As I embark upon a new pathway of exosome therapy, I have been reflecting upon what it means to be a doctor.
Once upon a time, there was a mystique around being a doctor fostered by our culture. It seemed noble, impactful, financially secure, and autonomous. Arguably, some of the brightest and ambitious youngsters dreamed of becoming doctors. The hoops they had to jump through were daunting: arduous study with high academic achievement, building a compelling resume, and then finding advocates for your candidacy…all that might earn you the right to another grueling four years of medical school followed by 2-10 years of residency and fellowship training. The low paying, low-prestige hazing of those med students, interns, and residents once contrasted with the high-paying, high prestige life of post-graduate life, but times have changed considerably.
Nowadays, the encroachment of bean counters who pay us and patients who view us a mere technicians has many doctors feeling a sense of lost autonomy and increased “burn out”. Here are but a few of slings and arrows we face: declining reimbursement, increased insurance denials, endless paperwork, decreased time, and the internet-educated and entitled patients. We went from Marcus Welby to Rodney Dangerfield, all in one generation.
If you don’t believe me, consider that in 2018, a survey found that 70% of doctors would not recommend their field to a family member. Most docs now recognize that patients’ and physician’s goals are in conflict with with the true decision makers: the corporations who run the hospitals, drug companies, and insurance schemes. This is evidenced by a survey in 2018 in which 61% of doctors now favored single-payer health care. The smart kids wanted to be doctors but they ended up working for the businessmen who only want to decrease the amount of money going towards paying for actual procedures, medications, and fees. Even worse, by any metric, we as a nation are getting ripped off. We pay the most and have high infant mortality and low life expectancy.
The previous paragraphs represent a relatively jaundiced view of being a doctor in contradistinction to the “good old days.” But let’s reverse it and celebrate what remains good and true of the calling: 1) provides a foundation for life-long learning, 2) can help grow insight, intellect, empathy, courage, and wisdom, and 3) allows you to help people who are generally appreciative and better for your efforts.
I once heard it said that after about thirteen years, most people achieve relative mastery in their career. That was true for me and my ability to diagnose, manage, and treat patients in my specialty and generally was about as good as it was going to get when I transitioned to writing and telomerase activation medicine.
Now that I am providing exosome therapy in addition to telomerase activation to patients, I have to revisit some foundational ideas around what it means to be a doctor. For those who haven’t wrestled with them, here are four key processes that work together for a successful physician-patient interaction:
- Omnidirectional communication
- Competence with probabilistic and contingent theories
- Understanding standard of care and when to deviate
- Managing expectations with informed consent
Omnidirectional communication. To me, this means understanding patient communication, medical findings, and tapping into your understanding of human physiology without getting bogged down in your patient’s bias or your own limited knowledge of a situation.
Competence with probabilistic and contingent theories. Any good doctor, as opposed to an artificial intelligence, shuns confirmation bias while paradoxically relying upon it as the primary tool of discernment. Instead of automatically assigning the meaning of symptoms, a good clinician parses out each remark and objective finding into multiple theories of how they relate and what they mean. This will generate a list of possible explanations called the “differential diagnosis” and we apply symptoms and signs to multiple concurrent conditions. As physicians, we also must assign a severity and probability assessment to working theories in order to “rule out” (i.e. make sure chest pain isn’t a heart attack despite the person having just eaten a ghost pepper chile). Thankfully, I believe if you give a decent clinician a few minutes and a reliable patient historian, they can diagnose and treat most people over the phone.
Understanding standard of care and when to deviate. It may surprise you but in the course of practicing medicine, deviations from “standard of care” are common. Although on the face of it, that implies they are unsanctioned, they can often become the de facto standard of care. That is because effective drugs may have only been tested in one condition but have other “off-label” uses according to clinical judgement. A good example would be epidural steroid injections for spinal vertebra and disk degeneration; the steroids do help many but weren’t approved for usage in this place and manner. Because off-label usage is common and relatively safe and effective, no one gets in trouble for this non-FDA approved standard of care.
From a business perspective, if a lot of people get hurt and sue, then the manufacturer may aggressively shut “off label” usage down. But if it appears to help patients and makes them money, they benefit and even promote the “off-label” standard of care that is not FDA approved. The patient-physician relationship, once considered as sacrosanct as the attorney-client one, remains a bulwark and “fig leaf” for drug companies, hospitals, families, and patients; but it all turns on the idea of informed content.
Managing expectations with informed consent.
This is by far the most crucial yet problematic aspect of practicing clinical medicine. I believe that truly informed consent is impossible but it is something towards which we nonetheless aspire. We hope that if we convey the risks, benefits, alternatives, and relative probabilities and sequelae, a person would make the same informed and consensual decision an artificial intelligence might. But the truth is that we all perceive risks differently and none of us have the benefit of hindsight. After a rare complication like a roller coaster accident, none of us would have chosen to go on despite a one in a million chance of death; but decisions about which rides to take and which medical therapies to choose always occur prospectively and without an option of the cosmic “do-over”.
Let’s return to the example of back sciatica and back pain. If I tell you there is a 100% chance of pain and down time from disc removal and fusion surgery with a 90% chance of pain reduction and a 10-20% chance of some recovery of motor function from chronic nerve compression damage, you might want it. But if you hear there is a 0.01% chance of dying from some unexpected complication and a 60% likelihood of recurrent back pain and a 90% change of decreased range of motion, you might avoid the surgery.
I always found that the most efficient question my patients asked when faced with a quandary was “what would you recommend if I were your mother?” That forces us to come off the fence and prioritize all the what if’s and likely scenarios.
This all brings us back to the question of exosome therapy for aging and illnesses. Since I began discussing this therapy in my blogs, I have had 55 people reach out to me saying they were interested but to date, I have yet to treat anyone but myself and mom. We have both received both IV, intranasal, and joint injections. Why? Because I am going to treat this like a real doctor, not a hot dog vendor or a robot.
A hot dog vendor puts onions, sauerkraut, relish, ketchup, and mustard on and charges you a fee. If you are allergic, that is your fault. If you don’t like the taste, it isn’t a big deal. Low stakes, low risks, and little need for clinical expertise there.
A robot with artificial intelligence might do a personality inventory for your level of risk aversion, suffering, potential benefits, and alternatives and give you a detailed rank ordered list of options, recommending your best course of action.
But I choose to treat this new endeavor like a real doctor. That is why ethically, I first tried it on myself and my mother based on my own risk/ benefit/ informed consent. Over a month has elapsed since I obtained the tools to treat patients, but I am still waiting to make sure it is safe. I have spoken to about half of those on the interest list but no one has been offered an appointment pending further observations.
I am waiting to find out three things:
- Are there any definite untoward effects? (possibly)
- Is therapy devoid of any noticeable effects? (no)
- Are there any benefits like those reported by doctors currently using the therapy? (probably)
If I were trying to sell hot dogs or create an algorithm, this would all be easy. But when I speak to a patient it takes me 8-30 minutes to ascertain their key medical problems, the provenance of how they became interested, what they can expect, and their level of understanding and risk within the context of a non-standard yet promising therapy.
To the uninitiated, it would seem like purchasing and administering exosomes involves little more than going to medical school, keeping a cold chain of custody, and putting a needle in the right place. I was asked by a lawyer about the wholesale cost of the therapy versus market rates of exosome treatment and I suppose the answer would be the same as why a wise person doesn’t use Legal Zoom and Law and Order sound bites to represent themselves in criminal and civil defense. You don’t pay the attorney for typing out a boiler plate motion; you pay them for the judgement and experience in knowing which strategies, forms, and communications apply and how to best use them.
All that being said, I have the suspicion that the therapeutic index (the range between what works and what could be dangerous) is favorable here. In other words, you probably could get a benefit from a little and take massive amounts without danger and do so without supervision. I say that based on theoretical and scientific understanding as well as the clinical experience I have garnered and heard about thus far.
My first hand experience tells me that there are powerful effects as you can read in this blog about me and my mom.
But I say this is not placebo because I can attest that you can expect something to happen and that something may be disconcerting when it involves pain or changes to sleep, appetite, thirst, and your circadian rhythm. And when those changes occur, you may feel mostly better, but it would be helpful to have someone to run your symptoms by. If reassurance is needed or medication needs to be adjusted, a doctor is “just what the doctor ordered” as the saying goes.
A medical doctor will understand that dizzyness, as in the case of my mother, might be occurring because of a low blood pressure on an established regimen that now needs to be tapered down. Since mom’s treatment six weeks ago, her blood pressure has dropped and she swears she looks younger. Since her treatment of her hands, the swelling and pain has decreased but also her foot doesn’t hurt any more even though we didn’t inject there. That is because the particles are smaller than viruses and go everywhere.
I was going to scrap the program when mom said she couldn’t smell but now that her sinus cold has resolved, her sense of smell has returned. My sense of smell was never affected so the working theory that olfactory nerve damage occurred is relatively deprecated, albeit not removed from the differential diagnosis given its severity. That is clinical medicine.
I distinctly remember one afternoon in the third year of medical school when one of my colleagues, Kelvin, memorably proclaimed during an early medicine rotation: “Man, we’re just gamblers in white coats!” I think the unsettling nature of incertitude was something he was wrestling with as a young clinician but I’m sure that if I were to ask him twenty-seven years later, mastery and wisdom would find that younger man’s epiphany quite banal.
Of course, my dear Kelvin. We’re not selling hot dogs and we’re not robots, here. We are quantum computers parsing out multiple possible meanings, outcomes, and desires in order to seamlessly integrate them into a prudent yet flexible plan that seeks to optimize our patients’ desires for improved health.
To be a good anti-aging doctor injecting exosomes, I have to spend some time with you. I have to understand all you medical conditions, where you think things are going, and what you hope to accomplish. Then I have to try to inform you about the unknown risks, possible clinical changes, and potential benefits. Afterwards, we have to anticipate changes, make adjustments, and measure and record outcomes.
By analogy, I could go and slaughter a farm animal, read a book on making sausages and order some meat preservatives. Then I could outsource some skins to put the hot dog meat into. I could then barter the hot dogs for some buns and I would be in the business of selling DIY (do-it-yourself) hotdogs. But when the first person sues me for food poisoning from my home made links, you can bet I won’t be choosing a DIY legal defense. Let’s face it, we all need professionals because if the communication is good and their ethics are aligned, then a professional steers us clear of the rocks where the Scylla of “unknown unknowns” and Charybdis of “things that we are sure of (but that are wrong)” lurk.
Because of concerns regarding Federal Trade Commission actions (which I have had an unpleasant run in with) and the fact that exosome therapy for anti-aging and disease mitigation is not FDA-approved, I need to deal with patients in the context of a physician-patient relationship. If you are interested in hearing the details of what happens to my patients, please email me at firstname.lastname@example.org to be put on a special email list that will NOT be shared with the larger audience.
With 55 patients already interested, I am not looking to advertise hot dogs or set up an “exosome mill” as it were. I am seeking patients with whom I can partner so I can work on their improved health while building more clinical experience. There is a reason they call it “practicing” and not “mastering” medicine. We just have to accept that freedom of choice in the context of professional management is the best we can do when it comes to something so new and potentially revolutionary as regenerative medicine.