The Cholesterol Debate: What the Keto Influencers Get Right (and Wrong)

The Cholesterol Debate: What the Keto Influencers Get Right (and Wrong)

Episode Summary Dr. 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 Markers 00:00 Introduction — Dr. Greg Katz, NYU Langone cardiologist and Beyond Journal Club co-host 01:40 What prompted the Substack: patients bringing in Nick Norwitz's content 02:51 Who is Nick Norwitz — LDL of 500, low-carb diet, and the clean CTA 05:38 Why Katz takes the question seriously but disagrees with the framing 08:01 Familial hypercholesterolemia outliers: why some FH patients never have events 10:05 The 50/50 problem — half of high-cholesterol patients have heart disease, half don't 12:27 The Jody Plute story: homozygous FH, Thomas Starzl, and the portacaval shunt experiments 17:37 Seven years of LDL 500 — is that long enough to know anything? 18:21 Limitations of coronary CTA: what it can and can't see 21:00 Why LDL gets put on a pedestal — and the cognitive dissonance of a diet that works 22:05 The conflict of interest argument — and why it cuts both ways 25:43 Burden of proof: mechanisms vs. outcomes data 27:16 Statins and GLP-1 levels — why a mechanistic claim isn't the same as a clinical outcome 31:38 Physician accountability vs. content creator accountability 35:24 The Keto CTA study: what it found, what it didn't, and why the blinding controversy matters 44:40 The new lipid guidelines: where they overcomplicate, where they overprescribe 49:38 GLP-1 deficiency framing and the over-medicalization of well people 55:54 Longevity medicine as "over-medicalization of well people" 57:35 What a well-designed trial would actually look like 1:00:01 Why the debate needs real research, not conjecture 1:02:37 How Katz talks to statin-hesitant patients in clinic 1:07:06 Wrap Co-Host Handles @anish_koka and @drdigiorgio Show Handle @drsloungepod Subscribe Links Spotify: https://open.spotify.com/show/44vw8eirsKKnjgNIrdDvrR [https://open.spotify.com/show/44vw8eirsKKnjgNIrdDvrR] Apple Podcasts: https://podcasts.apple.com/us/podcast/the-doctors-lounge/id1832097658 [https://podcasts.apple.com/us/podcast/the-doctors-lounge/id1832097658] YouTube: https://www.youtube.com/@TheDoctorsLoungePod [https://www.youtube.com/@TheDoctorsLoungePod]

Gaming the System: LTACHs, Guidelines, and the Evidence Problem in American Medicine

Episode Summary Dr. 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 Markers 00:00 Introduction — Dr. Anil Makam, UCSF hospitalist and health services researcher 02:09 What is an LTACH? Origins, optimal use cases, and the vent-weaning niche 08:09 How clinical practice led Makam to study LTACH utilization 10:08 Geographic variation in LTACH use — decomposing what drives it 14:16 Post-acute care economics: DRGs, payment systems, and perverse incentives 19:11 Medicare Advantage denial rates and the two-tier access problem 23:06 Market access vs. total closures: what the 100 LTACH closures actually mean 24:04 Short-stay outlier rules and the "magical recovery" at the payment threshold 26:07 Site-neutral payment reform and its effects on the LTACH market 31:51 Moving to guidelines: evidence vs. recommendations 33:38 The ATS guidelines study — what they found and the Twitter fallout 39:34 How to practice when most of what we do lacks strong evidence 43:38 Why guidelines are getting more confident on less evidence 47:10 The generalist vs. specialist lens on evidence appraisal 53:47 How do you measure what makes a doctor good? 56:41 Three buckets of physician quality: technical, relational, cognitive 01:00:06 Running a trial vs. appraising a trial — two different skills 01:05:16 Indication creep and applying trial evidence to the wrong patients 01:09:24 The FDA, Vinay Prasad, Marty McCary, and why reform failed 01:13:45 Wrap-up and where to find Makam Co-Host Handles @anish_koka and @drdigiorgio Show Handle @drsloungepod Subscribe Links Spotify: https://open.spotify.com/show/44vw8eirsKKnjgNIrdDvrR [https://open.spotify.com/show/44vw8eirsKKnjgNIrdDvrR] Apple Podcasts: https://podcasts.apple.com/us/podcast/the-doctors-lounge/id1832097658 [https://podcasts.apple.com/us/podcast/the-doctors-lounge/id1832097658] YouTube: https://www.youtube.com/@TheDoctorsLoungePod [https://www.youtube.com/@TheDoctorsLoungePod]

The FDA, Unicure, and the Limits of Accelerated Approval

Episode Summary Anish 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 Markers 00:00 FDA approval of AMT-130 and investor reaction 01:16 Unmet need and the case for regulatory flexibility 02:37 Sarepta, Duchenne's, and the cost of approving under pressure 05:09 Accelerated approval done right: the Amylyx example 09:14 Debating the AMT-130 data and the historical control problem 13:53 Why stock price matters for trial funding 17:20 How Prasad could have changed FDA culture differently 19:37 The FDA's role from Kefauver-Harris to today 22:26 Competing Huntington's therapies in the pipeline 25:39 Prasad's tenure: what worked, what didn't 28:27 Media coverage of the FDA and science journalism Co-Host Handles @anish_koka and @drdigiorgio Show Handle @drsloungepod

Salty About Medical Education: Bryan Carmody on What the System Gets Wrong

Episode Summary Pediatric 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 Markers 00:00 Introduction 02:02 How Carmody became the Sheriff of Sodium 05:03 Why people keep getting medical education wrong 07:46 The physician shortage: skepticism and incentives 09:03 Rebutting the AAMC's 86,000-doctor shortfall projection 11:17 Supply-induced demand and the limits of training more physicians 17:06 Third-party payment, discretionary care, and the real drivers of access problems 20:27 Who benefits from the physician shortage narrative 26:36 GME funding: $45 billion, hospital incentives, and the case for or against it 30:01 The Match explained: history, origins, and why it exists 35:22 ERAS, NRMP, and the financial architecture of residency applications 40:21 Preference signaling: what it is and why it's quietly capping application volume 44:12 Is the Match a monopoly? The congressional report and the anti-competitive argument 51:18 Step 1 pass/fail: the promise, the timing, and why it stalled 55:43 What actually changed — and what didn't — after 2022 58:00 What program directors should be demanding — and aren't 01:08:12 What we're not doing well in resident selection 01:11:59 Using selection systems to elevate the quality of every applicant, win or lose 01:18:45 The neurosurgery combine Co-Host Handles @anish_koka and @drdigiorgio Show Handle @drsloungepod Subscribe Links Spotify: https://open.spotify.com/show/44vw8eirsKKnjgNIrdDvrR [https://open.spotify.com/show/44vw8eirsKKnjgNIrdDvrR] Apple Podcasts: https://podcasts.apple.com/us/podcast/the-doctors-lounge/id1832097658 [https://podcasts.apple.com/us/podcast/the-doctors-lounge/id1832097658] YouTube: https://www.youtube.com/@TheDoctorsLoungePod [https://www.youtube.com/@TheDoctorsLoungePod]

Free Markets, Private Equity, and the Moral Case for Medicine

Episode Summary Jared 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 Markers 00:00 Introduction and guest background 01:52 What is the Center for Modern Health? 04:25 Objectivism, Ayn Rand, and rational self-interest 11:19 Healthcare as a private good vs. community good 13:58 Policy mistakes made for edge cases 16:58 You have a right to pursue health — not to be given it 20:14 Does Medicare violate rights? 22:47 Positive vs. negative rights in healthcare 24:47 The FDA, drug approval, and the Prasad/McCary departures 31:08 A two-tier FDA review proposal: private vs. public payers 42:25 Breaking up Big Medicine — the Hawley-Warren bill 49:43 Prior authorization: structural problem or reform target? 55:22 High-deductible plans and why price consciousness hasn't taken hold 57:43 Price transparency laws: do they actually work? 01:02:49 Section 6001 and the de facto ban on physician-owned hospitals 01:06:04 Stark Law, Medicare Advantage, and a possible reform path 01:11:19 Private equity in medicine: where are the actual rights violations? 01:19:02 Free markets and monopolies: the standard objection answered 01:21:12 Foreign-trained physician licensure 01:34:11 Immigration, physician workforce, and the battle of ideas 01:37:40 Center for Modern Health summer fellowship Co-Host Handles @anish_koka and @drdigiorgio Show Handle @drsloungepod Subscribe Links Spotify: https://open.spotify.com/show/44vw8eirsKKnjgNIrdDvrR [https://open.spotify.com/show/44vw8eirsKKnjgNIrdDvrR] Apple Podcasts: https://podcasts.apple.com/us/podcast/the-doctors-lounge/id1832097658 [https://podcasts.apple.com/us/podcast/the-doctors-lounge/id1832097658] YouTube: https://www.youtube.com/@TheDoctorsLoungePod [https://www.youtube.com/@TheDoctorsLoungePod]