What Do Unionized Residents Mean for the Future of Medicine? | Dr. Max Jordan Nguemeni
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Hello everybody, welcome to Knock Knock High with the Glockenfleckens. Over here we have Kristen Flannery, also known as Lady Glockenflecken. Switching it up, you are Will Flannery, also known as Dr. Glockenflecken. That's right. No first name on the Dr. Glockenflecken, it's just Dr. Glockenflecken is the last name. Dr. is the first name. Dr. is the first name. Yes. No middle name. Right. Okay. That's correct.

People don't usually abbreviate their first name with a period. Well, you like to be different. Okay. Yep. I guess that's the way it is now then. And how are you doing? I'm doing okay. I have some pain in my neck. It's making it hard to look over at you. I have to turn my whole torso. Is that what it's like when you're 40? Is that what I have to look forward to? This is what it's like when you're hypermobile and your trainer, who really was helping, moves to another state.

Well, you know, we're talking to somebody that has some experience in pain. That is true. Maybe I should have asked him if he could help me out. And addiction. Oh, well, I'm not addicted. You're not addicted. But we're talking to Max Jordan Ngumene. That's right. Somebody I know from Twitter. We talk about, we lament the death of our favorite, once upon a time, our favorite social media platforms. Yeah, it's true.

But he's a fascinating individual, assistant professor of general internal medicine and health services research at UCLA. He has an interest in primary care for people with sickle cell disease, and he's also passionate about managing pain and addiction. So we'll talk a little bit about that. He also was very central in the unionization efforts up in Boston. That's right. Mass. Mass.

Brigham, no, Mass General Brigham. Oh, you always get these mixed up. Well, it's like two hospitals have the same thing. MGB, I think is what he calls it. Yeah, Mass General and Brigham is the two different things. So I don't know. It's very, it's just a thing. It's hard for you. It's okay. It's all right.

Yes. He also does health policy and health equity research. But first we... Very smart. First we talk about the way that compare and contrast X and blue sky. Yeah. Much more important part of the conversation. Yeah. So just, you know, if that's not your thing, feel free to skip ahead about five minutes. What's your, what's your like top, if you could only choose like, let's say two social media platforms to just have on your phone. Instagram. Yeah.

Is it like you just have like a bunch of, I still don't understand. I don't use Instagram. I mean, I'm on it, but. Yeah. What do you, you just like looking at pictures? So embarrassing. I'm embarrassed for you. You're supposed to be a social media personality.

I have a big blind spot when it comes to, it's right over where my optic nerve is or my physiologic blind spot. That's where Instagram lives for me. Well, Instagram has many things, as you know, because you post there. There are photos and largely videos on Instagram. That's what I post. These days.

Okay, so Instagram, what's your second? LinkedIn. Gosh, LinkedIn. I am on LinkedIn. I do spend time there, but that one's not as much like for funsies. It's just more professional, I guess. But I don't know. It would have been Twitter. I would have said Twitter, but now Twitter's no fun. So I'm really, really hoping that...

somewhere we all settle in and can get back to the good old days of med twitter blue sky is pretty promising yeah i don't know it'll never get to be i think like the community aspect of it that that there was once upon a time in medicine um yeah but that's okay i mean it's you

Well, I hope we can at least get something approximating that because those were good times. I would probably also choose TikTok. Yeah, you would. I'm almost never on TikTok. Really? You never just scroll through mindlessly? No? Well, you're missing out. Am I? There's a ton of brain rot on that app. So if it's just a part of your brain, you just want it to rot away. Yeah.

TikTok's the app for you. I'm good. All right, great. Well, let's get to our guest, shall we? All right, let's do it. All right, here is Max Jordan. Today's episode is brought to you by Dax Copilot from Microsoft. To learn about how Dax Copilot can help you reduce burnout and restore the joy of practicing medicine, visit aka.ms slash knockknockhigh. Again, that's aka.ms, like Microsoft, slash knockknockhigh.

I feel like Preston, your voice is more recognizable, so you should start. Okay. So we have 90 seconds. Our producer said we have to run the clock out and tell everyone what the trailer is. We also talk too much and get off basis, but I don't think we'll do that in 90 seconds. But what is this podcast about? Margaret and I are starting a podcast. We're psych residents. And also I run a TikTok channel. And I do too. Westwell. I do POV skits of stuff in the hospital, but that's not important right now. Because what's important is we're going to be talking about...

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Join us to learn about the nuances that make us therapists. We're going to be talking about all sorts of things that go into the soup of mental health from our perspectives of people learning. After I told you that I took a test and found out my attachment style, how did that inform your new Hinge dating experience? I did in fact go on Hinge and practice my own attachment style. And did you attach to anyone? No, I certainly didn't. You

You can catch new episodes every Wednesday here on YouTube or listen wherever you get your podcasts. And this is a whole new show. So what do you want to talk about? Who should we have on? What questions do you have for us? What questions do you have for Preston to ask me that I won't answer? Come visit us on our website, howtobepatientpod.com. www.howtobepatientpod.com. Nice. How to be patient. How to be patient.

How to be patient. How to be patient pod. Come on over to the podcast website. All right. We are here with Dr. Max Jordan. Thank you so much for coming on. We've been trying to do this for a while, ever since we started talking to each other on

on X. The, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the

And it really did feel like a place where the medical community could talk to each other and exchange ideas and have discussions. And for me, it was just telling jokes. But you know what I'm saying. Yeah, I've been on Twitter my entire life.

Have you? Yes, I joined Twitter at the tender age of 16. Oh, wow. So a very long time ago. So you were like one of the early adopters then. You were like right there at the beginning. Yeah, it's like 2009 I've been on there. So it's even very weird to call it X. I mean, like you've probably heard this saying, I'm going to call you what your mama named you.

So that's Twitter for me still. Yeah. I mean, so this is one thing I wanted to talk to you about was this whole blue sky versus Twitter thing. Because there have been like...

Like over the past year, I guess there were two big instances where there was a big shift of people, right? It was when Elon took over, then a lot of people were like trying to find a different platform to use. And then now since the election, another big, you know, that's been a bigger exodus, I would say. I don't know. What are your thoughts?

You know, it's funny. I didn't really understand the exodus. So it was like, all of a sudden, now y'all are leaving. Did you not know Elon Musk was evil? Like, what was the shift? So, I mean, it sounds like a lot of people, myself included, like the platform is less and less enjoyable because you got all these porn bots responding to your tweets. Oh, it's awful. And, you know, all the new, like the right-wing verified accounts that are sort of like,

over onto your timeline. Well, are you sure the porn bots aren't just interested in health disparities and health policy research? I just, I don't know. Well,

You know, so here's the thing. I always tell people you have, so Twitter still has these safety mechanisms that I continue to use where like, I don't allow most people to respond to my tweets. If I don't follow you for most of my tweets, you cannot respond to me. And people are like, well, that's not supposed to be a democratic platform. I'm like, it's my democracy. Sure. It's what you, it's your experience, your personal experience. You want to make it how you want. Exactly.

So even with, even as bad as it has become, I still don't, I mean, like with all the safety checks that I've like ratcheted everything up, it's not the worst, you know, it certainly, I don't like all the, you know, the fake, the verified people that are just like engagement farming. I hate that. Yeah. Um,

I think people would rather just not do all that, right? They could just go to a new platform. That's better. Well, you know, and I was skeptical about the whole blue sky exodus at first too. And so it was like when Elon took over, I was like, I knew it was going to change. And a lot of people knew that, you know, it was going to be a much different experience. But I didn't like totally move over to another platform. I mean, as far as like my daily use of social media. Yeah.

But I will say, it's just, for me, it's not, you have this sense from people on Twitter who are saying, oh, all these blue sky people, they're just trying to surround themselves in their own bubble of influence, right?

I think that's dumb. For me, it's just, am I having a good time? That's the bottom line, right? I don't want to... Social media is for fun. Literally, in my bio on Blue Sky, it's like, social media is for fun. Don't try to ruin this for me. That's what it comes down to. Why force yourself into this platform because of some inflated sense of...

you know, good for the discourse when it's just, when it's just not fun. Like I, I don't know. So that, that it's very simple for me personally. And so I actually did a little experiment for myself, uh,

uh i over the past week and a half i just no twitter no x whatsoever i have so hard broken and then and i've just been on blue sky all right and and it's been it really feels like the early days of twitter in a lot of ways like there's not as many features it's not there's not as many people over there but the posting it just the the noticeable lack of like bots and like porn bots and stuff

Definitely a plus. And then just yesterday, I redownloaded Twitter and I just opened it up for the first time in like a week and a half. Immediately, I was introduced to pornography. I was like, this is okay. And then 20 seconds later, I deleted the app again. It was like, this is exactly...

what I thought that experience would be coming back to this platform after having a breath of fresh air for a week and a half. It's interesting hearing you two both say you get porn bots because I have never gotten that. So I really don't. It's really rare because...

I secure my who can respond to my posts. But if they're not secure, it's in the hidden replies or whatever. And I'm like a kid that's trying to touch the hot iron. And I'm like, I wonder what's in the hidden replies. And then I'll click and then I'm like, oh, God.

So I don't think I'm as good as you are at locking down the account. Yeah, you don't do that kind of thing. I don't have as many safety. Maybe that's where it could be better. It could be. But still, it's also... But I wonder if it's a gender thing on the algorithms part, right? Probably. Showing it by default to men. Yeah, I mean, the biggest consumers of porn are men. Right. And we definitely... And that was a clear...

difference that I was also able to notice with Blue Sky, there's definitely no algorithm that's feeding you content. It's like who you're following. It was kind of cool because it's like once I saw the tweets or the posts that have been on Blue Sky for the day, I was like, that's it. No more content. You better go do something else. I got to the end. It's like that just does not exist on X. So anyway, I'm really...

This time around, as more people have moved off of X onto Blue Sky, I feel like I'm enjoying the platform a little bit more. How about Threads? How does that fit into all this anymore? I don't know. I don't spend any time on it. I refuse to join another Mark Zuckerberg platform. Yeah, I hear that sometimes. Nobody likes Zuckerberg either. Instagram's enough. What do you get out of social media personally? What is your goal when you're getting on there and either posting content or...

It's a mix of things. There's I learn, right? Like I learn a lot on Twitter, man. Like people post their papers. I've made friends. I've made collaborators. I have two papers that, not just two, I have several papers that I've written with people that I first became friends with on Twitter. Like one of my favorite collaborator outside of medicines, a sociologist, Victoria Ray, we met on Twitter. On my like old Twitter account, that is basically like,

it's like only my college friends on there and like random black people on the internet. That's like my non-professional account. So the learning, meeting people randomly that you would have like not met otherwise, there's a lot of good entertainment on there, man. Like black Twitter, I mean like, you know, when I was on Twitter as a college student, like black Twitter became a thing when we were like watching Scandal live, like as a community live tweeting it, right? Like-

That's why I haven't left because if it was just the academic part, I think there's the academics have like left a lot of them. There's a lot of academics on blue sky, but I get way more academic engagement on blue sky, but, but the jokes are still on Twitter, man. Like there's just some things you cannot replicate. So, so black Twitter has not migrated over for the most part. There's been some, there's a black sky is a thing.

And someone said, I actually was thinking the other day when Drake sued UMG and Kendrick Lamar, and I was seeing jokes on Blue Sky. I was like, you know what? I think this place has potential. Yeah. If this is taking off here. It's going to keep growing. I mean, there are like 24 million users now. I think there were 20 million last week. So it's like, I think it's real this time, right? There's hope.

You got the other ones. They're like, what was it? Mastodon or something? I don't know. Mastodon. Mastodon's over. That's done. That was too complicated. Yeah, honestly, my biggest annoying... The reason why I was really resistant to migrate, I was like, man, I do not want to go and build another audience. Right. These 20,000 people that have been following me, I'm not about to go over there and try to go viral. You know what I mean? Yeah. Because I became...

quote unquote, accidentally. I like, I like, I'm not a content creator per se. Like, you know what I mean? Like, sure. It was accidental. So I was like, how am I going to have another accident on another platform? Like, yeah,

Well, that's how we all got semi-famous. Yeah, none of this was on purpose, that's for sure. It's just like, just being funny. Right. You especially. Well, it's just, you're in the right place, right time for a lot of it, especially with the pandemic. That's what it was for me. Also, I don't know, the academic discourse...

just see, I, it's never something that I've been really that engaged in because I, the argument, the arguments and the argumentative natures of people just, it just was exhausting to like see, seeing my replies. And so, I don't know. It's just like, so you mean to tell me you didn't enjoy Eugene goo in your replies? Like, Oh no, no, definitely not. I, you know, I,

I think that one of my central tenets of social media use is like never get mad online. Yeah. And-

And I catch myself getting mad on X on Twitter. And it's like, why am I doing this? Like, what's the point? It's just a waste of time. So anyway. Yeah. But there's so many more interesting things to talk about. So we don't have to just talk about X. All right. So you are an assistant professor of general internal medicine, which sounds very fancy, by the way. So congratulations on your role at UCLA. Thank you.

And health services research. Oh, sorry. Yes. Health services research. You wear a lot of hats.

And these are real hats, not like the fake hats that I wear as like literally as different. Yeah, exactly. And so I guess my first question about general internal medicine, like how accurate is my portrayal of like hospitalists? Like, do you actually sit there and pontificate to an extraordinary degree about the smallest decisions in patient care?

You know, I think to an extent it happened, but I used to call myself a surgical internist because I don't like a lot of that. I mean, look, I do not want to talk about hyponatremia on rounds at all. No. Like, unless it's severe, unless it is the primary problem, I will tell my interns, we can fix the sodium later. Yeah. Yeah.

Yeah. In the ICU, there was a lot of, yes, like a lot of that. I think it's even more so in the ICU. I mean, you know, we're rounding till noon. You feel like you need a Foley. Yeah.

Yeah. Just thinking and talking about it is hurting him physically. Trust me, we don't need to talk about internal medicine topics. I was going to ask you to give us a lecture on hyponatremia, but I think we'll skip that. Oh, God. So when did your, I guess the time when I became aware of your social media presence and kind of what you do is with regard to resident unions.

So I'd really like to talk with you about that. Can you give us just a summary of where we are right now with unionization efforts among residents, just generally? Mm-hmm.

We are experiencing a purple wave. And I say purple wave because CIR, I say ARC, like I'm still a resident. I mean, I think I get to say ARC for another, like for the rest of this year. Like I still feel like a resident. Yeah.

Yeah. I mean, all of Philadelphia area residencies that were not already unionized just filed at the same time, which is really cool. So like CHOP, Jefferson, Temple, because Penn won their election the same time as we did last year. So that's 3,000 residents in the Philadelphia area plus Delaware. Yeah.

In Rhode Island, we have Brown residents just filed their election. Or rather, filed their... We are planning to unionize. You could either recognize us or give us an election date. So I think...

Probably by the next couple of years, the majority of residents will probably be represented by CIR or unionized in general. But that's only half of the battle, right? Winning your election... And by the way, all these victories have been just about landslide victories, right? It's like pulling teeth together, but then once you do...

Our election at MGB, which was the largest, it was 2,500 residents and fellows, and we won, I think, 75% of people who voted in favor of unionizing. And the turnout was 65%. You mentioned pulling teeth. So what are the big barriers that you're referring to?

- So it takes a lot of work, right? Like just the organizing part and you know how it is in medicine, like people don't want to make noise. People are just trying to get through residency and get out. - Trying to survive. Yeah, survive residency, yeah. - So imagine we're all working these busy jobs and then we have to organize. So like when I was an intern,

the worst of times, right? Like work is over, I gotta now go door knocking, the equivalent of door knocking, right? We used to call these walkthroughs where we're like going workroom to workroom across the hospital to try to talk to people. Hey, may I interest you in a little project? And getting more people involved in the day-to-day work of making the union happen

was just so hard, right? I mean, I had a colleague in emergency medicine who told me, you know, man, this really feels like it's just a small number of people or a small army trying to whip up or a small number of people trying to whip up an entire army into unionizing. And I was like, yes, it damn sure feels that way. Why don't more of you get engaged? Right? Like, because...

But people are afraid. There was a lot of fear mongering, like certain program directors, you know, would tell, like in surgery, the surgery program directors might tell their residents, do you really want internal medicine residents to be in charge of representing you? Um,

they're going to want to take away your benefits, right? So like, there's all this opposition coming from administration. You know, they will put the residents in these captive audience meetings, right? They're like, it's noon conference, but then you show up and it's the, like, like we had a department chair and like some, and,

like the vice president of education canceled an educational conference, um, so that they can come talk to us about not unionizing. Oh, well, I mean, they couldn't say that per se, but so they could come talk to us by unit about the union project. And of course, like nobody wanted, wanted to hear that. Um,

So it was a lot of work. I spent a lot of time on this. So, yeah, because there are rules about, like, they can't come out and say, you guys, you shouldn't form a union. Like, that's... Are those like... Right. Like, they have to be a little more ambiguous about it. That's why, like, the surgeon saying, oh, well, you know, do you really want to intern it? Like, even that's...

That's like pushing the boundary of what you're allowed to say. Oh, yeah. There's a lot of boundary pushing. Yeah. I mean, I'm sure some program directors probably – I mean, I had a friend who's a surgical resident who was grilled in the operating room by an attending. This is ENT, you know, those seven-hour cases. Yeah.

there was a Boston Globe article that came out and one resident was talking about how like they were struggling to make ends meet and find time to go to the dentist and all that kind of stuff. And so then this attending grilled him in the oar and was like, are your teeth dirty? Like, you know, like,

Just, I mean, that is the most captive audience of captive audience meetings, right? You're stuck in a surgical gown. Yeah. Can't go anywhere. Someone is grilling you about unionizing. Yeah. And these are, these are at this point, like when we're talking about unionizing, unionizing, that's how it is.

in Philadelphia. We're talking about all the residents and all the programs in Philadelphia coming together under one union, right? These aren't just hospital individual unions? Or how is that? So it would be... So the union is CIR, and it's national, but it would be each chapter because you can only file... The filing is based on who your employer is. But...

I think they did a really smart thing of organizing at the same time because now all the hospital leaders are like under pressure, right? They can't use the person across the street and say, well, they're not doing that over there. Like, do you know what I mean? Yeah, that makes sense. Like when we filed in Boston with MGB, the residents at BMC were already unionized and

And so really, all were left at the time were BI and Tufts and maybe some other smaller hospitals whose names I don't... Like Mount Auburn, maybe. Yeah, Mount Auburn is one. But BI just filed. And they're galvanized by the fact that MGB is already unionized. And MGB had this sort of carrot and stick approach where...

they announced out of nowhere a new $10,000 stipend and an additional 7.5% inflation-related raise in March or so, when they had already told us in late January that our inflation adjustment was going to be just 2.5%, right? So it was clear that, okay, this big bump is about...

trying to get us to shut up about the senior thing. And they made it even clearer when then they send this letter, maybe a week or two later with every department chair signing at the bottom, the letter essentially said, uh, now that we've given you all this nice stuff, right? The, the, the new $10,000, the additional 7.5%, um, and your health insurance is not at no cost. Um,

can we ask you to stop with the union so we can address this as a family? So this was a union- Just bribery. A union busting tactic is just to give you a little bit more, just to say, okay, we're treating you well now, at least for one year. Right? Right. Yeah, and so they did that. And of course, we're not going to stop. Yeah, right. But it had an effect around town, right? So like now all of a sudden we're like-

My raise from PGY2 to PGY3 was like 15 grand.

And the BI resident next doors are like, oh, what are y'all going to do for us here? And so BI residents got a raise. There was like a market effect, sort of like marketplace shock. BI residents got a raise. The Boston Children's next door, they got a raise. And I think it probably also helped the BMC residents because they were in the middle of negotiating their contract. I'm pretty sure that also helped

them seal a better deal right because you can't be trying to pay people ten thousand dollars less than what their peers across town are making yeah so i think that what they're doing in philly is really smart and like we're just going to apply pressure on all these people all at once yeah and and yeah they can't they can't pitch you against each other that way exactly that's smart and so now it's been since uh because i remember when the boston the um

What was it? The First Union, the big BMG? You said, what was it? MGB. MGB. Yeah, MGB. Why I couldn't come up with the three letters. It's been about a year, I think, since that. Yeah, we won our election in June of 2021.

Two, I think, or three, I don't remember. So has it, now that you're like over a year later, has it gone as expected? Have there been, is it, is everybody playing ball? Is it, you know, where are we at? Has it gone as expected? Yeah.

So, you know, I mean, I left MGB four months ago, but like I was attending, I was part of the bargaining team up until like my last day. I was going to bargaining meetings and I'm keeping up with what's going on because I'm super invested in this. They're playing hardball. They're not...

meeting the residents where we think that they should meet the residents so they're like by the time i finished residency we had agreed on a lot of items on the tentative contract right but we're still not there with the big ticket items like the you know they they first came to the table offering us like a four percent raise over three years and we're like are you kidding right um

And only months later, they offer the Massachusetts Nurses Association, which is a union at the Brigham. They got a 25% raise over three years. So we know you can do more for the residents. And so that's one of the big ticket items that are still being negotiated over. Another one is fertility preservation, because they like to say, oh, we offer fertility preservation. But the reality is,

You can only get fertility preservation under that insurance plan if you have a diagnosis of infertility, which is not... One, it's not fair if you're like... And how do we diagnose infertility in women? You need to have been trying to get pregnant for a year. How does one get pregnant? So if you're a lesbian and you want...

to engage in fertility preservation or want to get pregnant. You know what I mean? So it's sort of structurally anti-LGBT. Or if you're a resident who has...

presumably quite smart because you've gotten where you are, and so you know how to prevent a pregnancy. You do not necessarily want to get pregnant, but you'd like to have babies later when your work-life balance is a little bit better. Right. And before your ovarian reserve has dropped. Then there's nothing there for you. But you made a good point about it being anti-LGBT type of policy, and I'm sure that's... Right. Yeah.

That's just not helping anybody, basically. Like, that's the whole point. It doesn't do anything. So those are some of the big ticket items. I mean, so the last few CIR chapters that have unionized or that have had contract renewals have been able to get those kinds of benefits, like at UCSF, UCLA, Stanford, you name it, like, I...

$15,000 to $30,000 towards fertility preservation or family formation if you're trying to adopt instead. That is something that some of these contracts offer. Because not everybody necessarily want to bear a child, but they want to be able to form a family. Yeah. Well, let's take a quick break because I want to talk more about this as it relates to physicians as a whole.

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Get up to 40% off select online vanities only at homedepot.com. The Home Depot, how doers get more done. All right, we're back with Dr. Max Jordan. So, Max, let's talk about this unionization effort as it relates to the larger physician community, because we can certainly learn a lot about it. In fact, I think it's...

It seems kind of backwards that this would start with, you would think that physicians as a whole would be interested in this as the corporatization of medicine becomes more prominent.

And leave it up to the youth, the next generation, right? People to think a little bit differently and to kind of be the, to spearhead this charge of unionization whenever it's, I would say probably much harder for trainees to do this because residency is the finite period of time, right? Three, sometimes three, four, five years, and then you're onto something else.

Right. So much turnover. So it's got to be so much harder to, to, to, to generate a lot of interest in unionization as a resident than it would be as a physician has been working for some, you know, private equity owned hospital system for 20 years. That seems like a no brainer that people in that situation should be unionizing. And so, right. Are you, are you feeling like there's, this is generating any kind of momentum in the greater physician space?

I mean, I think there are a couple of things here. I wholeheartedly agree. I mean, like one of the biggest reasons why we filed my second year and didn't wait, we're just like, we're not doing this because most of the people who were engaged were like either like PGY2s or like graduating fellows. And we're like, I was like, look, man, I'm gonna be on the job market next year. I am not organizing more. So yeah, like it's so hard when,

Yeah, you only have three years. And I think also the administration tries to stall, right? Part of the stalling tactic is like, okay, well, the Maxes are going to graduate and you're going to lose some of the engaged people. One of the big reasons why I think it's probably easier to get momentum among residents is that it's easy to explain to residents, look, you have no power. You have no ability to negotiate your contract.

you are working 80 hours a week, so you can't work anywhere else, right? Realistically, or maybe you can moonlight in this hospital here and there. But for the most part, like residents, we're locked in in a terrible situation, right? So like the union is like one way to really help

kind of get you out of what can feel like you have no alternative sort of option to help defend your interests, your material interests. But I think with attending physicians, there's so much...

individualism, right? So many physicians, like you probably saw that Washington Post article that was like talking about physician earnings and how like the median earning, median total earning of a physician is like $350,000, which obviously like, if you actually look at salaries, that wouldn't be median salary, right? But that's because a lot of physicians do other things, right? Like there's that doctor on Twitter who talks about doctoring differently. How do you do a VA disability exam? And like,

There's just like all this other stuff that physicians... Expert witnesses and doing all this stuff. And so like people aren't done... People don't necessarily... Or yeah, like legal consulting, blah, blah, blah. There's like so much of... So much opportunity out there for a lot of physicians to find ways to like...

maximize their profit, you know, sort of like think of themselves as big, like mini corporations, that the idea of solidarity with other physicians doesn't necessarily come like naturally for a lot of people, I think, right? Because people are like, why do I got to do that? I could...

consult for a pharma. I can do Botox in my living room. I can, and so forth. But, and if you notice among attending physicians, the people who are unionizing are the people who work

the longest for the least primary care, right? Like, so at the, at the, at Brigham and MGH, the primary care attendings who are like the people who taught me primary care, uh, are now unionizing. Uh, and I'm super proud of them. Uh, before, before this filing, I think Alina Health in Minnesota, um, that was the largest filing of, of, of attending physician unions in history. Uh, so I think PCPs, right, make a lot less money than, I don't know, neurosurgery or whatever. And, and,

a lot more pajama time than like anybody else so like being able to engage in this sort of like me as physician as a mini corporation is a lot more difficult for primary care doctors so like it's probably the activation energy to think of like solidarity with one another right um to address working conditions is probably lower in in this but in that specialty the other thing um

I mean, I think it's going to happen as many of us who have been part of unions are now becoming attendings. Right. That makes sense. Yeah. And hopefully, I mean, political education is non-existent in medical school. And if you think about who gets into medical school, it's people who are coming from well-off backgrounds, people who have been taught education.

either implicitly or explicitly that unions are bad because look at nurses, they want to take breaks. I mean, literally you hear surgeons complain about OR turnover time, right? And they're like, why can't I get an OR turned over in 15 seconds? It's because of the union, right? Because they want to take breaks. And so I think, I mean, even when I was organizing and trying to talk to my colleagues, I

about getting this project off the ground.

People would use the nursing union as a reason why we should not unionize because people would say, "Well, nursing unions, the nurses are all about me, me, me, and it's not about the patient." And I'm like, "What the hell?" But that is what a lot of people have been brought up with as members of upper class society that can be really anti-worker. But we have to realize we are workers. We work for big corporations.

And it's only getting worse, you know, as physicians are unable to own hospitals going forward at this, at least for now. You know, there's more Optum UnitedHealthcare-owned hospitals that are employing. Now, Optum is the biggest employer of physicians in the U.S., and so...

I agree with you. I think, especially as this new generation starts, you know, getting into leadership positions in medicine, that unionization efforts will increase.

So I agree. I don't know. What do you think? Yeah. Well, I'm just, like he said, now you guys are workers. That didn't used to be the case as much, right? You had more autonomy and more. And I think maybe that is some of the reason for the generational divide on the issue as well, right? It's because it's really sinking in for the younger generation who didn't ever get to be in a world where doctors had more autonomy, right? It's always just been this

I think the income disparity that you mentioned though is going to be a big barrier, you know, because right now like all residents are all making about the same amount of money. And so, you know, it's, it's probably easier to get people on board from a salary standpoint. But then you're talking about attendings with, you know, you got the surgical subspecialists that make, you know, two to three, four X times what, you know, pediatricians and some primary care physicians are making and,

And really to get, I think, a strong unionization effort, you need buy-in from people across the board. And I think that's going to be a big challenge, unfortunately. That's why the filings among attendings have been either like PCPs or hospitalists, right? Your generalist specialties. And I mean, even at the residency level, I got to tell you, the people who were the most opposed...

to supporting the effort or were the most afraid. Either it was like their program directors are scaring them out of this. Or like I remember one resident in a specialty that makes a lot of money was like, well, whatever, those $10,000 mean nothing for me. I'm going to make X amount of money, right? Like even at the residency level, people already know that they're going to be our bosses, right? They're going to be the ruling class.

of the medical profession. So even among residents, this idea of having solidarity among each other because we make the same salary, it breaks apart very quickly when they're reminded that even as residents, they are the ruling class. Within MGB, surgery residents and orthopedic surgery residents

just to name a few specialties, had like additional like material benefits that the rest of us didn't have, like meal cards, all this kind of stuff. And like, so when the effort got off the ground, like I remember a surgery program director saying, oh, they're going to take away your meal cards, those medicine residents, right? Like,

And sure enough, when we got all these raises, right, the institution took away all the program-specific perks. But even when you took away those perks, everybody still made it out with more money in their pocket. But now they're no longer the ruling class among all the residents, right? Like, you're not special anymore with your meal card. And, like, there was some resentment over that.

Wow. I mean, I, you know, that's like feeding yourself is one of the, like the biggest challenges as an intern. So I kind of get it. Yeah. I would have loved, loved having a meal card. Yeah. But, but to your point, you know, trying to see the forest for the trees, you know, not, not being obscured by these little tiny details and see the bigger picture, I think is really important. Yeah.

But I want to switch gears just a little bit because you, as an attending, by the way, you love being an attending? Is it great? No? I don't know yet because I haven't started supervising residents. Oh, no. But you know what? I got to tell you, I did an urgent care shift one time. Yeah. And I signed an EKG, right? Like, that's the first time you had that. I was like, the power that that has. Yeah.

I was like, wow. I wouldn't know. I've never done that. So I've never signed an EKG. No one would want my signature anywhere near an EKG. But I know one of your passions is pain management and addiction. Yes. How did you get into that area as far as being a focus of things you're interested in?

Yeah, I mean, like, I'm vaguely interested in health disparities coming into medical school, right? And, like, I feel like the essence of what we do as doctors is, like, alleviating people's suffering, right? Sure. At least that's how I feel. Good point, yeah.

Pain is suffering in various realms, but pain is a big one of them, right? And I think I was like a first year med student and I saw this young black dude who was my age and he had had like juvenile idiopathic arthritis. So at my age, I think I was 23 at the time, he had already had like two hip replacements, two knee replacements. Wow.

And the attending who was precepting the resident who I was sort of like hanging around with was being really accusatory towards him in a way that was just like not just. And it turned out that, yes, he had a new ankle fracture. And that really left me. I was disheartened, right? Like, and...

Like, it steered in my brain. And I went on to just see these instances over and over as a med student. And, you know, I was born and raised in Cameroon. Sickle cell... The sickle cell trait prevalence there is like 25%, right? So...

Multiple things have sort of like got me to the point where like I care deeply about doing people's pain care right. And I think we can do a lot better. Also, Helen Hansen, who studies buprenorphine and methadone and the opioid epidemic and the anthropology of it all.

She gave a lecture when I was a math student that really had me hooked on bupe. As in metaphorically. I don't know what bupe tastes like. Not physiologically. Well, tell people about buprenorphine. But bupe is a partial...

mu opioid receptor agonist and a delta and kappa opioid receptor antagonist. And it has these really interesting properties unlike all the other opioids in that there's a ceiling effect, right, on respiratory depression. So you cannot die from buprenorphine. You might be zonked, but you're not gonna stop breathing unlike all the other opioids, no matter how much bup you take.

unless you also take benzos and alcohol, like all the other stuff that can also depress your respiration. And there has actually been no...

documented sealing effect around pain. So you can keep giving more of it, right? It's also the most potent of all opioids besides fentanyl. So, you know, when I dose bup for someone who is opioid naive, it's in the microgram range, right? Micrograms. When you're dosing bup for someone who has opioid use disorder, now we're talking about milligrams, right? Because...

So second most potent opioid, so you only really need tiny amounts of it.

to alleviate people's pain or to get the effect that you want. And then it has the strongest affinity of the myopurid receptor, which means that that's part of why it can precipitate withdrawal if you were on opioids before. But it means that any small amount of buprenorphine in your system protects you from an overdose from other opioids because it's so tightly bound to the myopurid receptor. Oh, I see.

So what does that mean? You can give people bup and give them other things and not only makes it safer. So one of my like...

My pet problem in clinical medicine is like, how do I get more people to integrate buprenorphine as part of their pain management? And the VA has started to suggest that it's part of their chronic pain guidelines as of 2022 now. They're suggesting that people consider buprenorphine as a first line compared to all the other opioids.

They don't recommend it, they suggest. Is it just like a bias against any kind of opioid? Is that the wall that you're trying to tear down in terms of acceptance of buprenorphine? Is it pretty much accepted at this point?

I think it's a mix of things. I mean, people are super comfortable prescribing Tramadol and Oxycodone and morphine and all that kind of stuff, right? But I think there's an element of knowledge. People don't know a lot about buprenorphine. And part of it is, I think, I call this like buprenorphine sequestration. Basically, the fact that, you know, with the Data 2000 Act, when it was FDA approved for opioid use disorder, basically,

you know, that being like 18 years after it was FDA approved for pain, it became really popular. And then there was, you know, there was also the X waiver, which restricted people's ability to prescribe buprenorphine for opioid use disorder. I think there was like, it's like a thing that got memory hold in the medical community where like, it stopped being taught as an analgesic, right? Because it was the popular, the new popular agent for OUD. And so it's,

Many people think or thought that you needed an ex-weaver to prescribe it for pain, and an ex-weaver required, what, eight hours of additional training that people didn't have time for. So I'm sure you didn't learn about buprenorphine in medical school as an analgesic. Very, very little, if at all. Yeah, it wasn't. Right. You learned about morphine. Oh, yeah, for sure. Yeah.

So I think the fact that it became the mainstay for OUD and that there were all these barriers around prescribing it for OUD in the first place made it even more difficult for people to either learn or become comfortable prescribing it for pain. And so as a resident, I would tell, I mean, so I don't do well with authority. So I've run against walls.

in this realm where I would be like, this medication is safer than morphine and allotted and, and, and why are we not comfortable prescribing this? You know what I mean? But of course there's other stuff around whether insurance is going to cover it. It costs more. There's like all this other stuff. But I think even at the acceptance level, people don't know enough. Yeah. Because both of us at various times in our lives have, have received,

uh strong pain medicine for yeah surgeries and everything i would like to know what that feels like it's and uh neither of us have ever received buprenorphine as far as i can tell and i guess my my like my thought i like kind of lump it in with like methadone is like this is something you give to people who already have an opioid use disorder

Yeah, I mean, that's the most common. Right. That's the way it's usually given, right? Right. But at much lower doses, it's analgesic. Right. Yeah. I mean, the first FDA indication, 1982, it was the IV or IM bupe that was for pain. It was discovered to be analgesic. It was just incidentally found to be also really good to treat opioid dependence. Yeah. Yeah.

And so I feel like a lot of people probably have my level of knowledge about it and thinking that, oh, I'd never thought that this could be just something that we give for pain, just like anything else. And it's in some ways safer. So I don't know. Kind of.

Cool. I mean, if people will get on board, it sounds like it's got a lot of... Yeah. It seems like the benefits outweigh the risks, right? So, if you're talking about pain, how annoyed are you with social media and how people talk about fentanyl? Is it... I mean, it's... I can't...

I figured that alone might drive you off of X as a platform because I see you guys, some of you like pain specialists, people that are really interested in pain talking about some of the fentanyl and it just like, I feel bad for you because you're like, it's like beating your head against a wall trying to like explain. Yeah, the demonization of fentanyl. Or like, you know, you listen to, what was it? The vice president debate with the,

What's that guy, JD Vance? He called it, I can't remember what he called it, but he did not call it fentanyl. He called it something else. But yeah, I mean, it's super frustrating, right? Because opioids, like if I, I don't know if you've ever considered this, right? If you're on a desert island and you needed three medications to survive, have you thought about what you will need?

Oh. Caffeine. Okay, that's a supplement. That doesn't count. Unless you're a baby that needs lungs. I don't know, it feels like a medication when I get up in the morning. Three medications to survive. I would say aspirin.

Maybe. A blood thinner in case you start having a heart attack. Fair. Personal. Yeah. I mean, if you consider water a drug, it's a chemical, but I don't know. It's not a drug. Not medication is what he said. Medication. Medication.

Oh, God, this is a good question. Yeah, I've never thought about this one. You're asking the wrong guy. That's right. He would tell you you need some eye drops. You need some refreshed artificial tears. No, he hates Visine. We don't use Visine. We don't use Visine. Some contact lens solution. I don't know. What do you say? What are the three? I would want opioids, some kind of opioid, either Dilaudid or fentanyl. Okay.

Not just for survival, but just like pain. You're on a desert island, right? You break your leg. I would want steroids.

You can do a lot with steroids and antibiotics. Those are the three medications that I would want. Why didn't we think of any of those? Because we're not internists, see? Like he prescribes these things all the time. I would want antibiotic eye drops. But see, I don't think very broadly. I'm just very much in my own little world in ophthalmology. But those are good answers. Infectious keratitis or whatever. You don't want that.

And then one more thing before you go is you gave us some stories from your past. And one, I just, I have to have you tell about the accidental screenshot. Oh, God. Please.

Okay, I'm not going to go into super details about this, but I took a screenshot of a conversation with this woman that I was interested in or dating or whatever and meant to share it with my friends from college. And the screenshot, it was like me... You're in a group chat and you're getting advice, like, how should I respond to this, that, and the third. Yeah.

And so I responded to this thing that she was asking me about or whatever. And then I took the screenshot and meant to share it with my close friends from college. And I was like, look, guys, this is what I said in a kind of funny way. But I sent it to the PGY2 and 3 chat. Oh, no. And here's the thing. I don't have notifications on for WhatsApp. So I didn't realize...

that people had started to respond to the screenshot. And so like one of my close friends starts texting me. He's like, "Max, what are you doing? Delete, delete, delete that message." And I go to WhatsApp and there's like a ton of responses from my co-residents.

Oh, no. I was so embarrassed. It was so funny. I was like, well, I guess not everybody knows what it's like to be single and trying to date in Boston. Would this have been worse if it was at the very beginning of residency? Because it sounds like you were a year in whenever this happened. Right. This was the third year. I think it would have been worse if people didn't know you. Yeah. By then, people knew...

Also, this was internal medicine. Like, there are a lot. Yeah, PGY2 and 3, all the medicine. There are a lot of residents. Yeah. Can you imagine? And so, I mean, I deleted it soon enough that not everybody ended up seeing it. Yeah. Like, but a lot of people saw it. And so then, like, other people joined it. And all the rest heard about it later.

Yeah, probably. They were like, uh, what happened? What happened? Can someone fill me in? Was there a lot of back and forth about, about the appropriate course of action since it is a... A little bit, a little bit, a little bit. And in fact, at one time, uh,

A co-resident who I helped, I covered on a moonlighting shift or something. I don't remember. And then he sent me a treat and was like, you can use that for your dating life. Good. I like it. Yeah. The joke continued on for months. Didn't get to live that one down. Let's tell people where to find you. You got a sub stack, right? That you write on? It's called Adverse Reaction. I love it.

That's great. Adverse reaction. It's a free sub stack. So people can check that out. Also, are you restarting up your podcast?

I'm planning to at some point in the new year. I've recorded one episode so far. I'm just trying to get these grants off of my desk first, you know, research. Well, now that you said like, now you have to do it because we're talking about it on this podcast. Yeah, people, please go listen to it. There's like 50 episodes up. It's called Flip the Script.

There you go. Yeah. All right. Well, good luck with that. And, uh, let's see what, Oh, you're, are you, you're still going to be on X, I guess for now. Um, yeah. And blue sky and blue sky. Uh, any other, is that, is that your main social media presence right there? I use Instagram. Um,

Where my name there is game.set.max. It's like a tennis button. I like it. Yeah, because I play tennis. And TikTok. I think my TikTok name is also game.set.max. Yeah, I'm kind of all over. Oh, really? All right. I don't post much on TikTok, though, but I...

I think when I restart more content creation or whatever we call this, I will be pushing stuff. I'm a bit partial to TikTok. I think it's great. Yeah, Jonathan has told me. Yes, that's right. And all your social media, do you talk mostly about health disparities there?

there or what can people find there? I talk about everything honestly I talk about pop culture I talk about Beyonce I talk about Drake I've seen you talk about tennis as well yeah exactly honestly it is my fleeting thoughts it's just like whatever crosses my mind that I wouldn't mind being printed on the billboard I'll post it it's the way it's supposed to be alright Max thank you so much for joining us it was a pleasure to talk to you

Thank you for having me. And, you know, and thank you for all that you do, like your comedy and raising awareness around CPR. Can't even begin to say how much all of what you guys do means. I appreciate that. That is so nice. Especially this one over here, Kristen. Right. She's 10 minutes of CPR.

Yeah, well, as I always say, we had just gotten a mortgage, so, you know. That's what I should say. You're not leaving me right now. Exactly. Get back here. Well, thanks again for joining us and keep up the great work. Thank you. See you on Blue Sky or X. Yes, probably Blue Sky. Probably Blue Sky. Yeah, we'll see you there. Alrighty. Bye-bye.

Hey, Kristen. Yeah. I know you're a big fan of Demodex mites. Uh-huh. You know, the eyelid mites? Yeah. They're on your eyelid? Uh-huh. They're just right there in your eyelid? Yeah, thank you. Well, what if they flew at you? Oh, God. What if they jumped? What if they jumped?

Would that bother you even more? Oh, it'd be even worse. Would that be better? Jumping bugs are always worse. Well, I have good news for you. They're not jumping. They don't jump at you. But they are there and they can cause like crusty, flaky, itchy, red, irritated eyelids. So I can tell you're a little bit grossed out. Yeah. It's a disease. It's called demodexblepharitis. It sounds like no fun. Well, but it's pretty common. And a lot of people don't really know about it. Yeah.

But I mean, these like, they are kind of cute. I gotta admit, just a little, just a little cute. Maybe a little cute. Regardless, you shouldn't get grossed out by this. You should get checked out. Okay. Go to eyelidcheck.com for more information. Again, that's E-Y-E-L-I-D check.com to get more information about these little guys and Demodex blepharitis.

Are you ready to start a union? Am I ready to start a union? I think you need to start a union. A union of comedian doctors. Ophthalmologists. It'll be a very small group, but mighty. No, it's, I, you know, I always have, I mean, I might sound like an old guy, but, you know, we talk to the youngins. I'm always so impressed by just their ability to do things like organize and just, you know,

Fight for what's right. What they know is right. A strong sense of justice. Yes, to make positive change, which is why, you know, because we need a lot of that in healthcare. So I'm very encouraged by what Dr. Jordan has said. I'm glad they're doing it because they still have the youth and the energy. It's going to take a lot of that.

Give us your youth. Give us your energy. We need it. So let us know what you thought of the episode. That was great. It was a lot of fun talking with, trying to talk with him for a while on here. He does a lot of really cool stuff. So you should go check out his social media. Lots of ways you can hit us up. Email us, knockknockhigh at human-content.com. Visit us on our social media platforms and visit our Human Content Podcast family on Instagram and TikTok at humancontentpods. Got some great pods coming up. Mm-hmm.

And so thank you to all the great listeners leaving feedback and reviews. If you subscribe and comment on your favorite podcasting app or on YouTube, we can give you a shout out. Like at Tomorrow River on YouTube said, Dr. Oz, it's going to hurt. Thanks for speaking out.

Yes, that's in response to one of your Knock Knock Eyes where you talked about the nomination. I recorded it right after the news of Dr. Oz being the HHS director. No, sorry, not HHS. That's RFK Jr. Yeah, also great. Dr. Oz is the CMS. For Medicare. So Center for Medicare Services. Yeah.

which is just a scary thought. So you can hear all my thoughts about it on the, um, look back at the knock, knock guy episodes and you'll, you'll hear what I had to say about it. Um, needless to say, it was not thrilled. Um,

Anyway, thank you for that comment at Tomorrow River. And full video episodes are up every week of this podcast on our YouTube channel at Glockenfleckens. We also have a Patreon. Lots of cool perks, bonus episodes, react to medical shows and movies. You can hang out with other members of the Knock Knock High community. Dr. Oz is not invited.

Don't worry. He does not control the health insurance. Is he preemptively banned? If he wants to let me influence his decision making as the CMS director, I'll consider it. But anyway, until then, no. Go find another internet comedian ophthalmologist to be a patron to. Anyway. So join us. What else did I have to say about that? Oh, early ad-free episode access, interactive Q&A, live stream events, and much more. Patreon.com slash Glock.com.

Speaking of Patreon community perks, I sound like I'm coughing up something. You sound like an old man waking up in the morning. Patreon community perks. New member shout out, Jamie R. Thank you, Jamie, for being a patron. Welcome. Also, shout out to the Jonathans as usual. Patrick, Lacey, Sharon S., Edward K., Stephen G., Marion W., Mr. Granddaddy, Caitlin C., Brianna L., Mary H., K.L., Keith G., Jeremiah H., Parker, Muhammad L., David H., Times Two,

Kaylee A, Gabe, Gary M, Eric B, Marlene S, Scott M, Kelsey M, Dr. Hoover, and Bubbly Salt. I feel the need to point out that Eric and B are different people. Eric. It is not Eric B. Oh, Eric. Eric.

There's Eric and B. Yes. Yes. Because I feel like B is maybe getting the short end of the stick here, right? I'm going to call out B specifically because it's probably not been clear all this time that B is its own person. I'm sure B is very excited about this. So Patreon Luttime, random shout out to someone on the emergency medicine tier, Catherine R.

Thank you, Catherine R., for being a patron. And thank you all for listening. We're your hosts, Will and Kristen Flannery, also known as the Glockenfleckens. A special thanks to our guests, Max, Jordan, and Gumini. Our executive producers are Will Flannery, Kristen Flannery, Aaron Cordy, Rob Golden, and Shanti Brooke. Editor, engineers, Jason Portiza. Our music is by Omer Benzvit. To learn about our Knock Knock Highs, program disclaimer, ethics policy, submission verification, and licensing terms and HIPAA release terms, go to Glockenflecken.com or reach out to us at KnockKnockHigh at human-content.com with questions, concerns.

or fun medical puns. No one's ever given us any concerns. That's good, right? Maybe. They haven't read through those documents and realized, oh, there's a concern here. I have a concern about your submission verification in lightstick terms. Knock Knock High is a human content production. Knock Knock, goodbye. Hey, Kristen.

Yeah. You know, we love Dax Copilot here. We sure do. It's great. Love it. A little Jonathan in your pocket. Yeah. I know, right? QC. Yeah. Helping out with admin burden documentation. One of the things I really like is it can organize your notes for you.

Yeah. I don't know if this might come as a surprise to you. My notes sometimes not the most organized. Really? Yeah. I mean, I could use a little help and Dax is there to help me with that. That's right. While also, by the way, like looking at my patients when I'm talking to them. I love it when my physicians are using Dax in my appointments because they just have a better conversation and rapport. It's just a better overall appointment.

And one thing that people might get a little bit concerned about with AI products is safety. Yeah. But Dax Copilot is backed by Microsoft's robust security. I feel great about their security. HIPAA compliant. HIPAA compliant.

And so my patients are safe. I know the documentation is safe. And it's just a great thing. Yeah, very helpful. To learn about how Dax Copilot can help you reduce burnout and restore the joy of practicing medicine, visit aka.ms slash knock knock high. Again, that's aka.ms slash knock knock high.