Innovations in Healthcare Technology

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Welcome to MedEvidence, where we help you navigate the truth behind medical research with unbiased, evidence-proven facts hosted by cardiologist and top medical researcher, Dr. Michael Koren.

Hello, I'm Dr. Michael Koren and we have a unique episode of MedEvidence today. And I say it's unique because, as part of my job as podcast host, I get to meet a lot of people, and every once in a while I get to meet a kindred spirit, and when I find that kindred spirit, it's particularly fun for me and, hopefully, educationally rewarding for the rest of you. So that kindred spirit is Dr. Jonathan Baktari. And to start, Jonathan, I see that you have these beautiful books in the background.

If you notice, I have books in my background that actually got thrown out of my house because my wife didn't like it cluttering up my study. But here they are, and I feel like it reinforces what we both believe in, which is that evidence and data should support the decisions we make as physicians, and I can see that you're of a similar ilk, with lots of beautifully bound books in your background. I assume some of them are journals, some of them are probably books, and I'm really looking forward to this conversation where we can talk about what is evidence-based medicine and also how you, as a physician, took a journey to become a little bit different like me and not just practice medicine but do some other things that touch entrepreneurship and education, and also just spreading the word about how the basis for moving science and knowledge forward comes through evidence. So why don't you introduce yourself to our listeners and our viewers and let us know a little bit more about you?

Thanks, Michael. Yes, I'm a pretty much traditional physician. Straight arrow went from college to med, school, to residency, to fellowship, went to Northwestern Ohio State UCLA, did pulmonary critical care, internal medicine, then got into-.

Not shabby at all.

Yeah, I was an overachiever, I guess, for a while. And then, after doing clinical medicine, I was clinical faculty on a couple of medical schools and got to teach a lot and that was fun and then kept expanding my horizons and did more administrative medicine. I was medical director of hospitals and chairman head of different departments and that just sort of whetted my appetite to continue to do more and see if there was other things I could do in healthcare in addition to clinical.

So tell us a little bit how you became the CEO of a company. and tell us a little bit about your company and what your vision is for the company.

Yeah, we started E7 Health back in 2009. And I think what spurred it was really this idea that there was a lot of preventable deaths in the United States. The CDC claims that there's about 50,000 vaccine preventable deaths in adults in the United States annually. That's more than, or equal to the number of people that died in Vietnam annually and nobody was focusing on it. This is pre-COVID right, when adult vaccination wasn't a thought. But there's a lot of adult vaccines that are out there that are required. So we started that and we started basically a whole clinic that focused on advancing any areas of medicine that involved adult vaccinations whether it was travel medicine, student health, employee health and we really just focused on that at the exclusion of primary care, the exclusion of urgent care, and really drilled down and trained our staff and became subject matter experts. We were sort of like a COVID company before COVID hit, and then we wrote a lot of technology, our own software, our own platform because there was nothing out there that could handle that.

Was this patient funded? Were the patients funding this through consultation fees or government or private industry, or a combination thereof?

It was 100% private. So what we did is most of the services, believe it or not, a lot of the adult vaccinations, especially for travel medicine, student health and employee health, are not covered by insurance anyway, and so so it was yeah, it was all private. We reinvested any profits we made back into the business to really grow the technology and grow awareness and make an impact in people's lives. So we really became the subject matter authority on adult vaccinations, certainly in our region and maybe even nationally.

I think we're in Southern Nevada, so the West Coast and Southern Nevada, but I would think that even nationwide our experience with adult vaccinations. We carry every adult vaccine available in the United States and we handle pretty much any kind of clinical situation that involves adult vaccinations, whether it's for immigration, deployment meaning military deployment whether it's for even if you want to get an allied health job, you need a certain amount of vaccines, titers, tb, skin tests. We just basically did anything that adult vaccinations were involved in and from that we offshooted a couple of other companies called US Drug Test Centers and eNational Testing, but they all started from this premise of focusing on preventative health and wellness.

Nice, nice. So when you say you had reinvested in technology, is that educational platforms? Is that helping other doctors get involved like a franchise model? Give us a little bit more information about that.

Well, basically we didn't have any electronic health records that we could use, because most electronic health records off-the-shelf Epic and all these are involved in primary care, urgent care, so they didn't really deal with what we were doing. So we started off very slow, just did a little thing, but then eventually we wrote our own electronic health records, our own appointment software, our own patient care management. We basically got rid of all the paper. Everything's digital. We don't have a medical records department. Everything we do for a patient is on their portal. So we just decided to really heavily invest in the infrastructure for this sort of preventive health. Adult vaccination clinics.

Now do you see any patients outside of this company, or you've kind of moved on from that?

Well, we then grew like eNationalTesting, so eNationalTesting.com, which is a nationwide conglomerate of labs where we integrate with our software where patients can get a laboratory test in any city, in any state, a cholesterol test, a prostate test, Pretty much. We made getting laboratory testing kind of Amazon-esque. You know, three clicks and you're there. We thought that was between doctor visits or in addition to your doctor visits. Having easy access to laboratory testing, we thought would allow people to control more of their own health care.

So you and I were having a discussion before we got started about evidence-based care and we both share that passion, and I think people even some physicians, quite frankly don't completely understand what that means. So why don't you tell people what that means to you and have a little discussion about that?

Is it okay if I share with you an anecdote that happened to me in medical school that got me on this journey of evidence?

Yeah, I love that yeah.

Yeah, yeah. So I remember I was a junior in medical school, third year medical school, and we were on rounds I think it was an internal medicine rotation and there was a lot of us. There was like four or five medical students, four or five interns, three residents and there was an attending. It was a gray-haired older gentleman, didn't speak much, only spoke when he really had something to say. I remember we were arguing about something, something in medicine, and clearly the group of 15 to one of us broke into two camps. One camp felt this way and the other camp felt this way based on everything, and I don't remember the topic actually, but I do remember.

And so we were looking to him, to you know, like, as you know, moses or Solomon, to decide which group was right.

Right.

And he goes well, I'll tell you what. You know what. Why don't you guys go research it tonight, pull some articles, come back to me tomorrow and both sides like, give me your best shot. Okay. So of course you know, we're young, energetic. So we went and researched and we all came back and one group had all this evidence. And then this other group had all this evidence that they're right. And after all that we were sure he was going to say look, group A or group B is right, right. And he said listen, you want me to tell you what's going on here. I'll tell you what's going on. He goes. Let me ask you a question Do you know any doctor in the United States or in the world that doesn't believe in antibiotics? Like, have you ever met a doctor who says you know, I don't think it works, I don't believe in antibiotics.

Right.

Because why is it the worst doctor or the worst medical school still they all believe in antibiotics prescribes them? Yep, he goes. Do you know why? Because it works. Because when something works, we don't debate, right. Right, because basically what he was telling us is that there was no answer, because when you're, when you, when you have so much conflicting data, it means that there isn't. So that really taught me a lot, you know. It just said basically that the stuff that we question, whatever it's, just because we just don't have the answers yet, because we're pretty intelligent people, I to think, and if the data was there and simple, we'd all know it. I love it.

I like to say people that the purpose of medicine, the purpose of MedEvidence, is to help people understand what we know, what we don't know, and how we're going to figure out things that we're not sure of and you're bringing up. A great point of that is that there's certain things that we know for sure that antibiotics work, and there's certain things we don't know and we got to figure out through clinical trials and other means to determine what is not known now and make it known. So that's what evidence based medicine is in a nutshell. So I love that, but it can be confusing for people. We we filed a US patent that was granted probably about 10 years ago, a little more, actually called Ask 100 Doctors and we would give a group of physicians sometimes hundreds of doctors a scenario and ask them to vote how they would deal with a particular issue or question, and sometimes it was very clear cut, like the antibiotics yes, this person needs antibiotics. Or sometimes it was a 50-50, or sometimes it sometimes it was 70 30 and that would freak patients out.

You know, we thought that this was a great way to show patients that there's certain things that we feel strongly about. There's certain things that are controversial and get a sense for strength of consensus was. But a lot of patients said, well, isn't there a right answer for things? And that's really a difficult challenge for people is that there are many things that there isn't a right answer. There's a sense, there's maybe a consensus, but there may not be exactly the right answer and that's some of the critical challenges of that evidence. So I know if that's something that you deal with.

I imagine you have to because there's certain vaccines, for example that are, without a question, just life-saving, and there's others that are a bit more controversial.

Yeah. So I have a kind of a different thought on that, which is if something is not for sure known or there's some room for gray area, there may be other factors that people don't understand. So if you make it a simple question and send it out to a hundred doctors, you may get 50% answer. But there may be the art of medicine or the extenuating circumstances that does make it clearly one way or another. I'll give you a great example.

When I was practicing pulmonary medicine, somebody would come in with a one centimeter nodule and the textbook says you have two choices you either biopsy it Okay or actually three choices. You either biopsy it or you watch it with serial x-rays and CAT scans, or you just send them to surgery and just take it out, not even biopsy it. And the reason for that is if you biopsy it and you didn't hit the exact tissue, you may get a false negative. So biopsy it doesn't really help you. If it's cancer, you're going to take it out, if it's negative, you're not going to believe it. So which way do you go?

A lot of times that really depended on my patient. If, for example, I know that they're the kind of person that if I decide to do watchful waiting and get serial x-rays. It would drive them nuts or bananas. Okay, okay. So you know, or if they're the kind of person that you know, they, they, they can't, they, they, they can't be going to the hospital having major surgery or whatever. A lot of times that's where the art of medicine comes in. So I wonder, you know, when, when these questions are asked, a lot of it has to do with where the patient is, how many, you know? Do they smoke one pack a day or five packs a day?

There are a lot of judgment elements to it.

No doubt it's interesting, you bring that up because, as part of our patent, we actually had a process where there was a medical editor that was responsible for putting all those things into context for the people that answered the surveys.

And the surveys allowed both an answer to a multiple choice question as well as qualitative information which people found to be very, very useful, and some of the learning from that is deployed in our current MedEvidence platform that there's certain things, as you're beautifully pointing out, that are clear cut. There are other things that are very controversial, and even within controversial areas we can usually find a little subsection that we'll agree on, and I think that's where dialogue amongst knowledgeable people is great and when people can eavesdrop on that dialogue, they become much more educated, informed and feel empowered. Jonathan and I are kindred spirits. We're both medical entrepreneurs but most importantly, we have a passion for medical evidence, and Jonathan and I were going through some really interesting anecdotes and discussions about that.

But I want Jonathan to focus on something that he did recently that fascinates me and I want to learn more about it, which is that he studied the concept of DNR, or do not resuscitate. That's something we use in clinical medicine all the time to allow the nursing staff and others to know that we don't need to bring the big machines in and give people a bunch of drugs when they lose their heart rate or stop breathing. But Jonathan has a very interesting perspective on this, based on his review of the evidence. So, Jonathan, why don't you let our audience know what you've learned and tell us a little bit about the Forbes publication?

Oh, thank you. Well, as you know, I was a critical care doctor. I practice critical care medicine, so this concept of making people DNR is something that is part of what we do in the right circumstances, and everyone in the ICU who deals with patients who have terminal illnesses and who are not going to survive, use that tool to alleviate suffering and making sure patients don't go through unnecessary stuff if it's not going to change the outcome. But what fascinated me is what people who are doing it realize all along that anecdotally, that if you're made DNR, that all of a sudden you stop getting less care. That's not even related to your heart stopping, and so what we did is I reviewed all the recent literature in really clinical journals, really high level journals, and they all basically said the same thing.

Whether they looked at it from a nursing perspective, a resident perspective, the attending consultants what they found is when someone was made DNR, they were more likely to die sooner or not get necessary surgery or not get necessary treatment, often because a lot of the nursing staff doctors, residents equated DNR with do not give care. I, I think it was very common for like consultants who had lists of 10 patients to see that day. You know, as soon as they were told one of them was made DNR, they would like take him off the list to see that day because and that's we all know, that's so, oh, you know as a cardiologist. Oh well, that he's DNR. Let me uh. So I'm good, I'll see him once a week now, right?

Right.

And that was such a and the question was did that actually impact care? Were they dying of other stuff that had nothing to do with their cancer? You know, were they dying of uncontrolled AFib?

Yeah, it's a great point. It's a great point Because more and more hospitals are focused on knowing what the family and the patient's wishes are. In case your heart stops, you stop breathing, but that does not necessarily mean that we stop giving care. In fact, a lot of these discussions were specific about the fact that we will continue a care as usual, because DNR does not mean no care and we have hospice, we have other mechanisms for reducing the intensity of care, but DNR is not that mechanism. So that's a really interesting point. So tell me, give me an example of the kind of articles you reviewed and the data that were in those articles.

Yeah, yeah, if you go to BaktariMD.com, my article is also published in a blog, but also you can get it on forums. But basically different articles looked at, like the nursing perspective, where the nurses what was the attitude of the nurses? Did they see the patient less frequently? And also look at mortality data even after surgery how often they were offered surgery, how often they were offered intervention, but at the end of the day it always impacted mortality. And then the article all 10, 15 articles are listed, so if someone wants to peruse through them. But it wasn't just the nurses, it wasn't just residents, it was everybody who basically backed off and often led to higher mortality. They didn't survive procedures as well.

At every point the data was clear. If you review the data, it's not even a point of controversy, it is what it is. There is no way someone could look at the body of all those articles and there was more, by the way, I stopped after 10-15. I don't think anyone has ever put all those 15, 20 articles together because they're there and there was no article that said the opposite. So, since his impact look if we had a blood pressure medicine that accelerated the death of 2% of the people that took it. The blood pressure medicine would be taken off the market, even if it helped 98% of people. The point is, yes, of course lots of people benefit from DNR because it does prevent pain and suffering in that subset. But if simultaneously it's accelerating the death of another subset, normally, traditionally, we don't put up with that. We don't say, oh, it's benefiting this group, so we'll let this other group bear the consequences.

Interesting, yeah, yeah. So I love that. You know great, great analysis and you know that's helpful information for people that may be contemplating, and you bring up an interesting group of people. You know there's some people that hey, they say, hey, doc, I want you to do everything you can for me, but if it doesn't work out, don't, don't flog me. And the problem is that those two concepts may not be completely independent of each other and that gets very, very tricky. So interesting stuff. So let me pick your brain a little bit more. Obviously, you're very involved in the vaccine space. We have a lot of people that have concerns about the COVID vaccine, have concerns about the COVID vaccine. As you know, I personally have been very involved in development of the COVID vaccine, working with Moderna, Pfizer and Novavax on their products, and so what do you tell people as an educator about? Whether or not they should take the booster or whether or not they should be worried. At this point, I'm curious to see the type of advice you'd give people in general.

Yeah, well, it's interesting because the most common thing I hear about the COVID vaccine whether it was during the pandemic or even now is it hasn't been studied enough, it's been rushed. But I'm going to make the opposite argument. The way I look at it is the COVID pandemic. We gave that vaccine, the Moderna vaccine and the Pfizer vaccine to 200 million people. Okay, maybe we could argue it was rushed, but at the end of the day, 200 million people plus got it, and so that would make it the world's largest clinical trial ever. I mean. So when I still hear it hasn't been studied, I don't think any vaccine has ever come out where 200 million people have got it and we got to sit back and watch. You know the side effects, the efficacy, so yeah, I know the efficacy is. You know not exactly what people thought at the beginning, but the point is it's probably one of the most studied vaccines now compared to anything, not in terms of years but in the sheer volume of people that got it.

So the argument that hasn't been studied or hasn't been rushed is, I'm not sure holds water anymore. We have a large clinical trial, which was the pandemic, and I think so we have a good sense of. Yes, there are risks and we also know what the benefits are. But if you ask me for my medical opinion on balance, which is what we do in medicine the benefits outweigh the risks. But we would say the same thing about giving someone Tylenol or Motrin or anything we do. There's no such thing as no risk, even if you get knee surgery. You know the orthopedic surgeons say, ah, we're going to do this knee surgery, there's no risk. And so I think we're holding the COVID vaccine to a higher standard than we're giving knee surgery, because nobody says to their doctor unless you can guarantee me no side effects, I don't want this knee surgery.

Right, right, yeah.

So COVID is interesting in that there's also a very strong epidemiological trend that older people or people with pre-existing conditions suffer disproportionately from the consequences of COVID, and that, for example, is very different than what happened in 1918 with the Spanish flu epidemic, where younger, healthy people seem to do worse.

So I think we have to also think about that. What I like to tell people is you have to look at your individual circumstances and have a plan based on who you are individually. So if you're a 20-year-old with absolutely no health issues, well, chances are it really doesn't matter if you take the vaccine or not. And actually the data show us that the 20-year-olds tend to have more side effects of the vaccine, probably because it elicits a more robust immune response, which is what caused the side effects, whereas your average 60-year-old usually tolerates the vaccine without any issues and they get the most out of it. So you made this point earlier, which is that you have to know the patient. There's no one rule that applies for every medical intervention for every patient. It's got to be customized, and that's why physicians aren't going away anytime soon. They still need to understand.

But we do that anyway. Like, take the shingles vaccine, right? I know plenty of patients who had shingles in their 30s. Okay, plenty. But we don't give it to 30-year-olds because the cost-benefit analysis the benefit versus the risk which there are risk doesn't make sense. We'll let them get the shingles, but we're not going to give them the vaccine. So I don't think COVID is any different than any of those other things. Just like you're saying, the 25-year-old may not need the COVID vaccine, but a 65-year-old with diabetes, high blood pressure, would.

But we've been doing that with vaccines all along, whether it's the pneumococcal vaccine, the shingles vaccine, we have age limits and those cutoff for age limits is like what you're saying. It doesn't mean it wouldn't work below that age, it just means that the cost-benefit analysis in terms of what benefit you get versus potential side effects is not worth it. So the pneumonia vaccine, the shingles vaccine, you know where we have cutoffs. Even the you know Gardasil vaccine. You know there's cutoffs for when it's going to be beneficial or not, because we're always doing cost-benefit analysis of whether the benefit you're going to get from this vaccine is worth sometimes the economic costs as well as the side effects. Right, we could vaccinate every 25-year-old for pneumococcal pneumonia, and there are 25-year-olds that get pneumococcal pneumonia and so we would be helping them. But we'd also be vaccinating a lot of 25-year-olds that didn't need it and would potentially get side effects, theoretically. So we do that. So COVID is not any different than any other vaccine where we analyze the cost-benefit analysis.

Yeah, just for the audience. Gardasil is for cervical cancer, to prevent cervical cancer.

Yeah, HPV.

And it's recommended now for, I guess, pre-adolescent girls, and that was controversial about 10 years ago. Is it still an issue issue or is it pretty much accepted at this point?

No, but I mean, I think that works the other way now. Now I have like 30, 40 year olds wanting the Gardasil vaccine and before the cutoff was, you know, after you got a certain age we're not going to give it to you because we assume you've already had HPV and it's not going to benefit you. But there are people who were like in a monogamous marriage and had only one partner all their lives, or you know, and now they want the Gardasil vaccine at 40. And you know, do we give it to them? And of course we would give it to them anyway. But these cutoffs are meant to do cost benefit analysis of whether it will help you or not. So I think the COVID vaccine is just like the rest. We make a cost-benefit analysis, and by cost I don't mean necessarily financial.

I understand. So are there any vaccines out there that you're particularly excited about? Again, I think the take-home message is that we both think that the right vaccines are really, really important. They save lives. They eradicate diseases, like in smallpox. I just heard that they're trying to put forward a worldwide effort to eradicate poliovirus another potentially exciting win for vaccine therapy. But tell me about anything on the horizon that you're particularly interested or excited about.

Well, I mean malaria if we could come up with a malaria vaccine. We currently don't have a good malaria vaccine. Millions of people die of malaria. But what I'm really excited about is the promise of mRNA technology in terms of cancer and other modalities. One of the things I like to say is you know, millions of people died because of COVID. But if there was a silver lining, if it turns out that mRNA technology, you know, in the next 10, 20 years saves millions and hundreds of millions of lives from cancer and other infectious disease, that could be the silver lining. You know, obviously, losing all those people is horrible. Be the silver lining. but that really forced mRNA technology to come off the shelf, which I think it would have stayed on the shelf. There was such a social stigma to having this gene injected into you. What have you. So I think that pandemic caused that technology to come to the forefront.

Now we have to see if the promise holds true, if that mRNA technology can do other things that we're hoping. And just to clarify for the audience mRNA technology is not genes, but it's the material that translate genes. So it doesn't get into your nucleus, it doesn't get into your DNA, it just helps your body produce the right protein. So it is different.

Yeah, I mean, mRNA is technically a gene, but my point, though, is people give it that stigma whether it just creates proteins, we know that, but I think for years it probably was sitting on the shelf because it had a potential stigma, right or wrong, and that stigma, hopefully, is gone.

It's genetic material, but it's not a gene. These are little segments of genetic material that are definitely not genes

100% Genes are a huge problem.

That just freaks people out.

I got it.

So, yes, on our ends, we're doing some work on an acne vaccine right now, which is not something you would necessarily think of, but it's a. It's a problem that disfigures a lot of people, that creates a lot of anxiety and angst, and it's often based on bacteria that can be treated through a vaccine mechanism, and so vaccine technology may have a lot of different ways of presenting itself over the course of the next decade. That will solve a lot of problems for a lot of people, and it's exciting to be running these clinical trials from my end to see where that goes.

How exciting.

Yeah, it's cool stuff. Jonathan, you've been a delightful guest. I've learned a lot. Thank you for the education. I think everybody has your website information, Baktarimd.com, and I'll be following you, so hopefully we'll get other people to follow you. And again, thanks for the information and, on behalf of MedEvidence, thank you for sharing this wonderful insight, not only as a doctor entrepreneur, but as obviously somebody who's very concerned about public health. So thank you.

Thanks for having me, Michael, it's a big honor.

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