Episode SummaryThis week, Drs. DiGiorgio and Koka are joined by returning guest Dr. Sanat Dixit and special guest Dr. Sanjay Dhall, chief of neurosurgery at Harbor-UCLA and a leading spinal cord injury researcher. Dr. Dhall traces his path from a "commando shift" in a Houston trauma bay as a pre-med student to running solo trauma call at Grady Hospital as a young attending, then discusses the strange reality of his current institution: a major county hospital that doesn't bill professional fees or for implants, leaving millions on the table. The conversation moves through hospital alignment under for-profit versus non-profit models, the Christopher Duntsch case and what it reveals about resident training and the GME system, Dr. Dhall's controversial Wall Street Journal letter on NIH indirect costs, and a guideline fight over early surgery for spinal cord injury that got him removed from a neurosurgery executive committee. The episode closes with a wide-ranging discussion on AI and robotics in surgery — what they might realistically take off physicians' plates, and what they almost certainly can't replace.Chapter Markers00:00 Welcome and introducing Dr. Sanjay Dhall01:49 From a Houston "commando shift" to a trauma bug05:10 Running Grady's trauma service solo as the only neurosurgeon09:25 The unsupervised resident era and its billing aftershocks14:03 Harbor-UCLA doesn't bill for neurosurgery profies — or implants19:44 How county hospitals account for six-figure implant write-offs24:30 Fiduciary duty, taxpayers, and the case for billing aggressively28:00 Drug rep economics at county hospitals31:10 Comparing Cleveland Clinic, Mayo, and the county model34:29 The "color-coded sticker" idea and the bureaucratic mindset37:59 For-profit alignment vs. "non-profits functioning as for-profits"43:24 The Devi Shetty suture story and physician-driven cost control44:13 Physician ownership, conflicts of interest, and carve-out hospitals46:00 Jefferson's neuro hospital and the private anesthesia advantage48:45 The Christopher Duntsch case and a failure of training oversight52:10 How does an incompetent surgeon make it through residency?56:04 Troubled personalities in neurosurgery training1:00:04 Work-hour restrictions and the self-selection of old-school neurosurgery1:02:29 Is dissent tolerated in academic medicine anymore?1:06:31 Inside NIH indirect costs — where 40-60% of grant money goes1:10:19 The spinal cord injury guideline fight and getting removed from committee1:13:44 Burnout, call coverage, and the safety net argument1:20:27 Will robots ever do neurosurgery?1:23:11 AI for administrative burden vs. AI in the OR1:28:34 The pilot analogy, a ruptured aneurysm story, and the limits of automationCo-Host Handles@anish_koka and @drdigiorgioShow Handle@drsloungepodSubscribe LinksSpotify: https://open.spotify.com/show/44vw8eirsKKnjgNIrdDvrRApple Podcasts: https://podcasts.apple.com/us/podcast/the-doctors-lounge/id1832097658YouTube: https://www.youtube.com/@TheDoctorsLoungePod

Episode SummaryDr. Tracy Høeg — physician, epidemiologist, and former Acting Director of the FDA's Center for Drug Evaluation and Research — joins Drs. Koka and DiGiorgio for her first interview since being fired from the agency in May 2025. She traces her unusual path from ophthalmology dropout to professional ultramarathoner to one of the most consequential and contested researchers of the COVID era, walking through her school transmission studies, the myocarditis preprint that detonated on social media, and what she actually found when she got inside the FDA: career scientists who were sharp, collegial, and largely aligned with her — not the entrenched bureaucratic resistance she expected. She also gives the most detailed account yet of how her firing went down, why she refused to resign, and what she thinks it signals about pharmaceutical industry influence over the agency.Chapter Markers00:00 Introduction and Tracy's bio02:19 Origin story: French major, med school, ophthalmology dropout07:42 Seven years in Denmark: PhD, clinical work, ultra marathon racing10:55 Back to the US: PM&R, interventional spine, and the start of COVID research13:43 Funding research outside the NIH pipeline17:18 How government funding crowds out independent science20:59 Evidence-based medicine, spine, and the N-of-one problem25:35 The Wisconsin school transmission study28:32 If masks were a drug, would they pass FDA approval?30:04 Testifying before Congress three times32:46 The myocarditis preprint: origins, backlash, and vindication38:34 Post-vaccine myocarditis: what the data actually showed43:01 Regulatory failure, COVID vaccine risk-benefit, and the pediatric question45:09 How Europe and Scandinavia got it right earlier47:58 Cancel culture in academia and the chilling effect on scientific questions51:18 Joining the FDA: how it happened and what she expected53:50 What the FDA looks like from the inside vs. the outside56:38 Where real philosophical disagreements lived within the agency58:58 Reducing animal testing and CNPV pilot: what actually got done1:01:45 Leaks to the media: where they came from and what they meant1:05:17 What the FDA's role should be1:06:23 Pharmaceutical industry influence and the Wall Street Journal editorial board1:14:48 The firing: why she refused to resign1:18:53 The chain of command and who is responsible1:21:08 What the firing signals about FDA reform1:27:42 Advice for anyone thinking about taking a leadership role in governmentCo-Host Handles@anish_koka and @drdigiorgioShow Handle@drsloungepodResource link: Anish's substack: https://open.substack.com/pub/anishkokamd/p/they-were-fixing-the-fda-then-they?r=6chj5&utm_campaign=post-expanded-share&utm_medium=webSubscribe LinksSpotify: https://open.spotify.com/show/44vw8eirsKKnjgNIrdDvrRApple Podcasts: https://podcasts.apple.com/us/podcast/the-doctors-lounge/id1832097658YouTube: https://www.youtube.com/@TheDoctorsLoungePod

Episode SummaryDr. Noah Kaufman - board-certified emergency physician with 20 years in the ER, seven seasons on American Ninja Warrior, and a new direct acute care practice in Denver - joins Drs. Koka and DiGiorgio to talk about why he walked away from the employed medicine model and built Cough Care, a cash-pay, fully transparent urgent care. The conversation covers the broken economics of emergency billing, why most urgent care is a race to the bottom, how price signals change both patient and physician behavior, and what a parallel direct care system could look like at scale -including the franchise model Kaufman is already planning.Chapter Markers00:00 Introduction — Meet Dr. Noah Kaufman02:12 What led to leaving the ER after 20 years04:53 Becoming the patient — the moment everything clicked09:33 What is Cough Care and where it sits between urgent care and the ER13:54 Why he doesn't take insurance16:30 How ER billing actually works — the 2.6 cm laceration rule19:49 Can urgent care be shopped? The free market argument21:17 One month in — what he's actually seeing41:00 Does cost-consciousness lead to undertreating?43:39 The culture of over-treatment and the evidence behind it45:48 Longevity, peptides, and the gray market54:25 Patient autonomy vs. clinical responsibility1:01:36 What happens if every burned-out ER doc does this?1:07:33 The franchise vision — scaling direct acute care nationwideCo-Host Handles@anish_koka and @drdigiorgioShow Handle@drsloungepodSubscribe LinksSpotify: https://open.spotify.com/show/44vw8eirsKKnjgNIrdDvrRApple Podcasts: https://podcasts.apple.com/us/podcast/the-doctors-lounge/id1832097658YouTube: https://www.youtube.com/@TheDoctorsLoungePod

Episode SummaryDr. Greg Katz, preventive cardiologist at NYU Langone and co-host of Beyond Journal Club, joins Anish to dissect the online cholesterol debate — specifically the claims made by science communicator Nick Norwitz, who has maintained an LDL over 500 mg/dL on a low-carb diet for seven years with no coronary plaque on CTA. Katz takes the data point seriously, walks through the limitations of coronary CTA and the flawed Keto CTA study, and explains why he still believes the burden of proof lies with those arguing diet-induced hypercholesterolemia is safe — while acknowledging where the cardiology establishment, including the new lipid guidelines, overcorrects. The conversation covers the accountability gap between clinicians and content creators, the failure of risk calculators in young patients, and what a well-designed trial to actually answer this question would look like.Chapter Markers00:00 Introduction — Dr. Greg Katz, NYU Langone cardiologist and Beyond Journal Club co-host01:40 What prompted the Substack: patients bringing in Nick Norwitz's content02:51 Who is Nick Norwitz — LDL of 500, low-carb diet, and the clean CTA05:38 Why Katz takes the question seriously but disagrees with the framing08:01 Familial hypercholesterolemia outliers: why some FH patients never have events10:05 The 50/50 problem — half of high-cholesterol patients have heart disease, half don't12:27 The Jody Plute story: homozygous FH, Thomas Starzl, and the portacaval shunt experiments17:37 Seven years of LDL 500 — is that long enough to know anything?18:21 Limitations of coronary CTA: what it can and can't see21:00 Why LDL gets put on a pedestal — and the cognitive dissonance of a diet that works22:05 The conflict of interest argument — and why it cuts both ways25:43 Burden of proof: mechanisms vs. outcomes data27:16 Statins and GLP-1 levels — why a mechanistic claim isn't the same as a clinical outcome31:38 Physician accountability vs. content creator accountability35:24 The Keto CTA study: what it found, what it didn't, and why the blinding controversy matters44:40 The new lipid guidelines: where they overcomplicate, where they overprescribe49:38 GLP-1 deficiency framing and the over-medicalization of well people55:54 Longevity medicine as "over-medicalization of well people"57:35 What a well-designed trial would actually look like1:00:01 Why the debate needs real research, not conjecture1:02:37 How Katz talks to statin-hesitant patients in clinic1:07:06 WrapCo-Host Handles@anish_koka and @drdigiorgioShow Handle@drsloungepodSubscribe LinksSpotify: https://open.spotify.com/show/44vw8eirsKKnjgNIrdDvrRApple Podcasts: https://podcasts.apple.com/us/podcast/the-doctors-lounge/id1832097658YouTube: https://www.youtube.com/@TheDoctorsLoungePod

Episode SummaryDr. Anil Makam — hospitalist, health services researcher at UCSF, and faculty at Zuckerberg San Francisco General — joins Drs. Koka and DiGiorgio for a wide-ranging conversation on the hidden mechanics of American healthcare. Makam breaks down long-term acute care hospitals (LTACHs): what they're for, how regional variation and perverse payment incentives have distorted their use, and what the 2016 site-neutral payment reforms actually did to the market. The conversation then shifts to Makam's research on clinical practice guidelines — specifically his 2018 study showing that the majority of ATS recommendations were grounded in low-quality evidence, many carrying strong designations anyway — and what that means for how clinicians should read and apply guidelines at the bedside. The episode closes on the FDA, indication creep, the limits of central planning in quality measurement, and what it actually means to be a good doctor in a system where you can't buy your way to better medicine.Chapter Markers00:00 Introduction — Dr. Anil Makam, UCSF hospitalist and health services researcher02:09 What is an LTACH? Origins, optimal use cases, and the vent-weaning niche08:09 How clinical practice led Makam to study LTACH utilization10:08 Geographic variation in LTACH use — decomposing what drives it14:16 Post-acute care economics: DRGs, payment systems, and perverse incentives19:11 Medicare Advantage denial rates and the two-tier access problem23:06 Market access vs. total closures: what the 100 LTACH closures actually mean24:04 Short-stay outlier rules and the "magical recovery" at the payment threshold26:07 Site-neutral payment reform and its effects on the LTACH market31:51 Moving to guidelines: evidence vs. recommendations33:38 The ATS guidelines study — what they found and the Twitter fallout39:34 How to practice when most of what we do lacks strong evidence43:38 Why guidelines are getting more confident on less evidence47:10 The generalist vs. specialist lens on evidence appraisal53:47 How do you measure what makes a doctor good?56:41 Three buckets of physician quality: technical, relational, cognitive01:00:06 Running a trial vs. appraising a trial — two different skills01:05:16 Indication creep and applying trial evidence to the wrong patients01:09:24 The FDA, Vinay Prasad, Marty McCary, and why reform failed01:13:45 Wrap-up and where to find MakamCo-Host Handles@anish_koka and @drdigiorgioShow Handle@drsloungepodSubscribe LinksSpotify: https://open.spotify.com/show/44vw8eirsKKnjgNIrdDvrRApple Podcasts: https://podcasts.apple.com/us/podcast/the-doctors-lounge/id1832097658YouTube: https://www.youtube.com/@TheDoctorsLoungePod

Episode SummaryAnish sits down with Adu, a med student and biotech investor, to work through the FDA's contested handling of Unicure's AMT-130 — a gene therapy for Huntington's disease delivered via stereotactic brain injection. They debate whether the underlying data justifies approval, why the agency's mid-course reversal has rattled the investor community, and what the Sarepta precedent should have taught everyone involved. The conversation broadens into a bigger question: given that desperate patient populations will always demand access to anything showing a signal, who is actually best positioned to make the call on whether a drug works — the FDA, the clinician, or the market?Chapter Markers00:00 FDA approval of AMT-130 and investor reaction01:16 Unmet need and the case for regulatory flexibility02:37 Sarepta, Duchenne's, and the cost of approving under pressure05:09 Accelerated approval done right: the Amylyx example09:14 Debating the AMT-130 data and the historical control problem13:53 Why stock price matters for trial funding17:20 How Prasad could have changed FDA culture differently19:37 The FDA's role from Kefauver-Harris to today22:26 Competing Huntington's therapies in the pipeline25:39 Prasad's tenure: what worked, what didn't28:27 Media coverage of the FDA and science journalismCo-Host Handles@anish_koka and @drdigiorgioShow Handle@drsloungepod

Episode SummaryPediatric nephrologist, medical educator, and "Sheriff of Sodium" Dr. Bryan Carmody joins Drs. Koka and DiGiorgio to challenge some of the most persistent narratives in American medicine. From the AAMC's physician shortage projections — which Carmody argues serve the interests of medical schools more than patients — to the mechanics of the residency match, application fever, ERAS pricing, and the largely unrealized promise of pass/fail Step 1, Carmody brings his characteristic data-driven skepticism to each topic. The conversation closes on what's arguably the most consequential question: what should residency selection actually be optimizing for, and why are program directors squandering the leverage they have to drive real change in undergraduate medical education?Chapter Markers00:00 Introduction02:02 How Carmody became the Sheriff of Sodium05:03 Why people keep getting medical education wrong07:46 The physician shortage: skepticism and incentives09:03 Rebutting the AAMC's 86,000-doctor shortfall projection11:17 Supply-induced demand and the limits of training more physicians17:06 Third-party payment, discretionary care, and the real drivers of access problems20:27 Who benefits from the physician shortage narrative26:36 GME funding: $45 billion, hospital incentives, and the case for or against it30:01 The Match explained: history, origins, and why it exists35:22 ERAS, NRMP, and the financial architecture of residency applications40:21 Preference signaling: what it is and why it's quietly capping application volume44:12 Is the Match a monopoly? The congressional report and the anti-competitive argument51:18 Step 1 pass/fail: the promise, the timing, and why it stalled55:43 What actually changed — and what didn't — after 202258:00 What program directors should be demanding — and aren't01:08:12 What we're not doing well in resident selection01:11:59 Using selection systems to elevate the quality of every applicant, win or lose01:18:45 The neurosurgery combineCo-Host Handles@anish_koka and @drdigiorgioShow Handle@drsloungepodSubscribe LinksSpotify: https://open.spotify.com/show/44vw8eirsKKnjgNIrdDvrRApple Podcasts: https://podcasts.apple.com/us/podcast/the-doctors-lounge/id1832097658YouTube: https://www.youtube.com/@TheDoctorsLoungePod

Episode SummaryJared Rhoads, founder of the Center for Modern Health and senior lecturer in health policy at the Dartmouth Institute, joins Drs. Koka and DiGiorgio for a wide-ranging conversation on the philosophical foundations of healthcare policy. Rhoads — an Objectivist in the tradition of Ayn Rand — argues that physicians have a right to pursue health, not a right to be given it, and walks through what that distinction means for real policy debates: FDA drug approval, prior authorization, the ban on physician-owned hospitals, private equity in medicine, and foreign-trained physician licensure. The episode is a rare attempt to make the moral case for free markets in medicine, not just the efficiency case.Chapter Markers00:00 Introduction and guest background01:52 What is the Center for Modern Health?04:25 Objectivism, Ayn Rand, and rational self-interest11:19 Healthcare as a private good vs. community good13:58 Policy mistakes made for edge cases16:58 You have a right to pursue health — not to be given it20:14 Does Medicare violate rights?22:47 Positive vs. negative rights in healthcare24:47 The FDA, drug approval, and the Prasad/McCary departures31:08 A two-tier FDA review proposal: private vs. public payers42:25 Breaking up Big Medicine — the Hawley-Warren bill49:43 Prior authorization: structural problem or reform target?55:22 High-deductible plans and why price consciousness hasn't taken hold57:43 Price transparency laws: do they actually work?01:02:49 Section 6001 and the de facto ban on physician-owned hospitals01:06:04 Stark Law, Medicare Advantage, and a possible reform path01:11:19 Private equity in medicine: where are the actual rights violations?01:19:02 Free markets and monopolies: the standard objection answered01:21:12 Foreign-trained physician licensure01:34:11 Immigration, physician workforce, and the battle of ideas01:37:40 Center for Modern Health summer fellowshipCo-Host Handles@anish_koka and @drdigiorgioShow Handle@drsloungepodSubscribe LinksSpotify: https://open.spotify.com/show/44vw8eirsKKnjgNIrdDvrRApple Podcasts: https://podcasts.apple.com/us/podcast/the-doctors-lounge/id1832097658YouTube: https://www.youtube.com/@TheDoctorsLoungePod

Episode SummaryDr. George Tolis, section chief of coronary and general cardiac surgery at Brigham and Women's Hospital, joins Drs. Koka and DiGiorgio for a wide-ranging conversation on the state of cardiac surgery. He makes the case that TAVR — while genuinely transformative for the right patient — is being systematically applied too broadly, driven by industry incentive and the erosion of meaningful surgical consent. He discusses his collaboration with John Ioannidis that found no statistically significant mortality benefit for any new cardiac surgery technique introduced over the past 35 years, the paper's rejection by every major surgical journal, and what he paid out of pocket to make it open access. The conversation moves to the collapse of surgical training — fragmented pathways, work hour restrictions that leave residents unprepared for attending life, an academic promotion system that ignores teaching, and a culture that routes incompetent trainees around rather than out — and closes with a brief on Vasily Kolesov, the Soviet surgeon from Leningrad who performed the world's first documented coronary bypass years before Favaloro, and whose work was buried by the Cold War.Chapter Markers00:00 Introduction01:02 Air-cooled VWs, concert piano, and how Dr. Tolis got here02:40 TAVR: genuine breakthrough or being abused?08:02 Finding the TAVR threshold — and why informed consent is the real problem11:46 Collaborating with John Ioannidis: no mortality benefit for 35 years of new techniques20:02 Why the major surgical journals wouldn't touch the paper21:52 Minimally invasive surgery: minimal access vs. minimally invasive26:24 When do CABG survival curves diverge — and what does it mean?30:05 Surgeons signing off on TAVRs in young patients33:51 Health system economics and the heart team dynamic37:50 How to actually pick a good surgeon (ask the scrub nurses)40:36 Cardiac surgery training: the three pathways problem44:04 Work hour restrictions and the residency simulation gap51:16 General surgery is like MTV — they don't operate anymore53:21 A resident who finished training without ever applying a cross-clamp56:34 How to evaluate if a program actually trains59:27 Academic promotion has nothing to do with teaching01:01:33 Dr. Tolis's resident outcomes database and three papers nobody cared about01:05:32 The training timeline: finishing at 49, no runway left01:07:08 One-size-fits-all RRC rules for cardiac surgery and psychiatry01:09:16 Cardiac surgery as a disposition, not a therapy01:12:24 When ECMO becomes the final common path01:13:38 How you become nationally recognized without being a good surgeon01:17:16 Vasily Kolesov: the Soviet surgeon who did the first bypassCo-Host Handles@anish_koka and @drdigiorgioShow Handle@drsloungepodSubscribe LinksSpotify: https://open.spotify.com/show/44vw8eirsKKnjgNIrdDvrRApple Podcasts: https://podcasts.apple.com/us/podcast/the-doctors-lounge/id1832097658YouTube: https://www.youtube.com/@TheDoctorsLoungePod

Episode SummaryRadiologist, National Review senior contributor, and prominent center-right voice in medicine Pradeep Shanker joins Anish Koka and Anthony DiGiorgio for a wide-ranging conversation that covers AI's real (and overstated) role in radiology, the structural dysfunction of GME funding and physician immigration, what went wrong with COVID policy from both the left and right, the asymmetric treatment of physicians like Mary Bowden versus institutional failures like Aduhelm, and whether America is still a creedal nation. Pradeep and Anish agree on more than expected — and disagree sharply where it counts.Chapter Markers00:00 Introduction and guest background02:23 AI in radiology — where it actually helps07:42 Ground truth, image resolution, and the limits of AI diagnostics12:16 Should AI replace the Nighthawk radiologist?19:40 CMS reimbursement and AI — does it help or hurt?21:09 Physician immigration and the GME funding problem27:49 Supplier-induced demand and the third-party payment trap35:52 Why we're not building enough American medical schools39:23 Affirmative action in medical training47:41 How did we do on COVID?51:26 Depoliticizing the CDC and NIH54:09 Vaccine mandates — where Pradeep draws the line56:42 How do you rebuild trust in public health?1:02:30 Mary Bowden, Vinay Prasad, and dissent in medicine1:08:42 The Aduhelm asymmetry1:16:35 Is America a creedal nation?Co-Host Handles@anish_koka and @drdigiorgioShow Handle@drsloungepodSubscribe LinksSpotify: https://open.spotify.com/show/7vE4aCMpVHnSGwuOHiGVLpApple Podcasts: https://podcasts.apple.com/us/podcast/the-doctors-lounge/id1489323962YouTube: https://www.youtube.com/@TheDoctorsLounge