Big Beautiful or Big Ugly Bill?

Opening on physician advocacy 0:00

You know, we have been gifted a voice and a position in society which many people do listen to. And I think we need to use that voice, not just in siloed in this office space or in this hospital bed or in this operating room, but we need to go outside of that. We need to penetrate into administration. We need to penetrate into politics. We need to build community with with underserved people, not just when we're looking at them in the office, but outside of the office. The farm workers need to know we care about them, not in the office because we're treating them for a medical condition.

They need to know that we stand behind them. This is Doctor Talks, real talk from real doctors on the issues that matter to you most. Welcome to the Two Curious MDs podcast. Today we have Dr. Farah Karipaneni, MD, MPH, and fellow of the American College of Surgeons, who's a highly accomplished endocrine and general surgeon based in Fresno, California. In your current role, you are an associate clinical professor at UCSF Fresno, and you also practice in the community in Fresno, California. Oh, we have a little bit of overlap there where you did your general surgery residency in New York at Albert Einstein.

I actually went to my own residency there. And you blend all of this training that you have with also this work that you do in advocacy. So endocrine surgeon, public health advocate and storyteller. And you're also the only endocrine surgeon serving California Central Valley. Is that correct? Yeah, except for, I have now my, uh, our former residents who went to dinner fellowship. She came back and joined me. So now congratulations. Well, that is beautiful. And this is important because California's California central Valley is where two thirds of residents rely on.

On medical, which is California state Medicaid. And as we know, that's been in the news. So, as coverage shrinks and access roads, you know, you're bearing witness to a system in crisis. So, right now, it feels really, really current and important to speak to these stories that where. witnessing happening amongst us. And I think they're happening at such a rate that it's important to really bring them up, you know, speak for those who can't speak for themselves. And I really admire work that you're doing in this.

Yeah, you're welcome. Thank you for being here today. Thank you Farah for being here. You are such an advocate and a writer and a mother and an excellent surgeon and I would have to add that endocrine surgery,

Introducing Dr. Farah Karipaneni 2:51

the first time I ever heard of it was when you told me about it and I was like there's a specialty in endocrine surgery and the nuance and the The delicacy with which the surgery is, you know, provided is quite intense and the stories you've told me about them have been really riveting and I think I'm glad to have you here today. We're going to talk about some of the health care issues that we're confronted with these days. And that is the most beautiful bill. And this is the very play on words.

And it's it's a way of really marketing. I would say something that could be really, really impactful and also affect the health care of so many people who may lose coverage. And I want to really highlight the importance of discussing these things among physicians, among people who are definitely going to be impacted. for the patients that we see and can you tell us a little bit about what the most beautiful whatever bill means to you and and why this idea of a beautiful bill even matters like tell us more.

Yeah. So first of all, thank you so much for having me on. It's always such a blessing to be here with you guys. And I really admire all the work that you guys are doing in integrative medicine. And it's really a space that is so unique what you guys are doing. So thank you for all that you do. And thank you for having me. I think this is a very timely thing to talk about. You know, things before the Big Beautiful Bill were not going great for Medi-Cal patients and for the underserved in general.

And so this is going to be a huge hit. And I think it's a good idea for us to talk about it. I'm not bringing to this discussion any specific political background that I have. It's more in the capacity of my lived experience. as a subspecialty surgeon, a practitioner in an underserved area, having seen what the struggles are already and seeing what we're going to inherit as further struggles. And this, mind you, is off the heels of COVID from which we never recovered as far as healthcare. And those of us who worked in the trenches during that time and afterwards will know exactly what I'm talking about.

So it is an interesting time and there will be interesting challenges. And so what it means to me, you know, one of the biggest things out of all of the things that were rolled out with the big, beautiful bill. and for us to talk about as physicians are the Medicaid cuts. I think that's one of the most glaring things because the Medicaid funding was already very, very much in contention. Once the Affordable Care Act was passed, immediately thereafter, it has been under scrutiny and people have tried to bring it down since the beginning.

by reducing the funding, by getting rid of it entirely. And so there currently isn't much to take from that program without just completely slashing enrollment, which basically some people, you know, as far as the Congressional Budget Office analyzing the effect has said that potentially 7.8 million people will become uninsured Uh, which this congressional budget office is nonpartisan and of course, this somehow becomes a very partisan issue. None of this is partisan. This is just about people getting healthcare and we are doctors.

We are nonpartisan and people should get healthcare. Otherwise they will die and the other people who need healthcare, uh, will also die because the other people are flooding the emergency rooms. So I think that's something that everyone should also understand, even if you don't particularly care about Medicaid patients or the underserved. So this, this, um. You know, when you're talking about public health, you know, the health of the public matters to the individual and here right now,

What the Big Beautiful Bill means for Medi-Cal 7:10

we're kind of look everything is being looked at from the lens that actually doesn't even understand anymore what the health of the public means to the individual. You just said, you know, if you slash Medicaid for a certain group of people and those people lose insurance, how does that snowball and impact everybody else in a society? and how, you know, what are some of those aspects that we will start to see happening? You know, there's the crisis, you know, there's the place of crisis and the temperature is gonna go up there.

We know that for a fact, the people who are already underwater are gonna be even more underwater. You know, the hospitals are in crisis, the ERs, you talk about placement, you talk about, you know, all the kind of like resonances of the crisis that's happening and how it impacts everybody. I think we haven't thought through that, you know, and I think there's this kind of almost like a lack of empathy happening because of the partisanship. What do you find is Within, you know, I think we have to ask physicians always say, well, before I even look at a problem or try to solve the problem, what is this problem inviting me to do in myself?

you know, where do I find myself not up to solving this problem yet, is I think a place to start from. Because I feel like with the tools that we've had, that we've been employing for the last couple of decades of our lives, we are still in a place where humanity and medicine is an even deeper crisis. And you said this in one of your articles, humanity and medicine is in crisis. And we're kind of in like, whoa, that has come true. You know, so in some ways I'm kind of asking you what does that feel like to be to have been in this field for so long with the perspective you've had starting from where you are kind of grounded in the Central Valley and now looking at this scale of what's about to happen and all the ramifications.

How do you in yourself start to reconcile the gap, you know, that was just kind of like Yeah, I think we need to be fierce community advocates. I think it's no longer the situation of decades and generations prior where the physician was We were always going to have to be community advocates, but more politically so, I would say. It's not just going to work and coming home. We have been gifted a voice and a position in society which many people do listen to. And I think we need to use that voice, not just in siloed in this office space or in this hospital bed or in this operating room, but we need to go outside of that.

We need to penetrate into administration. We need to penetrate into politics. We need to build community with underserved people, not just when we're looking at them in the office, but outside of the office. You know, like the farm workers need to know we care about them. not in the office because we're treating them for a medical condition. They need to know that we stand behind them. They need to know that if you are going to go on strike right now so that you can send a message that the grapes aren't going to go bad because you're not going to pick them, they need to know that I'm going to give you some money so that you can stay at home so that you can strike.

That I, as a physician, care about that. And not just about your thyroid condition when you come to my office for like a reimbursable visit. Yeah, and I'm being I'm being reminded also. That what's happening in the body in the person's body is happening in the greater body of of the of the community, right? Like that endocrine problem is actually a community problem because chances are there's air water quality involved. There's toxins involved or some sort of stressors involve that. do impact not just the individual, but the community.

So I'm always reminded that our work is political because the body is political. What happens to the body is political. I think we should all read Rupa Maria's Enflamed. I think that's a nice blueprint for just the colonization, the capitalism of medicine, how it has led to inflammation on many different levels. And she puts it really, really well. And I think that should be required reading. Because what you're speaking to is inflammation. And just like our bodies have inflammation, at least to different kinds of diseases, I think there's an inflammation on a social, political level that has led to widespread inflammation of different communities, like redlining, for instance.

So many examples. Yeah. Can you just walk us through kind of the impact that you envision? I think with these kind of reductions, both in Medicaid, both in the impact that it makes on the Affordable Care Act and for the expiration of a lot of these tax benefits that were seen before that will be impacted by this bill. What would that, what kind of impact do you envision this loss of insurance or Medicaid coverage or even those tax benefits for people who need them having on you and in the care that you provide for the underserved in Fresno.

Well, I think there's so many things that could happen. We recently had one of our hospitals shut down in Madera. And when that happened, which is something that could happen if there's no funding for Medicaid that is is rural hospitals will be in a lot of trouble. And as they start to have less funding, because they have so many Medicaid patients, those patients will have to travel farther into areas that are these larger cities where people are not expecting there to be this overcrowding of really sick patients who don't have any insurance, there's just going to be more of that.

And in the emergency room, it's still kind of like an equalizer. The emergency room is not this capitalist thing where you can slip someone $20 and then your heart attack means more than that person's brain bleed. It's not like that, guys. So you're going to go to the ER. There's going to be a lot of sick people there. Why? Because they had to pay their rent instead of buying their insulin. guys like that's why okay and then so so you're not no matter how rich you are you are gonna need that emergency room to get your stroke protocol or your heart attack taken care of fast you know and there's a window for that and if you don't get the window then you could die and and that's you not the Medicaid patient but it's everybody really right everybody's gonna suffer so I feel like that's gonna happen more often already at CRMC, we see, and I think we've talked about this before, how the hallways were actual hallways before COVID.

And then in COVID, the hallways became units. And now the hallway to the hallway on either side is also a unit of patients. And it's literally reshaped how you walk into the hospital because it's not a hallway anymore. It's an actual unit for for patients and that we never recovered. And I shuddered to think, what's going to happen next? Where else could you put a patient? And now we started having discharge lounges and patients, the minute they can be discharged, we're like, you got to discharge that patient.

It's become like a quality measure. And it's always been a quality measure because you always have to get patients in and out. But now there's no space for that patient to even get their discharge instructions and change their clothes. You immediately get them out of the room so that someone can get out of the ER so the next patient can get into the ER. And that's just going to get a lot worse. And so in the most simplest of terms, it's going to be really hard for life saving care. Now, the other thing that's going to happen is that all those outpatient, what's going to happen on the outpatient level?

So, I'm thinking a subspecialty surgeon. So, if you can't get your surgery done, this has happened in Madera and I'm thinking it's going to happen more and more. If you are not Medicaid, let's say you have great insurance, but you had your surgery scheduled at Madera Hospital with another surgeon, a gallbladder or a thyroid, whatever. Now, Madera shuts down, you can't have your surgery there. You have to establish care with someone else who actually has privileges at a hospital that's open. So then you come to me to get your gallbladder done.

Well, now I have lots more consults than I had before, and my wait time is a lot longer. So you are not going to be able to get your care as locally as you could otherwise. So then you're going to go somewhere else, hoping that you're going to get better care there. Those places, we are at the point where they're already at Stanford, one in three people in the ER is quoted to be a Medicaid patient. So they're already seeing the overcrowding effects as well. So there's no guarantee now that you go to that higher level of care that you're gonna actually get yourself your timely gallbladder either.

Wow. Absolutely. Yeah, I mean, it's not that I remember the first time I walking through the CRMC and in Fresno and seeing over 200 people waiting for beds. And that was a shock to me. I was very shocked coming overseas where, you know, I was practicing global health and came back to America after 10 years.

Ripple effects of Medicaid cuts on hospitals and patients 17:10

And I walked through that year and I go, what happened to America? What happened to the emergency room? And then when COVID you know, happened, of course, the impact continues to get worse. And we're continuing to talk about the same problem and the same issue. And yet what is going on? Why aren't doctors, why aren't people in the health care space speaking about this or rising to the surface on the issues here? What do you think is needed to really move this, move this in the direction where people can listen and understand the consequence of this?

I think we need more physicians in these positions to make these votes. I think that physicians need to get political. We need to back physicians who are willing to make their jobs political. In South Carolina, there's a doctor, I'm going to try to find her name, that's running and she's on social media and she's really great. She's out there trying to challenge Lindsey Graham. Um, and, uh, Annie Andrews, uh, she's running to defeat Lindsey Graham and she's a mom of three. She's a pediatrician. Um, and she speaks out on these issues a lot.

And I think she's not a career politician. She's a pediatrician. Um, and she's been in activism, like mom's demand action, um, been on, you know, Instagram making reels about this bill that we're talking about now. And she is just laser focused. And I think we need people like that. And not everybody is gonna be that. We don't all have to reinvent the wheel. We can identify people like that and focus on supporting them. So it takes all kinds and we're not all gonna be the ones to jump into politics.

There's also local politics. There's a lot of money, for instance, right now, locally in Fresno County that hasn't been used, that's specifically earmarked for the homeless. Now, what are they going to do with that money? We don't even know. I'm sitting here. I don't even know about that money, right? But I know about it because of a local advocate who I work with on her organization called We Are Not Invisible. Um, and she, and so she knows that there's this money because she has time to go to these meetings.

And so, so we as physicians don't have to reinvent the wheel. Sometimes we just have to identify people in the community and then show up. So how do I know about this? Because she asked for a meeting with me. How did she ask for a meeting with me? Because she knows I care because I've showed up to a bunch of things. And so, uh, and that was a privilege actually that she, you know, felt that she that it was worth it to speak to me about the things that she has on her mind about the homeless community.

And I think building relationships like that, it takes time. It takes a lot of time to do. But once those relationships are there, they can't be broken. It's really, really powerful. I think we should do more of that. I have a question I really believe in this and I feel like we're almost looking at it from the lens of. Are we are we talking about redefining the role of a physician in society? Almost like, are we at that moment? Right? Like we have, you know, Farah, you and I, I think we have parents who are physicians, right?

So we kind of grew up with that. And there was always this way that a physician was, and that's how we're taught behind a professional kind of, you know, facade. Because I feel like there's still almost a generational difference between how physicians almost look at themselves in society right now. To my parents' generation, the boomer generation of physicians, this kind of public advocacy would be like, oh no. Right? Like, don't even I don't know if that's that's true for you, but at least that's and now, you know, us as I don't know what it is about the pediatricians wanting to like, step in and save everything.

That must be a thing. And then we're seeing like, okay, what do we then look at the next generation? And I'm seeing my residents who are, yeah, they're on social media. I see some of them really looking to the task of crafting the narrative. We have the Dr. Glom Flocken, I think that's his name. He's on social media talking about how Even just some of these things, you know, how funding and reimbursement and everything does impact and doing that in a really lighthearted way. But how do you think, so this is my question, how do you think we can redesign medical education?

Because we've been redesigning medical education, but I think we've been redesigning it for efficiency and for billing and coding. And I feel like we've really let down our current cohort of medical students because we've even squeezed their preclinical time to almost 18 months. And yes, we've dropped them into the clinical space, but then in the clinical space, they're learning from a different perspective. And I feel like You know, part of what drew me to medical education was when we would talk about the medical humanities, we would talk about social justice.

Actually, one of the courses I taught at USC had the Rupa Maria's book, Enflamed as their summer reading. Yeah, and it blew the lid open, though, because these are such dangerous topics to be talking about. in a class full of, right? Like I had 24 students and there was so much disagreement about the realities that they perceive because some are coming from Indiana and some are coming from California, Central Coast, some are coming from Irvine and they're all kind of getting together in the same room and they're all reading about the healthcare system from this other lens that they may never have encountered.

You know, the stories of other people in health care that, you know, would complexify what medical students choices. So how would you redesign medical education to better prepare doctors for what's going to happen? Yeah, that's a good question. I think having I think modeling is is really is really important. Everyone has a different technique with, you know, how they interact with residents. Um, some are more hands on some are more hands off. I personally, as a, as a learner learn from watching a lot more and then from.

once someone's interested in something from like them asking questions and expounding. But I try as, you know, in my professorship role to model more than directly tell. And everybody who works with me, like my whole like scrub tech staff, like my outpatient office staff knows about my stances on literally everything when it comes to social justice. And so sometimes it's just like having these conversations in their earshot as we're doing surgery or as we're advocating for a Medicaid patient or something like that.

But I think modeling is super important. So I try to share what I'm doing, not necessarily because I'm like, you should do this too, but just to show them what it would look like. And I think that's really important is because I don't think it's that they don't want to do it. I think it's overwhelming. I think a lot of us get overwhelmed too. I gave a grand rounds on compassion, compassionomics. I don't know if you guys have read that book, but it's a good one too. And one of the feedbacks was, we already do so much.

You want us to do this too? And it's hard. It's a lot, right? So when you say that about how we have to redefine our role, it is overwhelming for a lot of people who already are struggling. And we all see our struggles differently. We all have different financial struggles. Some physicians are really struggling financially. Um, primary care doesn't pay well, um, and you might not be married to someone who's working. You might be the breadwinner. So I get it. There's a lot, a lot going on. Um, but compassion is actually financially, um, it's a financially feasible model.

Physicians as community and political advocates 25:40

Um, and so is keeping Medicaid by the way, you know? And so sometimes you have to use people's language in order to speak with them. And so when it comes to, um, To to demonstrating the importance of doing this to colleagues and to trainees, we might have to make an argument like that with compassion, you know, and and with with being part of the community all of these outreach things. For me you know it it gives me so much and and so that's an argument that I make you know I make sure to demonstrate how much it has enriched my life.

And. And I always invite people to come with me, like try to invite them to certain things that I do. And not all of them, I would say most of them actually don't take that invitation as far as the residents, because I work with surgery residents, I also work with students. A lot of the students will be very receptive to that. And we've had book clubs, we've had outreach with them, a lot of things, they have more time and their surgery residents don't. So the most that I can hope for is that I have modeled something of what it is to be a voice in the community, to build community.

to be a voice for health disparities. Um, and I also, you know, as my residents know from how messy my, my office is on when my kids are there and how to, how to, how to be a mom, you know, as well, and, and, and just kind of like bring all the parts of yourself to where you go. Because, because, because as people remind you, you know, there's a lot going on. How am I going to do it all? Yeah. I love how you bring in all the elements of who you are, your identity, your work, your role as a mother, your role as a writer and as a person who represents and models.

You know, that's such an important role, all aspects of what you as a surgeon standing there in the middle of cases all day long, sometimes, you know, the cases that come in and the complexity of those. I'm also curious about You know what you what you talked about earlier you have an MPH you mentioned the book inflamed you're talking about social justice and what is not. really apparent, I think to a lot of physicians or to people in the healthcare field is that just prescribing medication is not enough.

Just, you know, seeing a person and saying, okay, this is, this is going to heal you. That's just not enough because outside of that space, there's so much more happening that is a direct impact of on how people live and how people live is what happens to their bodies. Right? So if you are impacted by by your socioeconomic stressors that you live in, the toxins that you're exposed to, the malnutrition, the stress of survival, and then not having insurance. on top of that, you know, where you don't have access in your block.

I mean, it's seeds to so many things, it's seeds to all elements of how we live. And that has an impact on everybody, as you mentioned. So how can we take this to a broader, a broader have, you know, platform because this is, this is bigger than just you, me. And I was talking about it. This is really scary. And I want to add another part of this. Definitely. That's really scary. And maybe I can expand on what you just said is with the creation of this kind of world, right? Where so many are going to kind of fall off.

the very delicate edge that they were already on, right? It's creating a sense of this ability we have to look at certain people as more human than others. or deserving of, you know, rights of deserving of dignity, right? And that's what's happening in stripping away their basic rights. The system is telling them you don't deserve dignity. or respect or your body to be cared for and how devastating that is on that level. And however, not just is it devastating to the bodies that it's happening to, but to us, what it does to people witnessing that and that happening is it challenges our own empathy.

It challenges the limits of our empathy, right? Like when we're talking about how can a resident, for example, who's training, who's in general surgery, who's so busy when faced with, oh, what are the other roles in society that you may be called towards? because that too is now part of our wheelhouse. Vaccine denialism is not just about the quality of the vaccines, it's about this war on vaccines that's happened, that's really baseless and has no scientific basis. We are in the midst of it going, Oh my gosh, you know, it's going to over time.

What happens is it of roads our empathy. Of course it does. you know, situations like this where you've had the 10th patient that day and you're having to discuss with them why they should give the flu vaccine to their child who has asthma because it'll actually help them survive pneumonia this winter. And you've had that for the 10th time and a part of you just is ready to check out. A part of you is saying this problem is bigger than I am and that's where the edge of burnout is, right? And that's what I think these conditions are primed for physicians to kind of get into because we're so empathic.

We see everything. We feel everything. We are also powerful. We know we should be able to do better. And when those things aren't happening, that's where we feel really powerless. That's where the moral injury kind of happens. That's where the giving up and the depersonalization and all of that starts. Right. Yeah. And so we're in that mix. Yeah, just tell me what you see here that can lead us to recognizing, to resisting, and seeing that it's a story. Yeah, seeing that it's a deliberately purposefully created set of conditions for us to lose our empathy and that that is that place where physicians are standing at.

And I saw us doing that in covid right in covid is where physicians storytelling really took off because we were really seeing like There's no other way for these stories to get out there unless we tell you what it feels like to sit next to somebody and hold up an iPad while they say goodbye to their loved ones. And we did that. Like you were right to the beginning you mentioned, we haven't even gotten over that. We haven't even processed that. And here we are right up against situations like that where we will be standing at the bedside of somebody whose life would have been saved by more food on their table, insulin, stable place to live, and just access to the basics, just the basics that we talk about.

And this is not a new problem. Structural violence has been around for decades. And for those who aren't familiar, I'm sure you guys are, structural violence is A form of violence, which some people may not see it that way, but that is what it is where in some social structure or social institution causes harm to people by. preventing them from meeting basic needs, which we should be calling rights, which the Constitution calls rights, but we're just not doing that right now, has roots in colonialism and slavery, things like institutionalized racism, sexism, classism.

The medical industrial complex is part of that. We are part of structural violence. And to answer your question, it's two parts. One is to recognize what it is and call it out when we see it, which is a huge thing to do. And then the second part is taking care of ourselves to make sure that we can continue to do that because it is a heavy call. But it was always a heavy call because the Hippocratic oath, which we all took, can I read a part of it? I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being whose illness may affect the person's family and economic stability.

My responsibility includes these related problems if I am to care adequately for the sick. I will prevent disease whenever I can, for prevention is preferable to cure. I will remember that I remain a member of society with special obligations to all my fellow human beings, those sound of mind and body, as well as the infirm. This is the modern version is the, the, the original version. Um, it's a similar vein, but there was a lot about, uh, of stuff that like, it's just not applicable modern in a modern society.

Um, but you know, we signed up for something like this guys, like, Yes, once we said we would do that, we entered into a world of finance and business.

Redesigning medical education for social justice 35:40

It's true. And then we adjusted. We adjusted to that, to the point where all of this kind of fell away because nobody was really doing it. But it's what we signed up for. And not that nobody's really doing it. Some people are doing it. Some people are clinging to this and other people are disillusioned and other people just completely forgot it. or never believed in it to begin with, maybe one of those things. But this is what we all signed up for. We all set it in our white coat ceremony and I believe it.

So it's not that alien. It's just alien because of what the medical industrial complex has turned into, which is just a business where there's a transaction and that's it. But we literally said that we weren't going to turn people's illnesses into the thing we were treating. We were going to treat the people and not the illness. And so I think as far as like, how do we do that? How do we continue to do that in this society? Well, I think it's really important to treat each patient as you would your family.

That's the first thing. And I think it's harder to do in an employed practice. It's harder to do when there's so many patients, but it's not impossible. So just remember that every moment you're in front of a patient is a moment you can resist, is a moment where you can dissent. And don't take that for granted. It means something. It means something to that patient. And that patient exists in a sphere of how many people care about you like deeply, probably like a ton, right? So that person is in that sphere.

And so you just did something really good. And then I think modeling for the residents, for the next generation coming up, modeling that, you know, being loud. I think that we need to be a little bit louder. Just make these videos, you know, where you talk about these things and flood social media with them and speak loudly about things. Go to the meeting and speak loudly about it. And then when you don't want to go to the meeting because you can't, then learn to take a break instead of quitting.

and then come back to it once you've taken your break. There's no shame in that. And we're not going to solve it today. Nobody has that answer, right? But if all of us did a little bit more, then it would probably lead to something good. And I also think that the system has to implode. Maybe this is the beginning of the end Maybe this is the thing we need in order for things to change. Something bad has to happen sometimes for things to change because people just, because the people in power are just not smart enough to figure it out before something bad happens.

Well, thank you. I think you really brought it all together, you know, all of the calling it out, what we can do, bigger voices, bigger stances, connection, community, you know, building on what we know with others, emulating that and really modeling that. And I really want to I mean, this was this was such an important episode to to to do and you showing up on a Sunday here on a July 4th weekend and as really connecting on this very issue that brings us together, I think in a lot of different ways.

I take care of patients. And I don't bill insurance. And every patient, they pay for their service. And we take it seriously. We take care of seriously. As a team, every person on our team knows that there's a value with this patient. This patient is valuable. Their experience is valuable. Their conditions can be addressed. And if everybody's seeing it in that way, automatically change starts to happen. Automatically the patients have to feel better because they feel supported, they feel heard, they feel seen.

And the inflammation tends to go down. You can actually measure that. Sometimes I wonder, is this the placebo effect in medicine? Because it gets so much better just because you're paying attention to your patient. And if only insurance systems could do this better. I mean, that's what it's for. and it's sad to hear that I have insurance and yet I don't find it valuable because it doesn't really cover for many things. It denies you this, and you get a headache, and you try to process that. And it's a daily trying to get prioritizations.

I mean, who wants to do that in a busy office? And they know it. They absolutely know it. They know that they can make it complicated. They can deny, deny. Who's going to fight? Not many people. And I tell patients, you have rights. You have rights. You can go and talk to your insurance. You can advocate for yourself. You can ask an advocate. You can get coverage for a lot of things, but you have to fight as well. And I remind that that's their responsibility just as much as ours. True. That's very true.

And it's hard. I mean, health literacy is difficult and calling insurance companies, like I would probably rather not do the thing that was denied for myself as a patient rather than call my insurance company and try to figure it out. I'd have to be dying or something. But I do it all the time for patients. And I think that patients or physicians need to realize that what you just said, which is there are certain things that they will deny, like They won't even look at it. It's just a denial. They're expecting that either you're going to accept it or they're going to have to have an appeal call.

So if we understand that as physicians, we have to be ready for that appeal call. We have to be ready to appeal because no, they didn't even look at it. The answer was always no until a phone call. So I always say yes to those. I always say yes to the appeal. I'm going to appeal. I'm going to appeal and talk to it. And you know what? Honestly, a lot of times it does go through finally. Sometimes it doesn't, but a lot of times it does. Yeah, but it's a purposeful process to deny first and then make somebody appeal and 20 or 30, 50% of people will appeal.

And this goes for patients too. I tell patients, read your insurance policy. Know what's in your insurance policy. Learn the language and also fight for yourself as well. And I think as I'm now starting to onboard insurance companies for TMS, I'm recognizing God the headache and the pain and the frustration and the fear that you're not going to get paid for services rendered. And yet you have that responsibility. But it's so important that we really address this on a larger scale, I think, to physicians and to patients and to the community at large, that we do have rights.

We can advocate for ourselves. We will advocate for ourselves. And we stand together on this. And I think that voice can be heard and shared as we kind of, as you said, call it out more loudly. And, you know, we also don't have to have an insurance-based system. And so, like, we have to do these things every day to take care of the patient in front of us right now because the policy is not going to change right now. But there has to be some view to, like we said, getting involved in politics a little bit more and, you know, dreaming of a non-insurance-based system.

There's so many countries, the UK, Canada, Sweden, Norway, Denmark. Yes, those happen to have higher taxes that are helping to fund those. And of course, that's not what we want. But we're going to pay for it one way or another. And as we just said, a lot of people are going to pay for it with their life, which is a lot more expensive than taxes. Yeah, I'm hearing 1st, I wanted to mention that I think the people who work around you guys get a lot of what you stand for. And I feel like that's part of the role of the physician, you know, as you're talking to residents and physicians who are feeling isolated and helpless.

I got a reminder from you that exactly you talking about in the or you making a stance you are you saying no no health care is a right and coming from a physician right coming from that place of authority that says no that is correct is so. I think life giving to that system around you that holds that to be true. And I think as we're talking about even holding space for what is correct, right? Recognizing that yeah, that might take five more minutes on this phone call, but I'm going to do it because it may make a difference, right?

Just taking that chance from a place of, And, you know, I'm reminded of the time when I was with my kids and, you know, we'd be at the checkout line. And as I'm walking out of Target, I'd recognize that, oh, I was given too much change, right? And I would tell my kids, all right, we're going back in. We got to give the change back because we're not going to walk away with more money than we're owed. You know, like those important moments where you kind of connect with the right thing to do and you do the hard thing or the slightly more difficult thing or the thing that's a little bit more complicated because it's worth it.

um to the people in front of you right so i'm being you know recognizing that and then looking for um those places of um and i'm really hearing also that physicians are starting to find that being becoming political um having a stance about housing clean air vaccines health care no guns all of that is actually It is actually going to help. I think it is actually going to help because we have enough data. We have data from firearm research done. We have data to show exactly what we need to do. So it's not like we don't have the evidence to base good policy on.

What we need is this ability to describe how this policy is going to, like you said, you know, impact not just the people who are losing Medicaid, but the people who are going to the emergency room for their stroke, you know, really breaking those contrasting bits in.

Structural violence, burnout, and the Hippocratic oath 46:30

And I just want to know for you right now, as we're kind of heading into maybe thinking, you know, kind of moving from this conversation, what gives you hope right now, as you're looking at the situation and what's kind of coming up? Well, for me, my faith and my personality, you know, I'm always a what can we do type of person. And like for me, making that extra phone call is wellness because otherwise I do feel hopeless and for some people they'll see that extra phone call their extra thing they have to do as as sucking away from them.

For me, I see it as empowering. And for much of what I do, I have no idea if it's going to make a difference because it seems sometimes like what's going on right now, it seems like it's so big that we couldn't possibly overcome it. But if you look at the arc of history, it goes up, it goes down, it has different ebbs and flows, and people have been defeated before. Goliath has been defeated before, you know, and so it's not the first time. And it will happen, in my opinion. I know it'll happen.

I don't know if I'll be alive for it, but I know it'll happen. And so I focus on what my job is, and my job is to do my part in my space. And I feel that deeply. What can I do? I can do my part in my space. I can show up to what I can do. So I'm showing up to the things that I'm trying to do. And I know it's not enough, but it's what I can do. And then what I can do actually is enough because it's all I can do. And when it goes down in history that she cared and she tried, she did something here and there.

And so that's it. Then I did my part, right? I did what I could do. That's it. And I have to be able to say that. I have to be able to say that. So that's what drives me. I'm going to do my part. I'm going to do what I can do. And I used to go on these missions to Lebanon to Mexico to, and I don't think there's anything wrong with global health or, you know, these outreach things, Kenya, Sudan, Uganda. But now what can I do is right in front of me, you know, like there's a lot of things right in front of me.

And that's where I'm trying to build these roots in this community that I'm in. And, you know, it's not an either or. It's just like we said, there's so much going on all the time. But that's what gives me hope is I can do what I can do, and I'm going to do what's in front of me, and I'm going to show up to those things. I'm going to say yes to this meeting. I'm going to say no to that other one. And someone asked me the other day, like, well, why can't you come at 630? Can you not come to this meeting?

Because it was a robotics meeting. Because there's steak being served there. And I was like, no, I love steak. I just can't come to the meeting. It's at 630, and it's not about social justice, and it's not with my kids. So I'm not going to be there. So that gives me hope, is we can do what we can do, define what you can do, and then do that. Do the heck out of that, you know? And then what you can't do, you can't do. I love that. I see you doing the things that really have value, that are really aligned with your values.

Yeah, for me. I love that for other people if they have something else going on, but find that thing that drives you. I hope it involves social justice because it's a really important time for that. Yeah. I also think it's not devoid of health care medical practice, right? It should be kind of enlisted as a course for all medical students and residents included. They're not excused, you know, to have because it's so part and parcel of the work that you do. I mean, you can't really ignore it. I mean, social justice has an impact on health care.

Can I talk a little bit? Yeah, can I also mention that exactly what you just hit the nail on the head is like, by not providing this education as part of medical training, we're actually under preparing our students and our residents in a lot of ways. And that's kind of a, you could look at it as a deliberate omission. to not stir the pot, right? I think at least from my experience of what happened here in Southern California was the health justice course was the battleground for the political stuff that was happening in academia over the last couple of years.

And it is a really tough, I think, course to teach depending on where your medical school is. I think in Northern California, you guys have a little bit more of an edge, a lot more depth of expertise there, knowledge, and also physicians who really are self-aware. But it was a real hard course to teach, I have to say. And we were kind of looked at as kind of the, oh, you know, Try not to stir the pot too much. It was actually seen as a bad thing that the medical students were leaving the course kind of really emotionally kind of riled up.

And we're like, well, of course you're going to get emotionally riled up if you look at these are just from reading papers, there was no editorializing. It was really from doing their homework that you really recognize a lot of this is pretty disturbing material when you first come upon it. I think having mentors and people who are working in this space and also know how to take care of themselves while working in the space and giving that as a role model example as you're doing is so important.

because it's really difficult when you first encounter these topics. And I also just kind of chat GBT kind of what things we can do as physicians and patients, and we'll post some of those items that we can in support or even, you know, speak to the professional organizations for physicians, patient advocacy and support organizations are out there. There's also health care reform and policy advocacy groups, and we'll post these in the show notes. So please use that list. and really voice your concerns.

This is about all of us, and it's about patients, and it's about everybody in between. I'd like to ask Farah. Farah, how would people be able to find you and connect with you and the organizations you work with? We are Healthcare Workers for Social Justice on Instagram. It's HCW and then the number four, and then SJ on Instagram. or care up in any MD on Instagram. I can also share my email address if anyone would like, especially if you're in the Central Valley. Any medical society that's your local one, ours is Fresno Madera Medical Society.

There's a board of directors, there's different committees like the outreach committee that goes to Sacramento for lobbying. And then there's a lot of different stuff too. So, and those will be doctors that you work with or like colleagues. So it's also building community and the same people kind of show up to the same things. Just like when I go to protests or go to like the homeless thing, it's the same group of people showing up to the same stuff. You know, it doesn't matter if the headline could be like whatever anti-racism or it could be Palestine, it could be anything.

It's the same people. And so, you know, these people are your people. Whether, you know, then make community with them. Whether physicians or not. Yeah, thank you. Thank you for being here and thank you for the work that you're doing. And, you know, the voice, your voice is powerful and your experience even speaks, you know, through that in such beautiful ways. And we really appreciate you being making time for us in this podcast. And we'll continue this conversation ongoing. Yeah, always. Thank you guys so much.

I appreciate it. Every time I get to talk to you guys, I learn something new.

Hope, action, and how to get involved 55:00

I learned something new from all of your podcasts as well. So thank you so much for all the work you do and just who you are and what you stand for. We are richer for all the work that you do. Thank you. It's lovely to be in this with you. Thank you. And we keep the curiosity alive. So I'm going to ask you one final question about what would be a curious question you would want for the next podcast. podcast. Curious question. Do I get to participate? I think what I would ask, I'm actually curious if you weren't physicians, what would you be?

Wow, that's a good one. I would probably be an activist and a fitness instructor. I'd love that. Oh, yeah. Because Let's be honest. I just went to Zumba class this morning and I realized I used to be a dancer, but now I can't seem to dance as well. But I would be a teacher and I'd be a teacher and I definitely would be. I'd love to teach. I'd try to paint and write. That would be my, I'd like to just continue to do creative works. That would be what I would love to do. I think I could just have a list of things that we do.

We do a lot of things. What about you, Soraya? Oh my gosh. There's this person I know who actually went on to have this life that's kind of like the fantasy life, which is just a gypsy. Her name is Bengali Gypsy. She just travels everywhere, does yoga and lives out in the outdoors. And I think a part of me recognizes that my biology is so, I've always lived in cities and all of that, but there's a part of me that's just like, yeah, like, you know, we live in the world. Like I want to live in a near body of water.

Um, I want to, you know, uh, learn specific skills, uh, whether that's farming or making baskets or, uh, you know, preparing food or something that's More grounded. I think I want to get in my body. So that's that's the fantasy one. But I think if I didn't do this, I would be a journalist. You know, that was always the curiosity of always telling the stories of people and the ways in which. evolves. But yeah, go live out in the world. And leave all of this behind. That's that's the little fantasy I tell myself.

Yeah, thank you. Thank you so much for a podcast. I think it would be cool to interview a woman physician, also a mother who has who has maintained some part of a clinical practice, but has also done something political, like has a political position as well, whether it's like local politics, or, I guess, on a national scale, probably not. But some somebody who has like, whether it's city council member or just something, and like what they what was their path to that how they balanced everything and how they've impacted the local politics around them and people's wellbeing through that role.

I just Googled what she did. I want out Annie Andrews. Can you get her on here? Yeah. Yup. There we go. So I said my search was physician mothers in politics. There you go. Okay. That's what you asked for. Dr. Akilah Webber, Donna Marie Christensen, Kim Schreier. There you go. Rupert Mario is a good one. Yeah, that would be a great one too. Thank you. That would be amazing. Thank you. Yes, we'll try to make that happen and that would be a wonderful conversation to have together. Yeah, stay tuned.

Thank you. Thank you for tuning into Doctor Talks. We hope today's episode has enlightened and inspired you on your path to optimal health. Each day is a new opportunity to make choices that empower your well-being. For more insights and strategies, subscribe to our podcast and visit our website, www.doctortalks.com. Stay connected, stay healthy, and join us next time on Doctor Talks. Real talks from real doctors on the issues that matter to you most.