine for you to trade your lab value and calls you to tell you where you can pick up your new medicine for your A1C or your dyslipidemia.

I don't love that.

Neither me. Um, let's talk about your preferred method of detecting plaque. So let's talk about, or actually, I don't know if this is your preferred method, but you do yourself perform a lot of carotid intima-media thickness test. Tell us about what that is and how it works.

Ultrasound is a great modality for detecting plaque because it's non-invasive and it can be done sort of anywhere. Right. You've seen me tote around my little ultrasound and and bring it to conferences and do this for people in real time. And I am a pragmatist. I know that not everybody has access to a high-quality ultrasound. So while I love it in my practice and I will happily, uh, talk about its its benefits, I am also not going to say that that's the right choice for everybody because ultrasound is very operator-dependent. You must be trained or have trained yourself and been, you know, measured to, especially if we're going to measure the IMT or the intima-media thickness. So let's step back. Arteries are a layered structure, like an onion. They have three layers: the adventitia, which is the outer layer, the media, and the, and the intima. Those two innermost layers, the intima and the media, will begin to thicken when there is either inflammation or subendothelial deposition of lipoproteins. And eventually, as it thickens more and more, then it becomes a plaque. And so sort of like the adenoma pathway of of cancers, right? There's this benign growth, and eventually over time it transforms into this big ugly cancer thing. We believe that yes, you'll get this thickening of the two innermost layers, and eventually it continues to thicken and grow, and then becomes a plaque. So you can detect that early. The IMT test, to be clear, that I do, also detects plaque. So IMT is its own very specific measurement of the thickness of the inner layers of the wall, typically done in the common carotid artery in the neck. Carotid artery brings blood up to the brain.

Is along the side of the neck here and here.

Yeah. So you have two carotid arteries in the front and two vertebral arteries in the back. Those four will bring blood flow up to the brain. But again, very easy to image, right, right, very close to the surface, and we can measure that IMT. Now, the vessel is a three-dimensional structure, right? You think of the whole back wall of that pipe. And to get a really good, precise, accurate measurement with very low minimal detectable change, um, you need a protocol that allows you to measure this many different ways. So you want to image all sides of that wall, and you want to have multiple measurements taken, and you want to have your imaging set up so that there's not any smoothing or any interpolation, and have all of this available. So I use a lab called Cardiorisk. Dr. Todd Eldridge is the, uh, engineer PhD guy who runs that and has developed this protocol. He built his whole career on reducing variability in manufacturing and in in processing plants, and he got real spun up about cardiovascular disease and thought, "This is such, this test has such high potential." But if you look at the cardiology literature, people don't like it. It's actually got a very, you know, um, storied and and mixed reviews in the past because it's operator-dependent, and people were not doing a good job of having uniform, reproducible results. So he set his engineer brain to this problem and said, "Okay, here's how we are going to make this a precise and reproducible test." It is the only thing in my 17 years of medical training that I have had myself to pass a double-blinded randomized test to be able to scan for Cardiorisk. I had to take an ultrasound and scan five random people off the street in Utah twice, and then my results were anonymized and sent to the lab. They were compared against their sonographer of 20 years, and she did the same five people twice, and their statistician ran the data and said, "Do my results of the same patient twice meet with, like, can you, I reproduce the scan, and are they the same as this other sonographer's?" And if you don't meet their quality measures, you have to like go back and do more scans and like practice more and come back and retest before you can scan for Cardiorisk.

This is a kind of certification for doing it, not just any sonographer, but doing it under this program you're describing.

Just, just for Cardiorisk. Like, you can, there's a button on the ultrasound machine that will calculate a CIMT. I get tests back sometimes that have that, and it just, like, the tool will measure a thing, and you can get a number. I just don't know how reliable it is. And again, the IMT is one part of this test. The other part that is arguably even more important, although a little less reliable in terms of measurement precision, is the detection of plaque because that's a separate piece of the exam. Uh, we are looking at a different part of the artery. We're looking at the carotid bulb where the artery, uh, bifurcates and splits into the internal carotid, which is actually what goes up to the brain, the external carotid, which feeds the face and neck, because that is a structure with different geometry. There is more turbulent flow in the carotid bulb. And just as we know, we see plaque in places where there are bifurcations, right? It is because there is decreased shear stress in the wall in areas with turbulent flow. So plaque tends to form there. If you're going to see thickening or you're going to see plaque, most commonly you'll see it in the bulb. You may actually also see it earlier in the femoral arteries than in the carotid arteries. That is an evolving part of that protocol and that idea. Uh, Dr. Fuster has done some really interesting work looking at, uh, early detection of atherosclerosis in in populations using that. But moral of the story is, if you see plaque, then you know you have the disease. And we can also determine, at least qualitatively, is it very soft, echogenic plaque? Is it heterogeneous or mixed plaque, or is it densely calcified plaque that's been there a really long time and is actually hard to see because it creates so much echo shadow on the ultrasound test. So we get a, some kind of qualitative assessment of the plaque, but also we are able to take that and the IMT, and, you know, those of us who use this will put that together in a way to help tell a story that is maybe not as data-driven as I would like for it to be in the sense that, let's say you have plaque burden, but your IMT is average for your age. So arteries get thicker as we age. That's a normal thing. And there is a, you know, because it's ultrasound and non-invasive, we actually have IMT measurements normed to all the way down to kids, right? Less than 10 years old, because we've been testing HOH patients and like looking for disease in people for a very long time. So we have these curves. Women have slightly thinner arteries than men. So it's normed to gender as well. And we can tell you, is your arterial thickness normal for your age, below normal for age, or above average for your age? And when I do these tests at meetings, it is fairly common to have somebody with some plaque and an IMT that is actually average or below average for their age. You're like, "Well, what does that mean?" Because I have the disease, but my IMT looks good. And there are multiple ways of interpreting that, right? One is that you have disease. You have atherosclerosis. So, we proceed accordingly. But what if your plaque is older, and what if your IMT being average or even below average is a sign that your metabolic health or your treatment plan, whatever that is, supplements, medications, lifestyle, is improving your arterial health, and that plaque is going to stabilize over time? So again, not super data-driven, but I believe that if I watch IMT come down over the years, and I like to do this annually for my patients if they're willing, then perhaps I believe that my treatment strategy is effective. Conversely, if I see arterial age increasing year-over-year more than chronologic age, I am concerned that whatever we have done has not been very helpful in mitigating your risk. And again, this is because, in my opinion, atherosclerosis, the formation of plaque, is the end result of a very large number of different risk sets, and it is why no one intervention has ever been successful in eliminating risk. There's always residual risk when we look at these studies of whatever intervention, whether it's lipid intervention, whether it's aspirin, whether it is supplements, there's always some residual risk, and it's because necessarily, to test a hypothesis, we have done one thing right, and it helps answer one question. But if you want to look on aggregate, then, you know, it becomes much more important to think about the full picture if you're wanting to minimize risk.

Okay, I'm going to unpack a bunch of things. Uh, one, I'll concede in my like larger, I don't know if you've heard me talk about this before, my larger opinion on atherosclerosis is that I think there's actually a long list of things that cause vascular damage, long list, which by the way includes even repair of vascular, right? So the, uh, but that there's actually a short list of the body's internal means of repair, leading back to the immune response.

And that I believe a lot of what is causing vascular damage is actually us out-competing that immune response. This is another place where not only bad diet, I think, can be problematic, especially binging and things along those lines, but that that also can apply to exercise, uh, that you can also out, you can have too much exercise and not prioritize recovery enough, and that can also cause vascular damage, right?

I agree.

But how much of that is actually causing the damage versus just not allowing the body to repair itself is an interesting topic to me, right? And I think that when you prioritize recovery, when improved diet and so forth, you improve the chances of vascular repair, but that there's also some degree of rate limitation from literally your immune response. Even if you went on the perfect diet, the perfect protocol, and so forth, if you have a whole bunch of vascular damage, I don't think you get an equal distribution across the, you know, across the body to be able to repair it, right? So that's a bit of a simplistic direction into this, but it does get me interested in t, uh, things like the CIMT because unlike the study that we did with longitudinal CT angiograms, even doing the third set of scans, there's already discussion about, you know, uh, about dosage of radiation. Even though that's like two millisieverts for like a low-risk person like myself and so forth, there's still contrast dye. So you're right. Not only do you have the capability with CIMT to be non-invasive, but on top of that, you could do them like every week. You could do it every day. You could do it multiple times a day, right? What's neat about that is then you've got also greater capability to test retest.

Yep.

Now, where this became relevant to me early on is before I had ever gotten a CT, and I was getting CIMT tests. And at first, I thought it was giving me really good data. And then I did a test retest. I had them take, I got a reading that I didn't love, and then I went to get one three days later, and I didn't love it, not because it was bad, but because it was too good.

It looked like my CIMT had dropped way more than I would have thought it could have. I got another test on the, uh, Saturday after, and I think it had been,

60% higher on, or not the Saturday, it was like three days later or something to that effect. And so, um, here's something I've never shared before on, I don't think, on this podcast or maybe anywhere. Um, I got a butterfly. You know what a butterfly is?

Yeah, I do. And I don't have one. And we can talk about why.

Oh, okay.

I have I have a Clarius instead. So I decided I was going to take it upon myself to treat this as an engineering problem because I, at the same time, was coming to the conclusion, well, actually, this is too operationally, uh, operationally operator-dependent, the way that you described, which is just another way of saying that unfortunately, there's too much manual control by the person performing the CIMT, right? Would that be a fair way of stating it?

Probably. I'd have to think about it, but I, I'll stipulate it for now.

There's there's not as much that is automated and controlled that prevents the operator from having a latitude in the way they make decisions.

Yeah, I agree with that. So, I mean, a CT is a CT is a CT, right? There's very little technical, um, there.

Less, but yes, still some, but yes. You know, it's and it's much more representative, representative of the whole picture, right? The problem with ultrasound, and if you ever are, you know, looking at it, you're like, "Well, could you like,"

I just wanted you to turn the probe just a little bit that way and see like the full thing, right?

Um, and and, you know, you are beholden to what the sonographer at that time took a picture of.

So, here's what I was planning to do. I was planning to make a mold of my neck and the bottom of my head to hold with existing positioning for the butterfly so that I could determine the appropriate points and that it would be absolutely fixed into what position it was, right?

Okay.

This didn't work.

Um, I'm not surprised.

There was a number of issues with it, which I won't go into here, but I, I was trying to solve that problem at least for myself. And I figured with, uh, 3D printing and with being, you know, me having the time and interest and being able to set actual, I could solve this issue of the positioning because part of that operator, uh, dependence is exactly where it's positioning, like you're talking about, like the, you know, 45-degree angle here and so forth, but also how much to press in. There is a relevance, as it turns out, to how much of the, um, uh, the lubricant that you apply, and lo and behold, what lubricant you use, which turns out to be relevant as well. And I'm all this time I'm going, "Okay, well, I'm going to get all these variables controlled as best as I can." But more and more, I kept thinking, "No, I just don't feel like I can actually trust this test to a degree that I want." But even then, when I was researching it, I was hearing what you're telling me here today, which is that there is a spectrum. The spectrum is, it's hurting the reputation of the test because there is such operational dependency. And that somebody can state, "Hey, this is a CIMT," and have that level of latitude, then it's why a lot of people aren't going to consider it to be as strong.

Yep. And that's a fair criticism. It's totally a fair criticism. And the number of people who are trained on Todd's protocol to get a test that he will report is precise to hundredths of a millimeter to detect change year-over-year, at least, is not very many, right? So I have people who come from out of state to come get these done annually because there's nobody closer. And like, that is not the stuff of a widespread screening protocol or a widespread thing. So when I am talking to the great wide world, if CAC is what you have, it is a good enough test. It is absolutely good enough to get started. And as a pragmatist, I would rather you got that than nothing. I'd rather you got that than a bad CIMT, and I'd rather you got that than nothing. So while I love CIMT and I really believe in it and use it, it is, you know, not a replacement for CAC most of the time. Uh, also, the cardiologists like to look at the heart. That's their organ, right? They don't super care about the neck or even the femorals. I like them. Uh, they're easy, but it's not as interesting. Even, oh, plaque in the neck is what potentially leads to stroke, at least in some cases. And so I think that's a pretty relevant outcome. But, and by the way, 90% concordance if you're looking at plaque detection in ultrasound, at least in Dr. Fuster's work, between carotid and femoral plaque detection and what we can detect with cardiac imaging, CAC.

Right? In other words, if you do find plaque, and and we should make a distinction here because you, you drew the distinction, which I appreciate. There are two things. It's important everybody keep this, keep this in the middle of their mind. There's thickness, which isn't necessarily plaque. It could be diffuse intimal thickness.

Correct.

And then there's literally plaque, an identifiable shape that you can that you can point to and you can say, "This, this is a plaque."

Yes. And I show patients like, "Here's a little, there's that big speed bump. That's the plaque."

It's a bump. And then you can further characterize it in the way that you were just talking about. And it's important that the characterizing is important because if you can't actually tell that it's a low attenuation plaque, which say it's got a very thin fibrous cap,

That's a big concern.

Certainly a big concern for me.

Yes. Yeah.

Because that's a plaque that's, uh, at risk of rupturing.

Right. And as you just mentioned, um, these carotid arteries,

They're feeding, they're coming up here to the brain, right? And so this is quite literally where a stroke can occur. And so if you have a low attenuation plaque, it's a big deal. But how common is it that you've got something from the other end of the spectrum where somebody has a poor lifestyle for whatever, you know, 40 years, they've improved their lifestyle, now all of a sudden they're crushing life and so forth, and lo and behold, they had a plaque in the carotid artery. They didn't know it. But you actually find it looks like it's an old plaque. This comes up from time to time as well, right?

Yeah. Frequently. And what I tell patients is, we don't have a baseline. And this is the flaw of any imaging test. It's the same with people who have been fervent exercisers for years and lo and behold, they get a CAC one day and it's a thousand, and they're

Totally distressed because they are crushing it with their cycling club, doing bike rides on the weekend, totally asymptomatic, and thought they were doing everything right. I mean, they're, you know, eating to train for their endurance activities and this that and the other thing. And we don't know, right? There are a large number of athletes who have who get an angiogram, right? Because everybody freaks out with their with their calcium score, and it's all in the wall, but it's not narrowing the lumen. They don't have a flow channel, and they don't seem to have much in the way of soft atheroma. If you do a coronary angio or CT angio.

And then you occasionally have people who are just like these people, they have like a 99% stenosis.

Yep. And it's abundantly clear, although you can't tell in an angio, that they must have done collateral, that there's actually neovascularization where they bypass their own.

Yeah.

Uh, their own coronary arteries, which is amazing that the body does this. But again, to your point,

We don't actually have a lot of good data on asymptomatic patients even when they have a lot of heavy-duty heart disease. Of course, the expectation is to well, treat anyway, right? Like take action because it is disease.

And, and we don't know how much soft atheroma there is. And this is the really the key question because we know if you take the abundant, you know, the totality of plaque, it's not really the calcified stuff that's causing trouble. We really do know that it's the non-calcified plaque volume that is going to rupture and cause trouble. Yes, the calcified plaque, if it creates enough obstruction, can cause stable angina. It can cause claudication or pain with walking in the legs. It does do some other things. Even in the neck, it can be enough turbulent flow that you could get a little platelet aggregation on an old calcified plaque in the neck and maybe have small micro-strokes from that. All that is possible, but most of the time we are really worried about that soft plaque, and we just don't know. Again, we, if we get this snapshot of your neck, I don't know how much soft plaque you have in your heart or in the brain or in other vascular beds. This is a, a one-time picture. And the CAC is more so that way, right? This is the iceberg. Have you done everything right and stabilized your neighborhood and your insulin and everything? And this is all just old scar tissue, and your body is, you know, dealing with your overtraining and your lifelong, and it's made other pathways, and you're doing great, and you have a lower risk of heart disease than in fact most other people your age because of all of the other great things you've done. Or is this actually a problem for you? Is there actually also more new plaque that's forming because of whatever all the gels that you're using or all the sugar drinks, or I mean, who knows, right? Um, the vaping on the weekends, whatever, like it's anybody's guess. But there are lots of al possibilities that if you have a lot of calcified plaque, you may also have a lot of soft plaque, and that is really where we, where we want to focus our energy because it's the calcium burden by itself is just the indicator we think most of the time of this untreated soft, vulnerable plaque.

I'll concede I'm, I'm more bullish on CAC than I've ever been. But I'm also just generally a fan of testing. And I think, uh, certainly if somebody was coming to me and they were saying, "Hey, I have some concerns." You know, and there may be a multitude of reasons why they would say this, but if they were saying, "I have some concerns," my the first thing I say is, "Well, imaging. You know, there's nothing beats the physical detection of disease." If they're, if they're really concerned, I'm going, "Okay, the gold standard in my opinion at this point in time is CT angiogram." If you want to go really out there, IVUS. But IVUS is invasive. It carries much more substantial risks than CT angiogram. CT angiogram though does carry some risks of its own. But I have told people before, um, who are wanting the lowest dose possible but to try to check from every angle possible, is get a CAC and a CIMT. But I've quite literally mentioned you before. I've said, "But try to get like a good quality CIMT if you're going to go there." So, I know this, you know, Dr. Lily Johnston and other people like her care a lot about the quality of the CIMT. And, uh, correct me if I'm wrong in this, that probably the quality of CIMT that I should be, uh, up to being able to recommend isn't available in most states. Am I wrong on that one?

Cardiorisk is getting broader and broader. They're now doing like pop-up clinics where their own sonographers are flying out. So, somebody called me from Hawaii. They have one happening in Hawaii sometime this year. There are a few in California. Uh, it's hit or miss. And there are other people who will, you know, if you find a practice that uses it, the practice will generate enough patients who all need to get scanned, and they'll fly a sonographer out from Cardiorisk to come do this. But it is certainly not like you can walk down the street and go to an imaging center and get a CAC like that. I mean, it's not that level of available, certainly not.

Yeah. And I mean, again, this is just, I think we're speaking the same language. Part of it is, hey, let's just make the tool work really well, right? Let's have it have strong accuracy. Uh, now, to your point, just like CAC, if you have a positive calcium score, uh, there's studies that with a lot of impressiveness show a correlation between, uh, your calcification levels and your soft plaque, but it's not deterministic. You can have a CAC of zero, and you can have soft plaque, or even severe soft plaque, even if it's rare.

Right.

Agreed.

Uh, how often do you find plaque in the coronary in the carotid arteries for which there's otherwise no disease in the carotid in the coronary arteries?

I don't have a great data set personally with this because I don't necessarily get coronary imaging for all the patients that I have CIMT imaging for. But concordance, if you look broadly at the literature, and again, I'm going to point to, uh, Dr. Fuster's work here, especially if you're also imaging the femorals in a lower risk, younger population, and you're getting both of those things, is about 90%. Right.

Um.

So, in other words, you, you're detecting identifiable plaques both in the carotid arteries and also in the femoral arteries.

Yeah. So if you look both places.

If you look both places, and you get plaque there, and you have coronary imaging, there's about a 90% concordance. So there will be some people who have plaque in the periphery who do not have it in the central circulation, in the coronary circulation. There will be some people who have coronary calcification who do not have much detectable plaque on ultrasound in the carotid and femorals. But again, overall, it's about 90% concordant. That's not terrible.

Generally, if it's just in one neighborhood, it's probably in the other neighborhoods, generally speaking.

It's a systemic disease. What we don't understand, and I, I think we just need to come back to this central point again because it's so important. The reason we have to have imaging at the individual level is because our population knowledge is great for populations, but I don't trust a pulled cohort equation or even the PREVENT equation. That's the newer one, right? This is great for population level risk. It doesn't tell me diddly squat about you.

And that's who we care about in this moment, right? You and me. So if you don't have your own imaging, I do not have confidence in those risk calculators, anybody's risk calculator, to appropriately bucket you because we know that there are people with low Framingham risk and a CAC of zero who do have soft plaque. There are people with low Framingham risk who don't have a CAC of zero. And so whether it's Framingham or Pooled Cohort or PREVENT, these are all interesting tools at the population level. All of our information about risk reduction is interesting at the population level. I am in the business of educating the population but treating humans.

I.

In front of me, and so we have to come back to this.

And this is why I, I believe it was even, I don't remember if it's the last talk I saw from you that was in San Diego or if it was literally the first one, it may have been the first one, but I was just genuinely impressed sitting in the audience at how many times you kept bringing things back to uncertainty principles, right? And that that gets back to the individual, as is these population level data. They're very important. I mean, again, I'm running one myself, but I, I myself have tried to condition, uh, my answers and interviews and so forth to even segment my own population of the keto cohort when I'm talking about them. There's the regressors are exciting, but I also try to fit in the, "We do have some progressors, and they should, you know, be mindful of it." The regressors are exciting because it also sort of pushes back on it's deterministic whether or not you have plaque because they had plaque in order to have less plaque. But even then, there's an uncertainty unless it gets confirmed.

Mhm.

I still want to see a visual confirmation of the of what got, uh, regressed, which is, you know, what we featured in the movie. Did you end up seeing our movie?

I'm so embarrassed that I have not actually watched it all the way through yet. I feel so bad.

It's okay.

Was like on my list.

I've had I've had multiple guests because everyone's busy. So so excited to see it though. I mean, it's not for lack of interest or a commitment to the cause. It is simply that it just hasn't, um, happened yet. And I'm sorry for that.

No, that's okay. That's okay. I have a TV over here and we'll just.

Yeah, two hours later.

Exactly. Two hours later. Um, okay, we're going to do another question. Uh, is there any evidence that following a ketogenic diet during pregnancy is harmful? For example, if someone is using a therapeutic ketogenic diet to manage a condition or conditions, is there evidence within the literature to suggest they should stop while pregnant? I actually think this question is for another Lily because there is another Lily in the space who actually knows more about pregnancy than I do. My, to the best of my knowledge, there is nothing that suggests it's harmful. There were a lot of people who will tell you that it's a bad idea and would be harmful, but I don't know of literature that would support that conclusion.

What's the, for those people who make that case, what, what's the argument?

I, I, I'm guessing, I don't know for sure what the argument is, but, uh, you know, hypoglycemia and nutrient partitioning and growing baby and oh my god, low glucose and too much fat. I don't know. I just, I again, I try not to be, I'm self-conscious about how many times I do feel like a low-carb or a ketogenic diet might be of special efficacy for a given situation that it's like I have injected doubt, like I add doubt where, just to be sure that I'm, but knowing about gestational diabetes, like that alone just makes me instinctively say, shouldn't it be the knee-jerk reaction that if anything, you'd want to be more mindful of not having carbs?

Well, and let me be clear. I don't mean to discount the risks of anything in pregnancy. You, you've had another guest on who rightly points out that there are a lot of drugs we don't know anything about in pregnancy because everybody is just too scared to test them. And I get it. I totally understand why there is fear. But, and I usually hate an evolutionary-based argument, but just think about the natural history of human condition. Uh, carbohydrates were not always a huge part of our diet, and we survived. We survived periods of starvation and famine and continued to just ate new humans. So it can't be all uniformly harmful forever. I don't think. I mean, you could argue that perhaps it was, and we just didn't have babies from those particular environments, but I don't think so. I just have to say that I don't, it's hard to, it's hard to believe that just like our diabetics need 60 grams of carbohydrates per meal, that our our pregnant moms also need like a prescribed amount of carbohydrate. Um, if you don't feel well on it, sure, that sounds like a good reason not to do it. If it's, um, you know, making you feel badly, if it's hurting your blood sugar for any reason, I mean, we should think about why that might be. But again, at the population level, uh, to me, just thinking back on our species, it doesn't make a huge amount of sense to me that it would be drastically harmful. But I don't have data.

Exactly. And I, again, I don't see why there's any reason to say we don't know enough yet, but it is true. I speculate the same thing you do, which is that we, we didn't, I, I whenever somebody's going, "Uh, our ancestors were on a carnivore diet." No, they were on a plant-based diet. I think our ancestors were on any diet they could get.

They weren't. Nobody was going, "No, no, no. I don't want to eat that food. I'm on a diet of that food." No, they were trying to eat whatever they could eat.

We know there were cave paintings.

And the cave paintings seem to celebrate meat in particular, right? Yeah.

Uh, but was there periods of famine and starvation? Yes. Like we've got that. What were you powered by during that period? You were powered by animal fat. Your animal fat, right? So it's not as though that's an ideal condition for justestating humans. But as far as needing carbohydrates, uh, that does seem like a stretch to me. So, I think that there's a wide variety of possibilities, and that the best way you can find out is of course to do these studies, but per the other guest, nobody wants to.

Yeah.

When there's literally humans being born involved.

Right? And I, and again, I don't blame any clinician who will sit and tell you that this is a bad idea because we have no data and it sounds really scary to them, right? It sounds like.

Keto acidosis. Sounds like uh poor dietary choices to some people that are not as informed about this style of eating. It may sound like a setup for hypoglycemia, right? I mean, pregnancy is an insulin resistant state. And why is that? Because we are prioritizing fuel for baby. We knew this very much on purpose. So, I can see all kinds of reasons why a clinician who's not been in the space would think that this is a bad idea and would tell you it's a bad idea. I don't have a study to show you that it's safe. I don't have that. I wish I did. It's a data-free zone. Um, my if I were to be pregnant, I think I would eat in much the same way that I currently eat and not really discuss that. But that's a very personal thing for me.

>> But um, that's maybe the safest way that I can answer that question is that's what I would do personally.

>> Okay, I got one more from the desk. Uh, that's another pregnancy one, which is uh, what are some of the common misconceptions surrounding nutrition during pregnancy? Do you really have to avoid all the things they say you do? This one's at least a little more generalistic.

>> Yeah, I'm so sad my mom's not here um because she's really the person who's much more an expert in women's health naturally than I am. However, uh, I guess as the token extra X chromosome in the room, I'll I'll give it a shot. I think that maternal health in general is undervalued. Right? Everybody recognizes that at least to a first approximation, mom's health is baby's health. But I think we are not focused enough and and particularly fourth trimester and after kids are born. This is I'm skirting the question, but I'm doing it very intentionally because what I see is women who lose 20 years of their own health care and well-being because they are caring for others. And if we were to shrink that into a microcosm, right, we have all this worry about what is happening to baby. But I think if we stay with what is happening to us in fact and our own blood pressure and our own how we're feeling and our own sleep and health and well-being, then that is in fact the rising tide that lifts both ships here. So I don't and it's not to say that none of those people are are not thinking about mom. Of course they are. But we have gone to a place in our culture where care of others again is this temple in which we martyr ourselves. And there's a reason they tell you in an airplane to put your own mask on before trying to help anybody else. Because if you die trying to save somebody else, then that's a real problem. So in my general ethos of the world, I would love for people to recognize that taking care of themselves is the way that we care for those around us that we love the most.

>> I would argue this, we do have a lot of data on, right? The health of the mom is super relevant to the health of the child. Uh, the common misconceptions I would say around nutrition is I feel like there's a lot that's stated with a great deal of confidence. I feel like it could benefit from a little bit more on the uncertainty side. So my uh, my sister had just gestational diabetes I believe with her second child uh, who's um um my niece and uh, by the way, our our sound engineer who's working with us right now is uh the youngest, but this was something that she was struggling with um, and she was prescribed a certain amount of carbs that she need to eat every meal, right? And long after that had happened and after I'd gotten into this space, I really went to look where that came from.

>> And I could not find it. I could not find anywhere outside of these kind of general recommendations from the ADA at that time, right?

>> Yeah.

>> You want to know where I found the information on where the ADA got that up for got that for its uh recommendations?

>> I'm scared to ask. I still don't know. I still have no idea. I did go all the way back to the very beginning of the ADA itself, which is over 100 years ago. It was founded by I want to say 12 physicians, but there were two particular founders. One of them that was kind of the the main spearhead.

>> And you can take um, his book right now, look at I want to say it's like the first, second page and he outlines it and it's very close to what a low carb diet is right now. It's very close. It would stand up today. It's not perfect. It had some some idiosyncratic things to it, but it's radically different from what the ADA is suggesting now in that the ADA in in this current plate, they have one quarter of the plate as being your favorite healthy carb.

>> Mhm.

>> I actually had dinner with a another physician recently who is in the cardiology space and much more of the very classic um vegetarian for plant whole food plant-based approach to cardiovascular nutrition. And she was sharing that she was actually really surprised that she herself had gestational diabetes and and she would, you know, took a hard look at her own nutrition and was like vastly undereating protein and probably overeating carbohydrates. And in fact, she feels much better now that she has and she's not gone away from a whole food approach, right? She has just tweaked things. And I wish we could all, no matter your uh religion, tribe, club, uh, dietary strategy of choice, side of the tracks.

>> Yeah.

>> Whichever version of nutritional dogma you ascribe to today. We could all just acknowledge that what was working for you may not work for somebody else. And what works for you today,

>> right,

>> may actually not be what serves you in pregnancy or what serves you in the next decade of life or what serves you as you are changing from becoming an endurance athlete to a strength athlete. There are so many reasons right

>> why we might adjust our plan and it doesn't mean that we have to be evicted from the club or shunned or like wear a you know, scarlet letter on our chest. It is truly the epitome of self-knowledge and experimentation to figure out what is working for you in today's era. So, it is actually no shade to her prior choice. It was working for her then and then something changed and she did what I wish we could all do, which is have the curiosity and humility to take a look and make a change and see what happens. Yeah, this is uh, the world of nutrition unfortunately and particularly on social media, it does get very, very tribal. It's unfortunate because I I bring this up from time to time, but it's definitely worth bringing up now. A lot of times there's this kind of againstism that I think gathers people together more than what they have in common. So, it's more what they what they're against, what they're trying to fight,

>> and then it, you know, connects a whole bunch of people. But part of why I bring this up with uh, my sister and gestational diabetes, it's diabetes, right? I've said many times here, and I've said it many times in public, there are a lot of friends I have who are on a high carb diet and doing fine. There are vegans I know who are on a high hard high carb diet. I've seen their blood work. They're mindful of their nutrition. They're hitting it. For them, it's it works. Right. Right. Okay. If you're diabetic, the scale is shifting a little bit. You may be able to do things with like say, calorie restriction. And I've known some people who have had

>> results from that.

>> Yep.

>> You though, probably it's more likely relative to other things you may more likely find benefit with low carb. And I'm speaking more to type two diabetes. In the case of type 1 diabetes, not that I'm a doctor, not that I want to give medical advice, I do feel like you can't not have a conversation about carbohydrate restriction, like I don't know how that could happen in the case of literally insulin insufficiency.

>> Now, we're talking something very different and something much more uh important towards that specific disease state that you're working with.

>> Yeah.

>> So, this is where the whole diet tribalism just gets on my nerves because we're not talking about what diet literally causes these diseases. What we're talking about is once you have the disease, what you do about it. So, like your friend, it could be somebody who even tries to change like their protein levels, that's not working for them, finds that they could tweak into something else. uh, you know, they modify, change, they find something that they want and it's not the thing you suggested for them, but they find it works for them. That's where we were all wanting to go in the first place. As long as it doesn't wreck their health,

>> Yeah. Yeah.

>> you're on the right track. If you like it and it's nutritionally complete and there's not a problem on the health side. Definitely one thing I I argue against is feeling like you had such uh, an identity stuck to the existing nutritional camp that you're in that you don't want to do it even though you're feeling great on it,

>> right?

>> Which we see all the time in the nutrition space. You see all of these influencers who are hiding that they changed their diet, eventually jump over to the other side of the the tracks. It's like, why? It's your health.

>> Yeah.

>> It's your choice.

>> It's your choice. And your body may be changing. It's okay, right? It doesn't mean that it failed you or that it's wrong or that it's not going to work. I tell PA I've have seen patients who have attempted a low carb solution to pre-diabetes or insulin resistance and have not seen success. And then they went to a much lower fat version, much higher carb, much lower fat, and they did see success. It's great. The goal is not having insulin resistance. How we get there is really immaterial to me honestly, as long as again, it's not wrecking your health. But and most people do well on carbohydrate restriction approach, but it's not everybody. And we have data that would support the idea that excess free fatty acids will also cause insulin resistance in our myoytes and in other places. So, it totally tracks for me that a model that is higher in carbohydrate-based energy and lower in fat-based energy, much lower in fat, much higher in carb, might also work. It's cool if it works for you, it's sustainable for you, you feel well eating that way. If you're not insulin resistant, I will celebrate that. It's great, right? What I offer to people is just what I see working most of the time in it as a place to start. This is just the conversation starter, but it has to work for you and it has to feel good and it has to be something that you can do for the rest of your life.

>> So, at the at the time we're recording this, because I kind of want to bring it around to something that sort of punctuates this point for me. Um, we had just released the case report with Nick Norwoods where he's had a total cholesterol of like around 700 for seven years, right? A little up and down based on on experiments. Did you you heard about this or

>> I've seen it.

>> Yeah.

>> Now, interestingly, he's also shared at the same time that because of the research he's doing, he's seen with both bimidoic acid and enzyami potential benefits uh for brain health. And in particular, he is concerned because he has an APOE44 and had determined what the heck I'm actually gonna adopt this and then shared it. A lot of the critics of our research have totally capitalized on the case report coming out and then saying, "Ha, he's on two forms of medication though, right?" And I say this with love in my heart. There's there's a number of people who I've done I do a lot of outreach with folks who are uh challenging of our research in the effort of trying to keep that level of uncertainty in check.

>> Right. The last year has been a test of that to some extent because a number of these folks seem to be comfortable with, you know, providing half the story and not providing another half of the story. And normally I don't let it get to me. I'm just kind of like, this is just the space. You know, you've got to Dave, go outside, touch grass. But I'll 100% concede this time around it kind of bothered me maybe a little bit more than usual because Nick is coming to his own health decisions. He didn't have to share that information anyway. Uh, but it's it's a big deal for him to discuss uh medication he's taking on

>> from his perspective in the research that he's done with his exact context in mind. So, it didn't just bother me with whether or not it was, you know, narrative building. Again, I feel like I've got a thick enough skin for this stuff, even if it's not me who's involved. It bothered me because I do see this so often in this space is that this is what gets people feeling like they're pigeonholed into a particular position of representing

>> the the space that they're in and what they're doing, right? And feeling less inclined to share with the internet individual choices they're making that may not fit the narrative that they're counted on for even by supporters. Yeah, we are all messy humans doing our best to figure out what is going on. And those of I will say us, I'm very new in this space. Um, you and Nick have been in it much longer. Those of you and us who are choosing to put some of ourselves out in the world as more public figures are learning and growing while that's happening, right? Everybody gets to watch it happen. And there is absolutely this tension between establishing yourself as an authority with something to share and teach the world versus being somebody who is curious and humble and learning and growing and changing their mind. But again, especially in medicine, we talked about this earlier, that is not rewarded. You're not growing. You are flip-flopping. You don't know what you're talking about. You're wishy-washy. like pick a side and stick with it. So there is absolutely tension there and I think that the drive to build an audience and the drive to like get people to come listen is challenging because there's this desire to be just sensational enough to capture attention and bring people into the ecosystem and allow that curiosity to spark and and for people to have that peak moment, but also not be so sensational that they discount you. And if you're full of nuance and say it depends all the time, which is my current strategy, you will find that growth is slow and a little painful and people are frustrated with you because they're like, I don't know what the answer is. I just watched this 20-minute video and you said it depends, and that's not helpful to me. Can you please just tell me what to do? What is the answer?

>> And to be fair, we've been kind of trained into expecting that.

>> That's true. I mean, this is the I think the other issue is just that I I believe there's the expectation that the doctors will know. And to be fair, as your book kind of covers, right, that's trained into you.

>> Yes.

>> Uh, I do want to get back to the book again for a second because I'm also always fascinated when somebody decides to jump off to write. Writing a book is not a small affair, right?

>> No, it's not. Um, you and a lot of people who are writing books, especially as doctors, they are they often feel compelled to get into the science at a deeper level and so forth. You had a lot to say about the experience you went through that I think is going to inform so many people, gets to that deeper level at your individual level uh, as to what you were, you know, struggling with, but having this additional insight insight you wouldn't have had if you'd never taken that job. Do you ever wonder about that? If you hadn't ever taken that job, you'd only gone on the medical track, you wouldn't have that additional sense of perspective? Do you think that shaped your later years, the years you're experiencing now?

>> It has to. I mean, this is the journey of life and every trial, every tribulation, everything that doesn't work out tends to be in retrospect a path forward or a blessing in disguise or a way that is an actual door that was opened right as as the other one closed. So, I am super grateful for all of the experiences I've had. I had a great time in many, many ways at that job. It just showed me what it was going to take for me to truly be happy in the world. And people have argued that people who have read the book are like, you talk about too much. There's too much in here. Like, what who's your audience? Who are you writing this for? What are you trying to say here exactly? And you know, that's fair. I It's partly how my brain works and partly it is that the epiphany is that in fact, there's a lot here and it's not just about burnout. This is not about too much documentation. It is not about insurance, prior authorizations. That is all part and parcel of our misery day-to-day. But that's not really the problem. The problem is much larger. And in fact, it is bigger than medicine. This is actually something that if I ask my friends and family who do other things outside of medicine, it seems to be very pervasive in the whole world, right? We are forming identities around work and around production. And I'm not sure that that's serving any of us that well.

>> I Well, first of all, I'll just say that I again, getting the excerpts. So, here's the process. Sharon handed me off the PDF. We had already gone over a number of the different quotes, but then she was reading the stuff around the quotes, and then after I got it, I kept looking at more and more of the material around the quotes that she had given me. So, I I will genuinely say that it's been a surprising page-turner. The problem is is I just haven't had the the time.

>> I didn't expect you to read it before we got here, by the way.

>> Right. But but what I'm what I'm trying to say is that um, I'm pretty sure that I will be like, it'll be after we'll make a deal. You'll watch my movie. I'll read your book.

>> I'll check on that with you. That's a deal.

>> Um, but I it just there was so many things that were quotable and had I had a little more time, I would have actually uh, pulled together some of the quotes. Um, yeah, no, I was in just this moment. And I was like, it's probably still on Slack, but I'm not going to interrupt. I'll just say I appreciated the number of times you had something that could just be a statement that you could throw up. You should like quote your own book in your like Twitter feed or something like that.

>> But it I just thought you were it was very eloquent, the observations you were making as to why there was this burnout cycle. Right?

>> Now for the next question, which is very pertinent for our time. Do you think AI is going to change the game? I hope AI is going to change the game and in a good way because the solution to the problem that I have identified at least, and you know, the book was written for the same reason I think probably that you have gotten into this space, which is to understand right? Something happened to me and I didn't understand why it happened and was this a me problem? Was this a failure of my my own sense of understanding of self? What what what happened? Like why did I feel compelled to quit my job and try to do something different? And was it just the job? Do I need a different job? Do I need a new job at a new place? Like what's the problem? And how are we not going to have a repetition? How am I not going to make the same mistake again? The book was my own way to work through everything that I had gone through to sit back and reflect on the two decades essentially that it took me to get here and try to understand what had gone on and why that why I was seeing it in friends and other people, right? It didn't seem like it was just me, but I was wondering. So, that's how the book came to be. AI does the boldface medicine thing pretty well, right? Um, we have OpenEvidence, which is a tool I use a lot and I talk about it on my channel. I really like OpenEvidence. It's very grounded in our current guidelines and it's um, a little rigid, but

>> Tell us what it is real quick.

>> Sorry. OpenEvidence is a AI-based platform that is really trained just on the medical literature. Uh, and it is run in partnership with the New England Journal of Medicine and JAMA and much of the many of the big journals and publishers. They are venture-funded. Uh, so it is free for physicians to use. You just put in your or clinicians, you put in your practitioner number and you can run unlimited searches. It has some other components like uh scribing, like capturing the audio from your appointment or doing some other things. Doximity is another tool that is sort of medicine-focused. I like it. I think it's a little more reliable than just using ChatGPT or Claude or Gac to search what is most frequently talked about in the big wide world. Um, but to get to get back to the question, AI will never be as human as a human. I don't think. At least we're probably a generation or two away from that. So can we offload the prior oaths and can we offload the notes and can we offload the differential diagnosis and like some of the actual cognitive load. So we didn't talk about the cognitive training from the government and how it's never actually applied in medicine, but like we talk about generating a list of possible diagnoses when a patient comes to you with symptoms. I am cold and tired, Doc. What do you think it is? Right? And we all, especially as we get more experienced, sort of jump to the most common thing we think it is or the most dangerous and try to rule that out. There's a lot of heuristics that doctors use to get through their day. But the proper way of course to do this would be to say, okay, what makes people cold and what makes people tired and what are the things and do you have any other symptoms and can we dig in a little deeper and like, let's make a list of all the possibilities and let's rank them based on the information that we have. What other information do we need and let's go collect that and then let's rearrange our list and we iterate this until we feel confident that one of these diagnoses should be the correct one and then we base a treatment strategy on that. That is rarely what really happens uh in at least my experience of medicine, right? What happens is we get the shortcuts. We get our fast-thinking systems as Danny Kahneman would call it, and we jump to some conclusions and we usually have some evidence for it. I'm not saying they're baseless and we get away with it most of the time. So we keep doing it and eventually though, it bites you in the butt and AI is something that could really solve this for us, right? And it is dispassionate. It doesn't have a diagnosis it likes better. It doesn't feel annoyed waking up at 3:00 in the morning to try to run through this list in its head and and answer a question on the phone in the middle of the night. So, can AI help us make better, safer, more cognitively sound choices and decisions while we, the humans, get to actually have the human healing experience with our patients that says, "I see you and I see your suffering and I don't have all the answers today. Here is what I commit to you that I would like to do to try to help. What do you think?" My my answer is not only yes, but almost certainly in all the ways we would hope it would be if we let it. So the catch is that it's ultimately built on training. And as as I'm well aware, there's a top-down directives issue, which is whether or not

>> it's allowed to bring it to, you know, you're touching on this right now, which is what I like to call the objectivity problem. So yes, if I go to a specialist, what are the odds that the specialist, even in their field that they're specializing in, are going to be equally as likely to come to the same conclusion based on what the diagnostic criteria are, or do they have the things they're into, the things that they see? So there's a little bit more of every problem is a nail and they've got the hammer that's specific to it. They've got their, you know, grand theory of of, you know, fill-in-the-blank, um, disease, but even things that are not that disease start to seem more and more like they could be, right?

>> Or related to it, right? So, we see this all the time, not because this is unique to doctors, it's because it's just how all of us are.

>> Yeah. All of us. We are trained to observe patterns and to act on those patterns, but we do have uh limitations in a way that we are blasting past with AI. So things like being a true diagnostician is already a massive capability of AI that a lot of people are taking advantage of right now. You know, you you may it it may appropriately say to you, hey, I'm not a doctor, but here's, given the symptoms that you've described, here's some questions I would ask for follow-up. And those questions that it's asking for follow-up are not based on what it's into. And they're not infected by whether or not it's tired at the end of its shift like you described before,

>> right? But importantly, it also in theory will get rapidly updated such that perhaps something that just dropped 90 minutes ago is now already part of its existing cognitive load that it can then go ahead and apply.

>> Right.

>> Yeah. And I I'll tell you a story. I had a breathing problem when I was younger and it was exercise-induced. Every time I would in be in PE, so it started when I was really young. I got super short of breath and for a while it was, well, you're just not conditioned, so work harder in PE. Okay, that makes sense. But I I remember dreading like our presidential fitness test because running the mile for me was a guaranteed way to like be toast for the rest of the day because by the end of the mile, I was really dysp- how it felt and it was miserable. It was miserable. I have two physicians for parents who love me dearly. Right. I had a stress echo as a child. I had asthma testing. I had allergy testing and everybody said, "You're fine and you're just out of shape." And so I kept trying harder, but I hated exercise as a young person. Like my parents had an exercise room in our house before that was like a thing where people had home gyms. That was super unusual. They were both really into fitness and wellness. Like they would go run and like, "Hey Lily, do you want to come ride your bike while we go for a run?" Like fine. But I hated it. I did not enjoy it because it was super painful for me. And it made me feel bad about myself because every time I did this, people were like, "You're really out of shape. You should work harder." And like I was a chubby kid, too. So like all of this comes together. And like Lily does not enjoy exercise. I did play sports in high school, but I could do short bursts. They were largely anaerobic. I played volleyball and I played softball, but I couldn't do soccer or anything that had long bits of conditioning.

>> And you didn't get diagnosed with exercise-induced asthma. I got worse on albuterol. I have a little bit of reactive airway, but they gave me albuterol and it made it worse. And we can talk about probably why that was. It increased my heart rate, which it was a heart rate dependent phenomenon. And I would go through periods where I get super irritated by this and like ask my parents and we would do some more testing and go see another doctor and nothing would come of it. And eventually by the time I was in college, I went to see an allergist who told me, "You have vocal cord dysfunction," which is not a common diagnosis, but it is something that voice training does. And I was looking at all of the by this time I was in a lab and looking at papers. And so I pulled all the papers on vocal cord dysfunction and read about it and I was like, "This isn't right." Like this isn't what I have. That is not reproducible every time. It's not consistent. Mine is every single time my heart rate is above 160, I cannot breathe. And I was trying to do martial arts at the time. I had an opponent's coach stop a tournament match like halfway through because he was afraid I was going to keel over and die because my breathing was so striderous and so loud that he was afraid for my health and safety to stop the match. And uh, so it was very limiting. And eventually my after my after I'd graduated from college, I was like scrolling PubMed one day in the lab as one does and uh, I ran across this thing called exercise-induced laryngeal malacia. There were like a couple of case one by an ENT head and neck surgeon in New York who was a pediatric headneck surgeon, one by a guy in Ohio. And you know, like most papers have the email address of the senior author at the bottom somewhere. So I like fire off emails to both of these guys and like the guy from New York gets back to me. Long story short, this is over a decade of having this problem. I feel like in 2026, if I had typed my symptoms into Chat GPT or Perplexity or any of these things, I probably could have gotten a diagnosis in under 10 minutes.

>> Yeah.

>> And you know,

>> That's a big deal.

>> It's a really big deal.

>> It's huge. And I and so I know that there are physicians and clinicians who get super annoyed when their patients come in with stuff from Chat GPT and whatever. I don't so much mind. I mean, is it always right? Of course not. And the training set is really important and how we are going to configure this to work for us in a safe and meaningful way going forward is a deep question that deserves a lot of care and attention. And it's okay. Like, let's use all of our powers that we have for good in the world. And, you know, let's consider it as a prior. Let's consider more information. It's great.

>> Do you have a a Tesla or some kind of smart car?

>> You do.

>> You do? Okay. So, I'm going to tell you something and then I want to know if you'll agree with me. I think it's very possible that in five years time, they're going to want to pass a law to make it illegal to drive manually. Do you think that's possible? In other words, it's so safe to have full self-driving that they'll want drivers to drive less manually because that's so much less safe. Uh, having actually been in the full self-driving module of my Tesla, I would have to say I think it's possible, but I don't think it's likely until the majority of cars on the road have that capability and then can talk to each other. Because while there are still human-controlled cars, the full self-driving is not adequate to account for all variability. When all cars can have the, you know, net machine learning um and be in mesh and like talk to each other and and coordinate, that seems more plausible to me. Or at least 90%, 80%. I don't know what the magic number is, but I would guess until that time, I don't think we'll see that yet. I don't know. I would hope maybe not yet. I don't know. I don't think it's ready yet.

>> Not that I'm saying I predict this, but I'm saying I could see it being possible depending on how fast the manufacturing can catch up to the software because the software in all my life as a software engineer, I've never seen anything approaching the light speed by which uh AI engineering is getting. Right? And where I'm going with this is why is this even conceivable? Why is it what I'm saying is so conceivable? Because there already is a stronger safety rating for Teslas because of how much they can. And this isn't granted, we're not yet to unsupervised full self-driving. It's supervised self-driving right now.

>> Sure.

>> But supervised full self-driving right now is extremely safe. It's because the cameras, the radar, everything else are doing a pretty good job of compensating for safety hazards, right?

>> And we have Waymos on the road. I mean, there are self-driven cars out there. They exist.

>> I was I was just in Austin and I was watching them and I was like, "Wow, this is just so So, why do we bring this up? Well, in the case of medicine, I would not be surprised if we're going to eventually come to a point where it's actually dangerous for a human to diagnose diseases relative to what the AI can bring. Right? The other component to this getting back to what you know, full self-driving in a Tesla would be is they've got all of the devices I just mentioned, all of that field awareness that comes from cameras that way outclass my two eyes.

>> Right.

>> Uh, even with lots of instruments and other things up front, if all of them are wired into central processing to allow for that level of capability on top of networking against other cars like you're describing, there's no way we could even comprehend what level of intelligent advantage that provides. By the same token, beyond just writing symptoms into Chat GPT, coming across more and more wearables, right? Like actually having devices that hook into the mainframe to be able to provide this aggregate information altogether is going to really advance medicine in a way that that we can hardly imagine. Again, provided we use it for good. Well, and here's here's a scary thought, right? We talked about the training set being critically important. There for a while, there's going to be some human oversight, probably appropriately so, but I would guess, for example, in medicine, that that's going to be the doctors, the physicians who are at the bleeding edge of of our field. But if you think about that, what does that mean? For example, for cardiovascular care, does that mean that if AI says we have some case series where people who have low triglycerides and very high HDL and an insulin of fasting insulin of three and no evidence of plaque do not need to have their APOB pharmacologically managed? Do you suppose that anybody who's a big wig in modern medicine is going to be like, "Sure, we can let that slide. We'll let that go. Um, AI has looked at it and actually calculates that the probability is that this is okay."

>> And this gets back to the top-down directives.

>> Right. I mean, this is this is and

>> Because what are guidelines? What are guidelines but top-down directives for humans?

>> That's exactly right. And while it, you know, if you practice in medicine long enough, you recognize that the purpose of guidelines is to bring up the tail of the de of the standard deviation or the the uh, standard distribution, right? The the bottom 10% of people who were underperforming because they are trying to outthink the algorithm and they're failing miserably in the wrong direction every time. But it also suppresses the top percent of the distribution who would ordinarily think for themselves and actually make better choices on average, right, than the algorithmic approach would allow. And we have acknowledged and accepted that it's worth bringing up the bottom to cut the people off the top of the knees. And we say, well, but if you're actually that good, you'll probably just continue to practice at the top of the distribution. The problem is nobody knows, right? We have a little Dunning-Kruger problem. Um, where those of us who are on one side of the normal distribution or other all think we're at the top part of it. We all think we're outperforming the average. And we may be blissfully unaware of the fact that we are in fact demonstrably underperforming. So while guidelines are intended to sort of smoosh everybody to the middle, I get that. I understand where that comes from. Uh, right now, we all still have the capacity to override a guideline and practice as we see fit. That is what my license says I can do.

>> Do you though?

>> I do. And it is. Can the guidelines be used in a legal setting to go after you?

>> They can, but they have been. So, interestingly, I do a little bit of medical malpractice work and and guidelines have been used both for and against um plaintiffs or or for medical defendants. And you can you can argue this either way. A guideline is not necessarily the standard of care. So standard of care is what a similar physician would do under similar circumstances with the same education and background and training. Um, a guideline if it is brand new. So for example, um, the like new lipid guidelines, everybody should get LP little A testing. Well, that's brand new. So if the case is brought today and somebody sues me because they had a heart attack and I didn't test them for LP little A. Like, well, there's a guideline that says you have to test for it. Okay. But uh, it just came out and this patient's been building plaque for the last 10 years. Is it reasonable to hold me to that standard today? And the answer is no. And so standard of care and guidelines are not the same. But everybody wishes they were. It would make life a lot easier and it will certainly be argued.

>> I'm usually

>> it should be argued that a guideline is the standard of care, but legally they are actually not quite the same. And you there are people who have successfully gone around them. That being said, of course, everybody feels safe and protected when they are in adherence with the guidelines, right? Um, and so if you were going to step out, you will feel exposed and you will not feel confident that you can out-argue somebody who wants to come at you with the guidelines. Now, it's absolutely reasonable to say, "I had a conversation with my patient and we reviewed the guidelines and based on shared decision-making, they understood the risks and benefits and have decided not to do this." That's often written in a way that sounds really punitive when patients read their notes, which is now also a thing, but it's not it's intended to protect the doctor from this very thing. And as long as that's in the note and somebody can reasonably believe that you actually did have that conversation, then you can yes, practice outside of the guidelines. Is it a risk? Sure it is. But we are all more likely than not to be sued in the practice of medicine. So um, you need to practice in a way that you feel good about and um, there are ways to protect yourself if you don't want to practice with the guidelines. It's a challenge and I'm not gonna say right. We have too many people in our community that have had their licenses and their practices and their public reputations dragged through the mud and gone to court and gone

>> especially in low carb world.

>> Exactly. Um, and and I'm acutely aware of several of these. But I don't think a guideline would have protected them.

>> No. But but this is um, I mean, certainly what what has been demonstrated is that there are institutions in place and the institutions provide a means of kind of uh, let's call it, gets back to the againstism, aggregate attack, if you will.

>> And it's it's unfortunate because it it is a tried-and-true tactic that if a loud voice is, you know, jostled, if it seems like extraordinary resources are taken towards um, going after a loud voice, it does become this warning shot for everyone else.

>> Yeah.

>> And then there's kind of a chilling effect and then a lot of people, and this is why um, there are many lean mass hyper responder doctors who've come to Nick and I, you know, in private and they're very conscious of the fact that they can't just be out in the open. And some of them from a particular country, it's interesting, uh, are are regularly afraid to recommend what has been working well for them.

>> Now, in fairness to them, they would say they don't know themselves. It's just that they've been getting enough benefit that they've decided to take on this risk, which is what I'm advocating for, right? Like again, if you can just say, we don't know for sure. Here's the here's the data we have so far with like say, ketoCTA, but I is the one who's spearheaded it. I'm not somebody who's wandering around going, "We've done it. Lipid hypothesis over. This is or or this is the one definitive study." Or I wouldn't be doing any more research. I wouldn't be like trying to get the five-year scans. I wouldn't be trying to do the um uh COI uh uh fundraising efforts in order for us to have this companion study, right? We got to still iterate. We got still got to go. But is there at least more data for a cohort that we didn't have any data for? There is. Okay. Can can can a doctor tell a patient, hey, we do have this keto study. It's just one study. It's exploratory, but this is the data as it is so far. You can decide for yourself. By the way, I am a lean mass hyper responder, but I'm also getting imaging. I'm also doing this and this and this. I'd like to think that that would be possible, but thus far, I'm not sure if we're there yet.

>> We're not there. And I I would be lying if I said that I'm not swayed by what I know to be the general recommendation in the cardiovascular space, in terms of nutrition, in terms of medications, right? I of course am influenced by this and the fact that I have conversations with other people who are not as pro carbohydrate restriction um totally influences me, right? Not trying to say that guidelines are irrelevant and they're not the standard of care. Yes, like they are a huge elephant in the room, we must acknowledge this. All the efforts that have been put forward to make new guidelines from smaller societies so that those of us who advocate for this for some of our patients can have a little bit of protection and uh so community support is all very necessary and worthwhile. But the the crux of the issue is this shared decision-making with patients and it takes time and it takes a little nuance and it takes an ability to have a conversation and be comfortable with uncertainty and patients don't always like that as I mentioned and doctors certainly don't like that. We would like to just have an answer and tell people what the safe thing to do is and this gets to an issue that I have noticed a lot in medicine. There are errors of commission and errors of omission.

>> And as a surgeon, I am acutely aware of this problem because if I take somebody to the operating room and do something to them and it goes poorly, I feel awful because my hands literally have blood on them in my, you know, very Shakespearean view of this scenario. And, you know, do I completely own the the complication? Not necessarily. Of course not. But it feels really bad, right? When you advise somebody to do this thing and it doesn't go well and you feel like you are really responsible. Conversely, if I say, "Gosh, wow, that's really high risk and I'm not sure it's going to go well. Maybe we should not do an operation for you and then they go on to lose a leg or have a heart attack or something bad happens." Well, that's just the natural course of disease. I didn't do it. I'm not responsible, right? I feel great about this. We don't feel great, but it feels really different, right? If you have touched this person and they do poorly or

They're doing worse. This is why I like a number of surgeons I've watched. At the time that somebody's facing it, they know the odds of a particular procedure and they'll report those, you know, the odds. I wish this happened a lot more with prescribing medicine because I'm sorry, it's just it's all too common that doctors will talk about the benefits of a given drug, particularly if it's new, without a lot of discussion about the detriments or the side effects to the same degree.

But exactly on the omission side of the fence, that becomes relevant, right? Yeah. So we get we get so concerned that, right, if we just watch somebody with known plaque, like we're we're we're not doing anything, and like that feels weird. And so people, even though errors of commission feel worse when somebody has a bad outcome, we also want to do something, right? We don't like to just sit and watch because then what are we here for? Uh, like there there feels like you ought to do something when presented with a scenario of risk. And we know that that's not true. And we know that there are myriad of opportunities to make people worse, not better. But it also doesn't feels like you're letting something go, right? If somebody shows up to you with plaque and is a lean mass hyperresponder and has these elevated lipids, you're like, "What if you have an event and I didn't do anything?" Um, if you had an event and I did something, well, you know, or if you have side effects from your procedures, well, I mean, it's the price of doing business.

Um, but there's two considerations there. One of those considerations is guideline standard of care, which is whoa, whoa, whoa, no, you do you do something for sure, right? The other consideration is what you genuinely feel yourself as a doctor. What what do you what do you yourself actually believe is the risk level of this person, right? And I think for a lot of people in that second category, for a lot of doctors I know, it it really is that I don't know. Yeah. I don't know.

This this patient that I had had severe metabolic syndrome. Through so one of our uh co-sight speakers, Susan Brun, came back from metabolic syndrome. Like she was really overweight, it's pretty bad. She's a lean mass hyperresponder and actually got into our study, right? Um, I'm blinded from her data, so I don't know where she landed on things. But would I be surprised to find that she had plaque if in fact she did, even though she's now lean, metabolically healthy, and so forth? I would not be surprised at all. Right. Is she at the same risk as somebody who didn't have metabolic syndrome, but maybe was a little bit overweight, does have like say high insulin, you know, right now, uh, is hyperinsulinemic, doesn't have the best diet, didn't make these huge interventions, let's say even half the plaque that Susan Bernie does? Do I think that she's at, you know, half the risk or even comparable risk? I don't know about that because I do feel like there is some there's some cycle of plaque stabilization. Of course, we have some science science behind that, but there's trajectories to all of this that's very hard to watch in real time. Although CINT might help with that to some degree.

I really hope it does. I mean, that is why I continue to do it. It's partially because I do believe I'm gaining valuable clinical data for my patients, but I'm also gaining valuable data for me as I try to manage patients over time, as I try to manage my own anxiety about what we're going to do for these patients. And like to be clear, my mom has plaque. And like part of what I talk about when I come to these meetings is like what my mom and I are doing because there is nobody in this world I love more than my mother. And so it is a very fraught conversation. And specifically correlated like you can, she both has a positive calcium score and plaque on CINT. Gotcha. Yeah. And so, yes, you're I mean, in in advising your mom, treating your mom, you're going to care a lot about that. But but we're zeroing in on such an important circumstance because for somebody who has no plaque, but they're lean mass hyperresponder, it's it's already like I'm watching in real time. Even people who are anti-l low carb are going, I'm not going to battle. You know, it's it's too it's difficult when they have both high levels of LDL, but you know, they're showing up at say age 60 with a not just a zero CAC, but like no plaque in the, you know, coronary arteries. I'm not comfortable with it, but they've been advised, etc. A lot of them have landed there. However, those people who do have existing disease and for which there seems to be a case as to their most recent intervention has helped them. How much does the risk truly end up being residual? It's a tough question to answer.

And how long? I mean, another question I have is so, you know, we talked a little bit about the immune response. I have a pet theory, right? That some of this, like all politics are local, right? There's probably a local feed forward mechanism within plaque that once you have it, there is this inflammatory milieu of oxidized phospholipids and all these, you know, transformed smooth muscle cells and all these things that will kind of keep feeding forward even if the metabolic environment at large gets better, even if HSCP comes down, for example, right? Just to think about general biomarkers, uh, that might require a little bit more fire putting out, right? Might require a little bit more attention to try to suppress that feed forward immune process. Again, total hypothesis. I have no data for this. But for the people who have been in metabolic disarray for 40, 50 years and generated some plaque during that time, then come to a way of eating, whatever that is, that has altered their metabolism and they have some biomarker that is still out of whack. Do we have to treat it? Well, a lot has gotten better, and I will never take that away from anybody, right? Especially not if it is something that otherwise modern medicine does really badly, like mental health or epilepsy or some other things, right? That are really really tough to manage with any other intervention. If this is what did it for you, great. Like, let's not touch it. But if you also have plaque in your arteries and a biomarker that is out of whack, do we have to treat it at all? Is a one good question. If we're going to treat it because we do think perhaps there is, you know, some process that might not stop quickly enough with just changing our nutrition and our lifestyle, then do we have to do it forever or is a year long enough? Is five years long enough? Like I could I think I could sell people on like, we just actually have to, you know, put out the fire for a year or two or five or I don't know. Um, but it doesn't have to be forever, right? And then once the fire is out, it won't continue to smolder and burn. Right. I mean, this is But I again, data free zone.

You use this in your book. That was another one of the things that I saw, which is where you were describing burnout and that um and I'm paraphrasing here, so correct me if I'm wrong, but there's this issue with when you're experiencing burnout, it's like being in a burning house and then when somebody goes, "Oh, well, you know, take up a hobby or try some yoga or something." It's basically like they're advising you to smolder slower. Yeah. Yeah. Right. But you're not getting to the root cause, right? Right. Um, so anyway, getting bringing that back to fire with regard to the arteries and so forth. My it's it's my opinion and I'll concede as a hypothesis too is that the vast vast vast vast vast majority of plaque that appears in our arteries are getting resolved by immune response. We're hardly even noticing. Little maintenancey things like apoptosis and small infarks here and there. A lot of it's just um primary hemostasis. Some of it does get as bad as its secondary hemostasis, but a lot of that are our immune response is like, got it.

I think cancer is the same way. I think there are huge number of malignancies that we have transiently. The immune system detects them, gets rid of them, we never knew they existed. Right. Exactly. And so then the question is, in the scenario where there is a plaque that's continuing to develop, the lipid hypothesis would say, well, that's that's because it's being fed, right? The lipids that are out there will continue to uh be picked up and will ultimately build up the plaque more and more. I'm not saying that I'm skeptical of that so much as I wonder how much of it is um existing error. There's a I like this hospital analogy. Here's how it works, right? So in a typical hospital, how much do patients die due to hospital error? Well, the number is not zero. Some number of patients are dying due to hospital error. Plaque formation may in fact be a part of the existing immune response for stabilization in the body. And there's certainly plenty to suggest that with like, you know, the fibrous, you know, the clotting and all of that, and therefore to the degree where there's like a breaking off, that could just be just in the same ways that there's hospital error. Hey, this was all part of a process of trying to fix things. It went wrong. Yeah. Right. But it's going to go wrong sometimes. So the reason I like the hospital analogy is the hospital down the street may not make that many hospital errors, but it does make errors, and you should know that before you go there. But do you still go there? Would you do? You're taking the chance that it's more likely to be beneficial than detrimental, right? Even knowing that sometimes it makes mistakes.

Getting back to the smart cars, right? Sometimes they'll decapitate somebody and that'll become the big news of the day. Uh, some degree of the immune response is building plaques, I believe, in a way that's a net benefit to stabilize and avoid hemorrhaging and all of the other stuff that ultimately sets things up either for aphrocytosis where you're actually getting tissue repair or for stabilization because it needs to be calcified regardless, right? There is however, in that process that might in fact be commonly beneficial, the risk of the hospital error that there's still something worse. What we do know sucks for hospitals is when there's a giant hurricane, right? Level five hurricane that's going on, fires, forest fires nearby. Do the rate of hospital errors go up in those circuits? Well, of course they do. And you wouldn't blame the hospital for the triage issue that's going on there, right? Can we blame the body for having more risks of cardiovascular disease when the blood pressure is through the roof and you're hyperinsulinemic and you're not getting enough sleep and you're binging all weekend with your friends from out of town? No, we we can't be surprised by that.

Here's an idea. Let's study people who have good metabolic health. Wait, I think I know. I've heard of this. Yes, you may have heard of it before. Um, but you know, the other issue that I run into, which I don't have a good solution for, is the surprising lack of interest in lean mass hyperresponders in particular. I suppose if you're cynical, you could say, is it really that surprising, Dave? Is it really that surprising, Dave? But um, I do hope I do hope that we can at least if not uh, you know, feed the populace, feed the AI because maybe the AI will be the ones who come back with that with those answers for us.

One one can hope. I think the, you know, it comes just down to fear. And so much of what we battle in everyday clinical practice is people who come in with half an understanding, right? And so the fear, I think, and I'm I'm extrapolating uh, having talked to some other folks, right? Because the fear is that there are a lot of people who have high LDL who are not lean mass hyperresponders who then do not wish to have any kind of treatment, metabolic or otherwise, for a pathologic state that in fact is not the same as the lean mass hyperresponder phenotype. And of course, now we're worse off than we started because they're still metabolically deranged and we can't manage the risk factor. Now you could argue that there's not that much help in managing the APOB if the metabolic system is still on fire. And I could agree with that. But at the end of the day, this comes back to are you big enough to have curiosity and humility and say you don't know? Are you big enough to live in the uncertainty of we are gathering more information? It is possible we do not know everything. It is possible that there will be something bad that happens to you, no matter what I do or don't do, no matter what you do or don't do. And I think I try to remind myself of this daily. It does not actually matter what I do, we are all still going to die. My goal is to keep you out of the hospital as much as possible. And one of the things that I do struggle with is this idea that, you know, once we're 60 or 70, that's good enough. As I get older and as my parents get older, I recognize that that is a lot younger than I used to think it was. And as somebody who is in a relatively affluent part of our country, I am seeing people in their 90s who are showing up with really bad disease. And it's way harder in your 90s to come out of this. I mean, yesterday I was on call and I took somebody um I had to it was somebody's other procedure that they were hoping was finished and it was not because they um welded the femoral artery shut by accident because there was so much plaque in there that their attempt to close it acutely created a a blockage. Wow. And I had to open it up and fix it. And this person is um not too far from 90 and it's going to be a big lift. And this person was getting a heart valve replaced and I mean all of these things. We still end up with a lot of disability in the very late years and everybody swears that by the time they get that old they won't get treatment for it and they will just sit at home and like die peacefully. And I wish that that were true. We have a real problem with our mortality in this country. And this is another thing I write about and it's something that I struggle with as a clinician because not everybody needs to die with an operation. Yeah.

Um, I had a mentor who taught me that and it was mostly in the context of people that were truly beyond saving in the hospital that somebody was asking us to try one more thing to just save. But even at the bigger picture, people walking around in or living life at home, just because you have a problem does not mean that you would like to undertake a very a very high-risk procedure. And this gets presented like, well, mom or grandma is so fit and healthy at home. She's doing everything. She's playing with grandkids. She's going to the park. I'm like, what if she could never do that again? What if she stays alive and we fix this problem, but she's in a nursing home forever? And then she doesn't really walk so well anymore because well, I fixed the blockage, but then she got a bladder infection and then she got a blood clot and then she got pneumonia and then she got really weak because she wasn't eating super well in the hospital and then when she was eating it was pancakes with sugar-free syrup and then then and then and then and then and then they get the dwindles and life is never the same. They never go back. Not never, but certainly for my disease processes that I manage in people that are this age, they rarely go back to the same life that they had before. And it's not a question of can I make you the same as you are right now. It is what are you willing to sacrifice to live longer? And this gets back to this identity crisis where all of our time is spent working. You're like, it's fine. I'm going to have all my fun when I retire. It'll be better when and if you suddenly get sick and you haven't actually done the things that you wanted to do, are are you ready to leave this world yet or no? You're going to cling to it at all costs because you're you have unfinished business. You have not lived your life in the way the best patients I have are the ones who are like, you know what, it's been a great run. Yeah. It's been a great run. I don't need a thing. Um, if you can help me with my pain, that would be amazing. And uh, thank you so much for everything you've done. And I'd like to go home now. And that might be for an hour, it might be for a day, it might be for a month, but um, I'm good. And I get it. But thanks.

There's that uh statistic that something like 80% of health care costs are for the last two weeks of life or something like that. Yeah, it's it's a longer period and a shorter uh total cost, but it's inordinate. Yes. And it's a little bit of reverse causality, of course, as you're already close, but the the larger point is salient, which is uh exactly what you're describing.

I think so many people agree with what I'm about to say, which is deep down you really don't care as much about your lifespan as you do your health span, right? No, none of us none of us are like, "Oh, I'd like 10 more years of life if I'm just like racked up in bed with some chronic pain and so forth." So long as I'm around, you know, for my kids to see me in that state or something like that. And this isn't, you know, I'm not trying to make light of what people again make as their own personal decision for what they want to do. But I will say a lot of people would agree with me that I'm I would like to be somebody who lived a good life, keeled over, whether or not it was when I was 75 or 85 or tomorrow. Right? If it's if you know the reaper's come for me, it's come for me. There was a way to save me, that's fine. But I I had a discussion with a family member at one time um who was facing a pretty serious procedure and I was having the discussion about DNR because they were of a more advanced age. I was like this really should have this discussion because I think you'll have a strong opinion on this when I talk about this with you. And they were on board with it. And then at a certain point they were like oh actually I'm not so sure. I I've seen videos on um uh there's a an acronym for it, but it's a NDE near-death experience, right? And they were like, I don't want to miss out on the opportunity if I may have an NDE. And I was like, okay, but if your brain is like devoid of oxygen for like say five minutes or something like that, I know enough that I'm pretty sure you won't want the state that it is. The other thing is um for anybody who's not undergone like intubation, you don't know until you hear from other people and hopefully you didn't have to experience it yourself. Sometimes it just needs to happen. It's fine. But being like really hooked up, you only see the Hollywoodized version. And it feels like somebody's just relaxing in bed. They don't get all of the other aspects of it as to why it is that somebody might choose a DNR at a more advanced age. But you brought forward exactly another thing that's not I think adequately considered, which is another Hollywoodized issue, which is that oh something bad happened to grandma grandpa, they had the procedure and now they're back exactly as we were, exactly as they were before the hospital visit. How often that's exactly wrong that they're never the same after that. Right. And there's a lot you cannot control as to what the range of how that will look later is. Yeah. And it's not the worst thing to getting getting back to uncertainty. It's not the worst thing to embrace that that uncertainty might change your mind as to whether or not you want to go out when it might be a good time to go out. Right?

These are dark things to talk about. But I talk about them. They're dark, but but they're life. Like, we don't none of us get out of this alive. Like, yeah. What is our perception of life, right? Yeah.

And and this gets really personal for me. I had a cousin who was diagnosed with metastatic breast cancer in her late 20s. And this is while I was in my surgical training. And she fought valiantly for about a year. And then she died. And I we were not sister close, but we were close enough. And her parents or the were my family away from home when I was at college and I would go and hang out with Suz on the weekends. And it was foundational for me that and at the time I didn't know what to do with it, but it shook me because I knew deep down I knew I wasn't happy with my life. And we all those of us who are I don't know under pick a number 60 may gets older as you get older, but um of a of a reasonably young age believe that we will have all this time. And Suz didn't. And I think about it nearly daily um what she would want for me. And it has been a big impetus for why I have changed my career because I don't know, right? I do everything in my power to control my health and my life now, but mostly I am trying really hard to live a life where if I got hit by a bus tomorrow or I got cancer tomorrow, I would be okay and I would feel like I did what I was here to do and the choices I made leading up to this day have been enough. And you know, while I'm watching my dad with his dwindles, like it's all very, it is dark and it's sad. And grief is such a human part of our existence. And the fact that we do not talk about it enough and we don't like it shouldn't be a forbidden topic. It shouldn't be taboo. It shouldn't be ugly to talk about dark. We have to have the dark to have the light. It is the nature of our existence. and clinicians, people in medicine, we forget this at our own peril and at our patients peril because this is what happens. We are not getting out of this alive.

Okay, this looks like a good spot to wrap. Uh, what's the name of your book? It's called Disconnected. Disconnected. And um, you talk about so much of this in the book and granted, I've still just seen the the fragments and I have to say there's just so many things about it that uh, I'm looking forward to. Uh, where can people find you, Lily? You can find me on LinkedIn, El Johnston MD, or I have a YouTube Lily Johnston MD. Thank you for coming on. It's been such a pleasure, Dave. Thank you so much.