Work in Healthcare? ZDoggMD Wants Your Voice to Be Heard (And to Change the Practice of Medicine While He's at It)

; Zubin R. Damania, MD

Disclosures

January 30, 2020

This transcript has been edited for clarity.

Eric J. Topol, MD: Hello. I am Eric Topol, editor-in-chief of Medscape. It's a real treat for me to bring back Zubin Damania—ZDoggMD, as he's known—who is one of only two people we've had twice for a Medscape One-on-One interview. Zubin is quite a distinctive fellow. Welcome, Zubin.

Zubin R. Damania, MD: It's a thrill to be back, Eric.

Topol: Since we last convened for Medscape, several years ago, you have gone on to quite an illustrious career as an Internet celebrity, creating viral videos. But you also moved. You had been at Turntable Health in Las Vegas. Can you tell us what happened with that?

Damania: We had a really cool idea for building this concept of health 3.0, which in our mind meant that you have to shape a system to align the incentives with what you want. And what we wanted was to prevent disease before it happens, team-based collaborative care, everybody practicing at the top of their training, in service to the patient, but also in service to each other—because if we don't take the caregiver component into it, we're missing half of the equation, right? So with that in mind, we designed a no copay, unlimited access, all-you-can-treat buffet of care, and we had an insurance partner, Nevada Health Co-op. They put our product on the federal exchange so that patients could get access to this high-touch, relationship-driven primary care that, with subsidies, was pretty much for free.

Our job was to navigate the patients through the system, keep them out of trouble, and keep them from unnecessary admissions and out of the hands of cardiologists and other specialists, unless the patient needed it. It worked quite well. We had wonderful outcomes. We had a good number of patients enrolled, and then one day that same insurance company called us up and said, "Yeah, we're going to be out of business in 2 months, so you're going to have to find another medical home for those patients or another partner."

When we approached other insurance partners, they said, "Oh, sure. This looks great. I would send my own family here. But we'll give you one fifth the amount per patient per month as what those guys were giving you. And you have to charge a copay" (which breaks the model). "And maybe you could do Botox or something like that to make up the shortfall." At that point, I decided instead to spin it down.

Our friends at Iora Health are continuing the same model in multiple different states with Medicare Advantage, which is a good, stable partner with incentives aligned for a system like that. I stayed in Vegas for another couple of years, doing my show. But now I'm back in the Bay Area because I think there's a lot more cool healthcare stuff going on here for our show.

Topol: Besides your show and videos, what are you doing? Are you back in practice or are you staying out of that?

Damania: If I had a full-time practice, I would be beholden financially to an organization or something like that, and I wouldn't be able to say the things on my show that I say. One of our real pitches is that we're an unfiltered voice. So instead I'm faculty at UNLV School of Medicine. I go back to Vegas and I round at the county hospital with the house staff for free, as university faculty. If they want to fire me, that's cool; they're not paying me anyway. But they actually appreciate the voice and viewpoint I'm trying to give. That is my clinical work. And then I focus on the show, the videos, trying to shine a light on bright spots, where things are actually working in healthcare, and then shine a light on where they're not working, because I believe both are important for the tribe of medicine—to help us come together and have a collective voice, which we've been lacking for so long.

Topol: You're touching on an important topic that I want to drill down with you: Physicians and the medical community need to have a voice. You already hit on that when you said that if you were involved with a medical group in the Bay Area, you might not be able to be unplugged, unbridled. We also know that in general, physicians don't have a history of being activists. But you have been that way since, it seems to me, back in medical school, when you gave one of the graduation ceremony addresses. Was that your breakout moment in '99? Or did you start when you were in the crib? When did that get going?

Damania: Ever since I was young, I was a wise aleck. I never did well in hierarchical organizations, for some reason, and it came off as arrogance. Teachers would say, "You're arrogant; you think you know more than us." But that's not really how I felt. Inside, I felt like an imposter. But I could see enough to realize that this organization makes no sense, this hierarchy makes no sense, and what they're doing makes no sense. In medical school, I expressed the parts that didn't make sense in this graduation speech at UCSF in '99. Now faculty there embrace what I said. I recently was back for a reunion and got an innovator award and all this cool stuff. But at the time, I remember being told that there were faculty who believed that I shouldn't graduate for having said what I said, which was the truth about our experience in a hierarchical system. I talked about the fealty to authority, conditioning, where we learn to just sit down in the face of a system that's broken instead of standing up and saying, "You know what? We have power to actually change this system."

Topol: I suspect that the commencement address was not accompanied by rap music.

Damania: It was before I got involved in the rap game. That took another 11 years before I created ZDoggMD.

Topol: So ZDogg has been going for a decade? How many videos have you made during that decade?

Damania: There's a good 400—episodes of our show, multiple music videos, different interviews. It's gotten crazy. And it's spun out in a way that I never would have imagined. It wasn't planned that way, but it became this path that made a lot of sense.

Topol: It is remarkable how much these programs resonate in the medical community. In part, of course, you're a rebel and you'll say things that people are thinking but you'll actually articulate them and do it in an entertaining way. What does it take to get you to say, "I'm going to do a video on this topic"? What stirs you to do something?

Damania: Anytime I round at the hospital, I'm pretty pissed off. I see things in terms of social determinants of health, how we make errors in the hospital, the fallibility of the humans in this very complex and poorly designed nonsystem. And it gets me upset because I think, What if that was my mom or my brother or my kid? And then I end up doing a video or a series of videos about it. We have about 2 million followers across our social media platforms. A lot of healthcare professionals are part of this effort. They call themselves the Z-pack. (I didn't come up with the name.)

They give me input every day in the form of about 2000 Facebook messages, Instagram, Twitter, all that. So they'll say, "Hey, this is happening in my hospital." Or "Have you seen this article?" Or "Can you believe that? Could you talk about this?" I'll find the signal in all of that noise and then act on it. I'll think, That's a story no one is telling. That's how I listen to the front lines. I also listen to administrators and leaders because they have an important voice that needs to be heard. They also are suffering from what we're calling a "moral injury." They have to serve so many masters, and it causes hurt when you have to make these compromises, whether it's based on money, their own personal needs, the needs of the patient, or the needs of their staff. Trying to give a voice across healthcare has been our goal, and not focusing just on doctors—empowering one of the biggest groups, which is nurses. When they get together and get mad, oh, man, they don't lose. So how can we empower that and use that to help transform medicine? It's not just about the doctors.

Topol: These 2 million Z-pack people in the ZDogg camp must include a lot of nurses and doctors and administrators, and probably not only in the United States, right?

Damania: It's international. But it slices right through a cross-section of healthcare professionals in this country. There are 12 million healthcare professionals, and 2 million follow ZDogg. Some of them are activist patients. We call them muggles—nonmedical folk. It can be gratifying. When I'm in an airport, I'm often recognized maybe three or four times and it's always different—a respiratory therapist, a nurse, a healthcare administrator, a doctor's husband. We have to do something good and important with that kind of reach. And that's what I wake up with every morning: Okay, what are we going to do today that's going to make things better?

The things that get me angry are often things that get all of us angry when we think about them, but we're scared to talk about them because we might lose our jobs.

Topol: I don't know any other physician who has that kind of a community. Probably the most followed doctor in America, outside of Dr. Oz, is Sanjay Gupta. But you're right up there. You're saying things and getting the word out on vital issues that help bring people together. You're a voice to take on, whether it's anti-vaxxers or all the conspiracy theories. What are some of the things that have you juiced up and the ones you think have been most successful?

Damania: The things that get me angry are often things that get all of us angry when we think about them, but we're scared to talk about them because we might lose our jobs or affect our incomes. This is something I'm sensitive to. Upton Sinclair said that it's difficult to get a man to understand truths if his salary depends on him not understanding them. When I was in full-time practice, it was hard to say some of these things because if you're attacking a fee-for-service, volume-based mill, well, that's how our system makes money. That's why my salary is subsidized. I'm benefiting from that. There's this deep disconnect. It's almost a kind of moral distress that you feel. So now I try to find those things and talk about them loudly, like price-gouging in the air ambulance space. Marty Makary, at Hopkins, wrote a great book on this, The Price We Pay, and we had him on the show. He got me so mad reading his book that I just took chapter by chapter and started ranting about this idea that hospitals are suing their own patients en masse, patients who cannot afford to pay. These kinds of issues are important.

On the caregiver side, we see so much violence against frontline healthcare professionals now because there's been an erosion of the social norms around what you do in hospitals. The opioid epidemic has made it very dangerous. We haven't put a priority on keeping our people safe because we consider that to be an occupational risk. "Oh, it's part of a nurse's job to get punched." So we did a video called "Say Something." It's based on a very beautiful song by Christina Aguilera. Our video is about healthcare worker violence. I got thousands of stories from people, mostly women. This is never spoken about that it's women who are getting abused in our hospitals, nurses getting punched in the stomach when they're pregnant, getting cut and bit and killed. One interesting dirty secret about this is that nurses are often assaulted and injured, but doctors are murdered more often. There are fewer attacks, but they're more severe. And these are the things we don't talk about. I want to be able to give an unfiltered voice to that.

The other things we want to talk about are issues no one wants to talk about, like abortion, religion, or politics, and why it is that good people disagree on these issues. I want to talk about that because it allows us to understand our patients better, to have more civil discourse and dialogue. Why are we protecting our children from bad ideas when we should be exposing them to these ideas and confronting them, and arguing instead of deplatforming people and shutting them down? These are the kinds of things that get me up in the morning these days, until something better comes along.

Topol: In a way, you're a kind of antiforce to what is considered the traditional doctor, right? You're the true activist, trying to uncover things that are either hidden, suppressed, or unknown.

Why do you think you have these couple million followers? They're captivated by what you're doing, what you're singing about and performing. It's not just the humor or that it's entertaining, but you have a big message and it continues to grow. Why are you such a standout? Why aren't there more doctors who do things like you?

The inclusion of the whole healthcare tribe helps; if I were just aiming it at physicians—physicians are a tough crowd.

Damania: It shouldn't be rare. Honestly, there's nothing particularly special about me except that I have a degree of oppositional defiance. If someone tells me not to do something, I'll find a way to try to sneak around and do it with a smile on my face. I've been lucky, in a sense, that I hit YouTube at the right time, in 2010. People like Kevin Poe and others have been doing social media really well. There's a guy named Doctor Mike who's been successful on social media. He's a young guy, just out of residency, and mostly aimed at muggles, trying to teach patients. He's very attractive—one of Instagram's sexiest doctors.

I'm the ugly bald short guy who paid his dues going through this academic system and is now going to tell you the truth as far as I see it, and I'm not going to lie to you or try to sell you something. If we do sponsored episodes, it's usually, "Hey, this guy's got a device that thinks it's artificially intelligent and is going to help us with our EHR. Let's figure out whether it's nonsense and have an actual conversation." I think that's what resonates with people. Also, the inclusion of the whole healthcare tribe helps; if I were just aiming it at physicians—physicians are a tough crowd, Eric. I did a performance at a TCT conference for interventional cardiologists. I ended with "Lose Yourself," an Eminem joint. Twitter blew up—"Best thing we've seen; it's amazing"—but the live audience didn't know what to make of it.

Topol: That would be the norm.

Damania: Four thousand interventional cardiologists from all around the world. They've never seen anything like that. I gave a similar talk at an American College of Cardiology event that was predominantly nurses, with a few doctors, and got standing ovations, high fives. Very different audiences. Physicians are conditioned to be a bit "in the box"—you know, polite. That conditioning is fine, but we need to get them to act because they're smart, creative people. If they stood up and stampeded, we would change the world. That's why I loved your article in The New Yorker where you talked about doctors organizing.

Topol: We should get your help to pull that together. It's coming together. We have remarkable enthusiasm and the leadership is getting established. We have a tentative name—the Osler's Alliance. We're going to enlist your support for sure, because what you do will help. You are organizing doctors and the medical community around an important front.

In social media, people have very emotional responses. Do you get much blowback for your efforts?

Damania: Oh, I get hate almost daily. I get emails that would chill your blood. It's a mix of things. Sometimes it's an anti-vax cult member. We had Paul Offit on our show; he's a luminary in the vaccine world. And the anti-vaxxers found out that he was coming to our studio in Las Vegas, showed up during the live broadcast, and started pounding on the glass holding a picture of a child they said had died of a vaccine injury. It was SIDS, of course. The parents were there, and when you have been led to believe that vaccines murdered your child, of course you're going to act that way. It's very hard to blame them. Who has been doing that conditioning? We've dropped the ball as educators, and these conspiracy theorists have grabbed it and run with it.

So we get that crowd. Sometimes physicians don't like what I say. If I stand up and say, "Hey, you can't have doctors online bullying nurse practitioners. It doesn't become us to do that. We should be practicing at the top of our training and license, and that's all we need to say about that. But going out there and bullying people, saying they have low IQ, things like that, it's beneath us. It's unprofessional." I got a lot of hate for that.

And if I do anything controversial, if I talk about vaping or anything with nuance in it, I'll get a lot of hate, which means I'm probably on the right track. If I don't get hate, I feel like I've done it wrong. I haven't gone hard enough on the nuance, because I do want to upset the fringes on an issue.

Topol: You're a rebel by definition. We first met at the earliest Future of Genomic Medicine (now called Future of Individualized Medicine) conference. Somehow, I think everyone could feel in their bones that you would have an impact like you have. That impact is still developing. It's really quite remarkable.

Where do you go from here? What's the ZDogg plan for the next decade?

Damania: I wish I wasn't stuck with the name ZDogg, but in 2010 I was trying to come up with a handle that no one had taken on Twitter, and ZDoggMD came up. I'm thinking, I like Snoop Dogg, let's go with that. Now it's done. The problem is that it has a tinge of clownery and stupidity. But as we move forward, we really want to be a more serious force. The comedy is important, the music is important, but I want to serve a higher purpose with our show. Now that we're in the Bay Area, we're getting more guests on. I'm hoping to get you on the show because I'm fascinated with all your work on artificial intelligence and everything else you've been doing, especially with organizing physicians. Also, I want to learn a lot more.

The other thing I try to talk about is meditation and those sorts of pursuits. You can talk about moral injury and burnout a lot and say that these are external things that are pushing on us, that we need to fight back on, but then we also need to work on our own personal framing and locus of control. If we decentralize our control and say "this is all out of my control," it becomes very hard to affect change. When we work on things with true mindfulness, meditation, these sorts of practices, which I've been working on myself and trying to teach my audience about, it gives us space to be less reactive, more understanding, more compassionate. I want to go down that route a bit more—not in the "woo-woo," Deepak Chopra, everything-is-beautiful way but in a more realistic, useful way for frontline healthcare workers and others to use.

Topol: When you do your videos, you often have lots of other people in them. Are these extras? Are they on your staff? Where do you get all these people?

Damania: They're all volunteers who want to be in the videos. If I put out a call, 50 people will show up and want to be in the video. It's really fun. We're working with San Mateo Medical Center and we're shooting videos on their campus. It's a fun collaboration because we have a county safety net hospital that we can help by raising awareness for their foundation and things like that. In exchange, we get to shoot in a real hospital, which we've always done in Las Vegas. That and the real medical staff extras help make it authentic. It's not a Hollywood production, although those production values are there—we use 8K cameras and hundreds of thousands of dollars' worth of equipment to make a video that healthcare professionals can feel like, wow, this is a world-class music video about, for example, a doctor who steals pens from nurses.

You would think that's a dumb topic. Who cares? The nurses care. These affluent doctors who could buy their own dang pens are coming up to the nurses and asking, "Hey, can I borrow a pen?" And then they walk off with it. So we did a parody of Rick Springfield's "Jessie's Girl," about Jessie's pen. "I wish that I had Jessie's pen. Oh, never found a ballpoint like that."

Topol: We recently did a Medscape One-on-One with Jen Gunter. You're kind of her male counterpart. She's much more focused on women's health and you are more focused on general issues, but both of you are rebels, taking on the miscommunication in medicine and the misinformation.

What's noteworthy here is the different breed of doctors the two of you represent. Recently, Stanley Goldfarb, a former dean at UPenn, published an editorial in The Wall Street Journal. He wrote that doctors should "stay in their lane," just as the NRA said about doctors and gun safety. He wrote that there shouldn't be anything in the medical school curriculum about things like climate change, social injustice (which he put in quotes), gun control—all the things that get you going. He said that doctors should just take care of their patients, basically ignoring where medicine is headed.

You anticipated that in the past decade—the broader view of what it takes to provide care for patients and have that more panoramic perspective. Where do you see medicine going in general?

Damania: We have to be vocal on all those issues. And here's the thing: We may not agree. When we talk about guns, maybe there are doctors who like to hunt and believe in the right to have a weapon. They don't think gun control in its current form will work. Okay, fine. Let's hear that voice. Let's put it into the mix. And then we'll hear the voice that you often see on Twitter, which is a more leftish voice. That voice says, "No, we need to actually talk about this as a public health issue." Before he became Surgeon General, Vivek Murthy got into trouble just for mentioning it. That's censorship. We should be able to speak freely about whatever we're passionate about, whether it's climate change or something like abortion.

Jen Gunter and I got into an offline argument because we both feel so passionately about this, talking about a woman's right to choose 100%, but acknowledging that many people who we are trying to influence are uncomfortable with the moral ramifications of that. But let's at least have a conversation. Nothing is black-and-white. It's one of the great fallacies that the world is black vs white, good vs evil. It's not. Everyone has their own moral palette and they're trying to do good in the world. So let's get boisterous. We went through a lot of hurt to have knowledge and credibility; why aren't we trying to use it for good in the world? That's part of the healing process. So, yes, we have to have a voice in these issues.

Topol: Do you see a remedy in the future for this disillusionment and physician, nurse, and clinician burnout? Are you hopeful that we're going to get out of these doldrums of medicine?

Damania: I am. You know why? Because I've seen it work. I've seen bright spots. Our staff—doctors, nurses, health coaches, licensed clinical social workers, pharmacists, phlebotomists—got together every morning. It was a nonhierarchical, everybody-teaches-each-other moment, but they all had their own specialty and training, and they operate at the top of their license. They worked harder than they had ever worked in any organization. But they were happier than they had ever been.

Everyone thinks healthcare workers are just overworked. Well, this is true. We're overworked with stuff that doesn't matter. If we're allowed to work hard at what matters, and we're given the tools, the resources, and the autonomy to do that, we will bust our butts because hey, we got through medical school, residency, and fellowship training. We are good at that. But we need the capacity to do our jobs. And when they have it, people work really hard. They work long hours, but they come away invigorated, feeling a sense of purpose, a sense of connection.

Many of us suffer in silence. So many of us are burning out. Burnout is like dialysis: It's the end stage of multiple insults, one of which is this moral distress or greed; another is poor personal tools to deal with the stress. We think that if we just work hard, we can fix it. That's going to end badly. If we can communalize our pain, with shared suffering comes some relief—"Oh, it's not just me. I'm not crazy, the system is crazy."

That's what Samuel Shem's book, The House of God, did, remember? All of us thought, It wasn't just me who felt morally bankrupt during residency. It's a whole thing. This communalization of pain can bring us together. I've seen it work with burnout. I've seen it ameliorated. I've seen the benefits of communalizing our pain, giving us a voice, so I have no doubt that it's going to get better. But it's going to take folks like you to organize physicians. It's going to take folks like me to keep shouting and going, "Hey, we're hurting. You're validated, your suffering is real. And it's not just yours alone." That isolation and disconnection is what's driving people to despair. When people disappear off the grid, that's when you worry about things like suicide.

Topol: I share your optimism. And I'll look forward to talking more about that and the gift of time that we might be able to derive from technology and AI. I think I'm speaking for a plurality of the Medscape community when I say that what you've achieved in the past decade is laudable. We're going to follow you closely. And we're going to revisit all of this in another decade. You're still a young guy, you're a force, you're teaching a lot of people what it's like to be able to get out there and speak your mind. So keep up the great work, Zubin.

Eric J. Topol, MD, the editor-in-chief of Medscape, is one of the top 10 most cited researchers in medicine and frequently writes about technology in healthcare, including in his latest book, Deep Medicine: How Artificial Intelligence Can Make Healthcare Human Again.

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