Announcer:
0:00
Welcome to MedEvidence!, where we help you navigate the truth behind medical research with unbiased, evidence-proven facts Hosted by cardiologist and top medical researcher, Dr Michael Koren.
Dr. Michael Koren:
0:11
Hello, I'm Dr. Michael Koren, the executive editor for MedEvidence!, and I have a great honor today of interviewing the 20th Surgeon General of the United States, Dr. Jerome Adams. Jerome, thanks for being part of MedEvidence! I'm super excited about this discussion and you gave a fabulous talk at SCRS that stands for the Society of Clinical Research Sites. You spoke about your experience as Surgeon General and I wanted to use this opportunity to have you talk to our audience about your unusual pathway as a physician and anesthesiologist, as I understand it, and secondly, talk about the concepts that you learned during your term as Surgeon General, particularly as it relates to evidence-based medicine. So, with that brief introduction, again, my honor for you to be part of this. Thank you for participating and tell us a little bit about how you got to be Surgeon General of the United States. What a fascinating story.
Dr. Jerome Adams:
1:11
Wow. Well, thanks so much for having me here, and I don't know how unusual my story is, but I will tell you that it's not the pathway that is traditionally talked about. I was just talking to a group of pre-med students the other day and I mentioned how often you hear about folks who are children of doctors, or you know nieces and nephews and that's how they got interested in medicine. But for me, my pathway started in rural southern Maryland, in a community where not many people went on to college, much less to pursue advanced degrees.
Dr. Jerome Adams:
1:53
I actually grew up in a farm country on an old tobacco farm and both my parents were teachers, but again, certainly no one around me pushing me to to become a physician. But I actually was in the hospital quite a bit. I had many encounters with the health care system because I was an asthmatic, like far too many black boys. Three times as likely if you're a black boy to have asthma. Three to four times as likely to be hospitalized or die from asthma. And we don't have a lot of time here so I don't want to give you the full story. But I actually almost died when I was growing up. I had status asthmaticus. For those who aren't familiar with that term, it's when you have an asthma attack so severe that the medical treatments they're giving you can't break that asthmatic attack. And I was at a rural critical access hospital where there wasn't even a pediatrician on staff. So they did all they could for me but they had to medevac me to Children's Hospital in Washington DC in a helicopter to save my life.
Dr. Michael Koren:
3:07
And Were you intubated, were you put under a ventilator?
Dr. Jerome Adams:
3:12
Wasn't intubated, wasn't put on a ventilator. What's interesting is, I think I probably would have at other hospitals, but again Rural Critical Access Hospital. While I'm sure they were capable of doing that, they weren't accustomed to intubating peds patients, and so, again, it's interesting, my kids Now we live in a community where there are three hospitals, two of them level one trauma centers, within a few minutes of, within about 20 minutes of where I actually am sitting at this moment. So if my kids ever needed something, they could get it.
Dr. Jerome Adams:
3:48
But far too many people who live in rural communities and marginalized communities don't have access to high quality medical care, and so before I even was interested in becoming a doctor, I inherently knew that there were certain people who didn't have the same opportunities to grow up healthy and safe, and so my parents were schoolteachers. They encouraged me to learn about STEM programs and I enjoyed science and math and I actually went to school, to college, to be an engineer on an engineering scholarship. But while I was there, I had the opportunity to meet Dr. Ben Carson at an event.
Dr. Jerome Adams:
4:34
Oh wow, the famous neurosurgeon, the famous African-American male neurosurgeon, right, and that was the first time in my life I'd ever met a black doctor.
Dr. Michael Koren:
4:43
Really, wow
Dr. Jerome Adams:
4:44
Yep, I said, huh, I guess that could be a pathway for me,
Dr. Michael Koren:
4:47
Right
Dr. Jerome Adams:
4:47
And that changed my life. It convinced me to switch into the pre-medical track and went to medical school at Indiana University. While there, I got involved in the American Medical Association student section, where I went to Washington DC, lobbied on behalf of the things that we, as medical students, thought were important, and got to meet then Congressman Mike Pence.
Dr. Jerome Adams:
5:17
Well, 10 years passed. Congressman Mike Pence becomes Governor Mike Pence and I had gotten my master's in public health after medical school and Governor Pence needed someone to run his State Department of Health. He knew me. I was a known commodity because I'd been going to DC to see him for years. I had my MD and my master's in public health and he asked me to be his state health commissioner. And so I ran the Indiana State Department of Health for three years and Governor Pence became Vice President Pence and my name got thrown into the hat to be Surgeon General. And so that is my very abbreviated version of the pathway from being an eight-year-old boy who literally almost died because he couldn't access care to medical school, to becoming the Surgeon General of the United States.
Dr. Michael Koren:
6:08
Wow, that is an intense story. Thank you for sharing that. Were there any conflicts when you were trying to decide about a clinical career versus a public health career?
Dr. Jerome Adams:
6:18
Well, I actually started off first of all convinced I was going to do primary care because that was what I knew and what I had experienced.
Dr. Jerome Adams:
6:28
And I will tell you that I got frustrated because I realized that, no matter what I did in the hospital or in the clinic, I was having difficulty changing my patients' outcomes.
Dr. Jerome Adams:
6:40
Number one because they didn't have the resources and number two because only 20% of your health is determined by what happens in a hospital or clinic. The other 80% happens in your community and we don't teach our medical students, our nurses, our pharmacists how to move those social determinants of health, if you will. And so that's what sparked me to get my master's in public health, number one. But I'll also be very frank with you, it's also what pushed me to go into anesthesia, because I realized that if I wanted the anesthesia, I actually would have more time and more resources to be able to devote to doing the other things that I felt were important: volunteering, leaning into those social drivers of health, because I'm older than what I look and you know there weren't programs like there are now for medical students where they integrate teaching about public health and social drivers. So I had to say, ok, this is my doctor hat in the hospital, what I'm doing and this is my working in the community hat I had to completely separate.
Dr. Michael Koren:
7:46
Sure. What advice would you have for people who are considering being involved in the public health sector if you're trained as a physician, any words of wisdom based on your experience?
Dr. Jerome Adams:
7:59
Well, a couple of things. We know that the United States spends about two and a half times the OECD average, which is all the other wealthy countries, on health care per capita. So, while we often think that there's not enough money in the U. S. healthcare system to do the things that will keep people healthy, um, we, we spend more than any other country, but yet we're still ranked 40th in terms of life expectancy, terrible on infant mortality, terrible on obesity.
Dr. Jerome Adams:
8:26
So what? What I would say to folks is number one we have to understand that our system is broken. That we're doing what I call downstream sick reimbursement as opposed to upstream, true health care, and so if you want to be happy as a physician, if you want to feel like you're actually changing people's lives, you have to be willing to get a little messy and to ask your patients about their social drivers, housing, transportation, access to food, child care, and you've got to learn or demand that your system helps provide resources so that you can address those things, and you don't have to do it yourself. But you've got to know what exists in your community. You've got to understand what your patient's problems are and then what resources exist in the community to connect them with that care.
Dr. Jerome Adams:
9:17
So for me it was a matter of feeling like I can't do my job if I don't lean into these other aspects of overall health.
Dr. Michael Koren:
9:27
Yeah, it's a great point. Most of us in medicine are trained in disease management, not necessarily health promotion, and they're two different mind frames, I think. So I think you're spot on, so I'm going to change gears a little bit. The other thing I mentioned I was going to talk to you about is this concept of evidence-based medicine. Quite frankly, you probably had to deal with a lot of tensions during your time as Surgeon General, given the fact that you had this thing called COVID pop out of the blue during your tenure. Oh my God, I can't even imagine what that was like for you. But, as we all know, there was a lot of pressures to perhaps abandon some of the concepts of evidence-based medicine because of political pressures and just social pressures of being in the midst of a crisis, which, of course, we get. So let's start by just talking about how important evidence-based medicine is and how sometimes it could be easy to move from that principle that's our North Star as physicians and maybe talk a little bit about that.
Dr. Jerome Adams:
10:35
Well, I don't know if you had a chance to take a peek at it, but I actually wrote a book called Crisis and Chaos about my time as Surgeon General, and I talk about the challenges that we have in terms of being able to practice, to be able to understand evidence-based medicine. You know you talk about the pandemic. What's interesting is what we thought we knew in early 2020, in many cases isn't what we now believe to be true right now. So one of the challenges we had is what is evidence-based medicine? And the truth is it's making decisions based on the best evidence that you have at the moment. But we also know that science continues to evolve, and so it's on us to always take what we have available right now and make the best decisions we can, but always have a healthy degree of suspicion and never be overconfident that you know it all, because it can be completely upended you know, within during the pandemic, it was literally every day new information was coming out where we learned that putting people on ventilators early was actually bad for you, which is something we traditionally wouldn't think for people who have an infection going on. We learned that the vaccine, while great at preventing severe disease and death actually didn't prove to have much long-term durability. And that hurt trust in the vaccines, because many people and many early on were demonized for not taking the vaccine and then they find out that, hey, it doesn't work to do the thing that you were telling us would help us get back to normal life. And so, all that said, a couple of key points I'd make, and I make these points in my book. Number one you can't make good policy decisions if you don't have good data. So we have to really demand that our policymakers, our health care systems, do a better job of getting data to us so we can make.
Dr. Jerome Adams:
12:44
Also important that we understand the US literacy in science and math is actually pretty terrible when you look at the rest of the world, and so it's difficult to have nuanced scientific conversations about the scientific method and the scientific process when most Americans don't understand it. We have to understand, from a communication standpoint, that the average person you're speaking to has a fourth grade education. So I tell people, if you ask me as a doctor a question, I'm prepared to go back and put together a 40 slide PowerPoint presentation and present in words that only people who've gone to medical school would understand. That's how we're prepared to communicate. We're not prepared to communicate on podcasts and on TikTok and on Twitter and in two-minute combative interviews with Rachel Maddow or Sean Hannity, and so we need to understand that and lean into communications training for physicians.
Dr. Jerome Adams:
13:46
And the final point that I'd make and this is probably the most important point is that we have to understand that communication and education doesn't happen unless you've got a foundation of trust. People need to know that you care before they care what you know don't, and so you have to form those relationships with people so that they inherently feel that you're telling them something that's in their best interest, and then they will open up their minds and their hearts, and that's hard to do in this current political climate.
Dr. Michael Koren:
14:17
Yeah, well said, beautifully said. So we hear from patients. You keep on changing your mind. First you thought ventilators were good, then you thought they were bad, and you articulated it really, really nicely. And you see a sign behind me that says Truth Behind the Data. And you said that so nicely that we have to act on what we know at a given time. And what we like to say in MedEvidence! is that there's things we know for sure, there's things we don't know, and there's a way of learning about the stuff we don't know. And, to your point, we have to have the trust of patience to say, okay, well, I know this and we're going to make this decision based on what we know at this time. But while we're learning more, we need to be very aware that things may change. And in fact, we are generating hypotheses and the process of science advancing is to test those hypotheses and then share the information with everybody else in an honest way, not pointing fingers, and if your hypothesis is wrong, that's okay. That's how we advance things. So, Exactly.
Dr. Jerome Adams:
15:24
Another quick story that I'd give you that illustrates this and I talk about this in the book too is in early 2020, when we put out the recommendations that people mask. We went back and forth because we previously never recommended the general public wear masks, because we hadn't encountered a respiratory virus that had such a high degree of asymptomatic spread. And I explained it to people by saying if someone has the flu, you typically know they have the flu, they're coughing, they're sneezing, they've got a runny nose, their eyes are watery, they're symptomatic, it's invisible, and we also tell people when you're symptomatic, stay home. So our recommendations weren't wear a mask and go out and go out. They were if you're sick, stay home. Well, when you've got a virus, that's got 50 percent plus rates of being asymptomatic, that doesn't work.
Dr. Jerome Adams:
16:20
We learned that and we had to shift our recommendations. But the politicians, along with the lack of the public's knowledge about the scientific process and also, to be frank, along with the hubris of many public health officials who were communicating early on, combined such that people said well, now we can't trust you. You told us not to wear masks, now you're telling us to wear masks. Clearly, you guys can't be trusted. It's like no. We made the best recommendation we could at the time, based on everything we knew about these types of viruses, and then we got new data and we had to shift our recommendations.
Dr. Michael Koren:
16:56
Yeah, really, really well said. And yeah, I would add to that point that during the COVID pandemic, as we were learning about things, particularly as we were recruiting patients for vaccine studies here in Northeast Florida, we were starting to understand that there were huge differences in different populations and what would happen based on infections in those populations. And you made the comment and I'll paraphrase it by saying one size does not fit all. And in fact in COVID we found something very different than, for example, the flu pandemic of 100 years ago, which is that older people and people with preexisting conditions had absolutely devastating effects from COVID, but younger, healthier people did not. But if the younger and healthy people were exposing older, vulnerable people, you had a problem. So again, you have to take these recommendations and personalize them for the individuals.
Dr. Jerome Adams:
17:57
And I think Well and that's another tension that we have and will continue to have for the next several years We've shifted, I think, as a country, to a individualistic mindset, and that's a challenge too. In medicine, you have a singular patient in front of you and you're supposed to make recommendations for that patient. In public health, we're taught one person does not exist alone and we need to create societal policies and healthy communities so that everyone has a fair opportunity to live and to grow and to make healthy choices, and those two things oftentimes run in conflict, and we saw that with the COVID vaccine and now that's being extrapolated to many other vaccines. Do you take the measles vaccine to protect yourself or do you take it so that you're not spreading measles when you go to school to other people? Do you take the COVID vaccine to protect yourself? Are you taking it to protect your grandma? And the answer is both.
Dr. Jerome Adams:
19:00
But it's difficult when you have these all or none framings of either you're doing it for other people and hey, that's not my job to protect other people or you're doing it for yourself. And also interesting most people didn't recognize the risk that they had. 60% of adults in the United States have one or more risk factors for a negative COVID outcome obesity, hypertension, prediabetes or diabetes. So all these people out here saying hey, just make the old people take the vaccine and leave me alone, didn't realize that 60 plus percent of them were in a high risk group.
Dr. Michael Koren:
19:33
Right, yeah, very, very well said. But again, I think the key point for the people that are listening is that you need to put all these recommendations into the context of the individual.
Dr. Jerome Adams:
19:45
Exactly when you're talking to an individual, you have to help them understand. This is what it looks like for you, so you can make a wise choice
Dr. Michael Koren:
20:00
And I also will say that I think the deterioration of the doctor-patient relationship is also a factor here, because years ago people would go to their personal physicians and have discussions with that person that would be customized for the needs of that person. And when you're consuming your information just from broad media outlets, they're never looking at the context of the individual, it's just impossible to do so.
Dr. Jerome Adams:
20:20
Well that and another interesting point about the pandemic and I'm glad you brought that up because I point out something else that many people don't think about. The pandemic; this was the first time in most of our life where we had mass vaccination clinics. People weren't going to their doctor to get vaccines, they were going to the local football stadium.
Dr. Jerome Adams:
20:43
Yeah they were going to the local firehouse or they were going to the local pharmacy, and it wasn't a situation where you went and you had an opportunity to to talk to your doctor and get your questions answered. It was show up, stick your arm out the window and get the shot and that's a very different dynamic and to your point it went around that traditional patient-doctor relationship and conversation that gives people that confidence in something like a vaccination.
Dr. Michael Koren:
21:10
Yeah, absolutely. Very well said, Jerome. In the interest of time, I'm going to ask you if you have any final comments to summarize one, your career pathway and two, this concept of evidence-based medicine in the public space.
Dr. Jerome Adams:
21:26
Well, one thing I do want to hit on that we haven't yet, when you talk about evidence-based medicine, is that in many cases relies on clinical trials, and one of the things that you and I have discussed and we talked about at SCRS is the fact that the lack of diversity in clinical trials hurts our ability to actually make evidence-based decisions for different populations, because we just don't know. My asthma, for instance, we know that pulse oximeters weren't tested on people with darker skin color, though it was decades before anyone realized that pulse oximeters were falsely reading the oxygen levels in people who look like me. The medications we use for asthma, again, weren't tested on African-Americans, and so it took us decades to realize that they work differently. So I think it's incredibly important that we continue, not just from a moral standpoint, but from a quality standpoint, from a economic standpoint, because if you're giving someone an expensive medication that doesn't work for them, but you don't realize that, you're wasting resources and money. For all those reasons, it's important that we continue to focus on increasing diversity in clinical trials by engaging with communities, building trust in those communities, and I think that's a great place to close on.
Dr. Jerome Adams:
22:43
It really comes down to getting out of our hospitals and clinics, creating relationships with the community, building relationships and trust, and once we do that then we can have more nuanced conversations about the science and the data and if we do that, then I have hope for where we can go positively in the future. But we also have to acknowledge there are very real headwinds that we're facing in terms of politics, in terms of the media, in terms of health and science and overall literacy, and I would hope that doctors continue to stay encouraged. When people are asked who do you trust for health? They don't trust the government, they don't trust the CDC, but they do THEIR doctor doctor. So take heart in that and leverage that bully pulpit that you have with your patients to help improve their health and society's health.
Dr. Michael Koren:
23:41
Very well said Again, Dr Jerome Adams, the 20th Surgeon General of the United States. Jerome, show your book one more time for the audience. It'll be on my reading list.
Dr. Jerome Adams:
23:52
It's at Barnes Noble, you can get it on Amazon. com and again, I hope folks will take a chance to read it, because I really talk about the mistakes we made during the pandemic, but just as much I talk about why we continue to make the same mistakes. Many of the reasons that we discussed today.
Dr. Michael Koren:
24:10
Thank you for a great interview and best of luck to you, and thank you for your service.
Announcer:
24:15
Thanks for joining the MedEvidence! podcast. To learn more, head over to MedEvidence. com or subscribe to our podcast on your favorite podcast platform.
