thanks everyone for joining us I am privileged to have dr. Rishi Desai on he
is a amazing amazing clinician and amazing educator well let's start with
the clinician part first first of all he's a pediatric infectious disease
specialist at Stanford University but even more importantly our Rishi you were
as far as I'm concerned one of the stalwarts and the pillars of flipping
the classroom on YouTube and on the internet because you worked with khan
khanacademy tell us a little bit about that yeah thank you for inviting me
Rajat it hang out with you a bit I started there because I was excited
about kind of making online tutorials making videos and I started doing that
with them mostly around kind of pre-med topics and and they kind of got into
MCAT so getting kids into into Medical School and I loved doing it and then
about three years ago I switched over to osmosis and continued kind of helping to
make videos but but now I have moved roles so now there's a whole team of
folks that make videos and and I just love doing it's a lot of fun I think the
problem today has been is trying to figure out what information do we need
to know and what information can we just look up what do you think yeah no I I
couldn't I couldn't agree more and in when I have fellows and residents with
me now I care more about who has the best question than who has the best
answer and what I mean by that is like you know you walk by a patient who's on
dialysis and if you don't even think to question how that affects their
medications because now that the meds are even dialyzed off if you don't even
think to ask that question then you'll never even think about Reed dosing their
medications but if the question pops up in your head then you can easily go look
up or talk to a pharmacist about kind of figuring out how to read dose of
medication so I think the best doctors are the ones that are kind of coming up
with the right questions and thinking about things and then the easier part is
then going to look things up I remember becoming a third year medical student I
mean I'd be getting up at 5:00 6:00 in the morning going in doing rounds coming
home at 5:00 exhausted and then realizing that I still have to study and
you'd look up the syllabus and they'd say okay here's Harrisons right I mean
it's like a doorstop one of the things that
come up recently here in in the media it has been the new hypertension guidelines
and I think it's a a great example of all of the issues that are plaguing
medical education for instance they always used to tell us we're teaching it
here in medical school but we'll have to tell you up front 50% of what we're
teaching you is wrong we just don't know what 50% it is and here we have the new
hypertension guidelines yeah exactly and I would love to hear your take on them
because I think these guidelines get a lot of play on Facebook and Twitter and
things like that but but it's good to dive into and understand kind of what
the changes are because it's such a major major thing that affects all
Americans and and frankly people around the world right and I know you've
uploaded a video that's gone over these and we've we've done the same because I
think it's important the the implications are enormous we're talking
a hundreds of thousands millions of people we're talking about medications
pharmaceutical companies everybody has their has their say about you know is
this a push towards farm and pharmaceutical companies is this a push
away from that lifestyle diet so let you know if we just look at what the
guidelines are there's actually a lot of interesting material there the first
thing is that the last time these guidelines really came out and were
comprehensive was back in 2003 so this is 14 years in the making
there's a lot of political issues with this the National Heart Lung and Blood
Institute basically handed over the responsibility these guidelines back in
2013 to the American College of Cardiology and the American Heart
Association and so they've picked up with it and now they've come up with
these guidelines but what's interesting about these guidelines first two things
number one is the classification both the old and the new guidelines agree
that a blood pressure of less than 120 systolic is okay it's normal and both
guidelines agree that any blood pressure above 140 is abnormally high where they
differ is that sweet spot between systolic 120 and 139 and whereas before
they were called pre hypertension they wouldn't get a diagnosis you know if
somebody told you that you had pre whatever your
like well that means I don't have it right so now on the other hand instead
of them not having it they've taken that sweet spot of 120 to 139 and they've
done a little bit of risk stratification they've said that if you're between 120
and 130 or 129 that that lower region you've got something called elevated
blood pressure do they just call it elevated you get a diagnosis of
hypertension you get the icd-10 code for that whatever it's gonna be
and why is that well they've looked at new research and though people are about
two times higher the risk of getting coronary disease and stroke so what
they're recommending for those people is not necessarily pharmacological therapy
but lifestyle then they take the second strata between 131 39 and they say okay
this is now stage 1 hypertension but not everybody has to go on medication is
about 30% of those people who have either coronary disease or they've got a
greater than 10% chance of developing coronary disease in the next 10 years
and they say those are the people that we should start on pharmacotherapy
whereas before they would just be pre hypertension they wouldn't be getting it
so the question is is are there going to be more people diagnosed with
hypertension the answer is yes are there gonna be more people on medications for
hypertension I think the answer is gonna be yes and so they're getting more and
more aggressive so the question is is where did all this come from they've
looked at all of these studies and the big study to look at if you're
interested is a study called Sprint and what they found and they excluded
diabetics from this so that's important but what they found is that reducing
blood pressure to below 120 as a below as opposed to just 140 actually reduced
ordinary artery disease cardiovascular death and CHF so that's basically the
new guidelines in a nutshell and there's a lot of reverberation going on in the
Nets and through the society so we'll see what happens yeah that's the price
to synced and accurate explanation I think one one thing that I always think
about is you know anytime you're moving the goalposts as it were the the
ultimate goal posts you really care about the thing we
all care about is not like what label and what drug even but are you
preventing deaths which you alluded to and already preventing bad outcomes and
we'll see you know in 5-10 years if giving more meds now which is pretty
much what everyone agrees is gonna happen really does those things and when
we hope it does we hope it prevents deaths prevents you know real severe
hypertension from developing because you started earlier you were more aware of
it and the analogy would be you know something like colon cancer where if I
know that you know I've got you know some sort of familial polyp
a lot of colon cancer my family I'm gonna get early screening I'm gonna be
more vigilant about it so that's your 120 to 129 range we're
not elevated heparin I'm gonna be thinking about it more may be getting
more frequent checks than I otherwise would have because we know that that
seems to be predictive of a bad outcome down the road it makes sense and I
understand why but I also understand that the concern around you know these
major major powerful groups getting getting more money and getting more more
patients using their medications and things like that exactly I think what's
important is that they're at least they're stating that they're that what's
driving this is evidence-based and I think the evidence is there the other
interesting thing about this is the way we monitor blood pressure and you know
back in the 1980s 1990s how do we get blood pressure medication readings we
got it by going into a doctor's office and some healthcare professional
measuring our blood pressure now what do we have we have fitbit's right we can
know more about the human body when we're not in the doctor's office
than we ever dreamed up what they're noticing and what the issue is is that
you know blood pressure is a result of your environment if you're under stress
you're gonna have a higher blood pressure and so every any time anybody
goes to the doctor's office there could be under a little bit more stress and so
what the finding is is that these ambulatory blood pressure monitoring and
home blood pressure monitoring are typically a little bit lower than what
we're seeing in the doctor's office and so if we're gonna be using those to
generate hypotheses it makes sense that we're probably gonna have to lower down
that classification to meet those numbers yeah exactly and that point is
huge right like right now we see a doctor maybe once a
year and maybe twice a year that's a snapshot you know that's literally like
taking a Polaroid camera and just snapping two quick shots you know that's
all you get and what you're moving towards is a movie where you just watch
someone continuously and you get such a rich understanding of kind of what their
blood pressure is doing and blood Sugar's doing and all this kind of stuff
and so we're gonna see much more of this correcting of guidelines as we get
better and better data sets and saying okay you know what a one-time check of
135 that actually means that probably most of the time as you correctly
pointed out you're riding at 140 145 and so as I see that and correlate that
we're gonna get more and more accurate assessments of who really is at risk and
who isn't right and it's almost analogous to the hemoglobin a1c right
which was a built an average of your three months of blood sugar exactly and
we don't have that for hypertension yet but you know you could easily imagine
that we have a new measure that you know as you said 50% of what you know you
know in two years we'll be doing this this again you and I and we'll talk
about how how you know the guidelines are out because we have better data sets
and now we've now we call it the you know hypertension a1c or you know
whatever it is but like some long-term measure of hypertension rather than just
a snapshot the other thing that they talked about that I was surprised at was
this thing called white coat hypertension I remember when I was quote
growing up I remember studying mix app if you remember mix app except was that
thing for internal medicine and I remember studying a mixed-up question
and the thing you have to know for this question was that white coat
hypertension was a risk factor for getting left ventricular hypertrophy
right so now what are they noticing that fits into the 50% that was wrong
what they're noticing is white coat hypertension which again is you have a
normal blood pressure at home and you come into the doctor's office it's a
little bit elevated well when you follow these patients out their risk for for
coronary events is the same as those who are normal tensive so so in other words
if we take that blood pressure reading in the office we could be treating
patients that don't really need to be treated
I teach over at Loma Linda University one of the things that we've been doing
is every three or four months I have to go in and teach third-year medical
students about the pulmonary aspect of medicine and we try to do that in three
hours so imagine going in at one o'clock in the afternoon and coming out at five
and just me talking for four hours about everything from the five mechanisms of
hypoxemia to the reasons why someone gets a pulmonary embolism now what we've
done is we've put that whole lecture now online and and now what I do when we go
in is we usually we have like a little Jeopardy session you know medical
jeopardy so you do that for about an hour and then after that we go up to the
simulation lab and for the next hour we talk about a case we simulate a case and
I think that's that's kind of part and parcel of what flipping the classroom is
but Rishi tell me one of the biggest barriers that I see at least on our side
and you can tell me what you see on your side is sometimes the students just
don't get down and and look at the material before the class what's the
best way that you found to make sure and make that make sure that that happens
yeah that's that's the biggest issue and a lot of faculty struggle with this as
well at Stanford one thing that they've done is they've started doing almost
like on and actually some of the meetups are in physical spaces that are not in
the classroom so they'll have a few faculty members like five faculty sign
up for a random Friday night to go to a really nice bar or a really nice
restaurant and they'll invite students to come to that place and just talk to
faculty about whatever they want to talk about and the idea is that you would
only go there if you wanted to go or they'd have a discussion topic like
let's talk about hypertension and the idea was that you'd only go there if
you've actually prepared for it you know if I'm gonna go and and it's somehow a
social setting seems different I think sometimes when you go to a physical
place I collect Rahal because we're pre-programmed to think we're gonna get
spoon-fed like like you and I were right that's what you should kind of be used
to but somehow just moving the physical space or different space gets people in
a different mindset like oh I'm going almost like a book club if I'm gonna go
to the book club I'm gonna read the book I'm not just
gonna go to the book club if I don't read the book I'm same idea like you
would only go to these meetups with faculty
if you've actually done the pre-work and it becomes really evident when you go to
these places and you have done the pre-work that you you aren't able to
participate as fully and so I think that's been one kind of small trick but
it's a psychological trick it's just literally moving the space to a
different location and people start kind of only going and only signing up to go
if they've done the pre-work and it's kind of a neat thing because unless
people show up frankly you know because they people haven't done the work don't
show up and that's fine then they can go you know stay home and do the pre work
while the folks that do show up have a rich discussion about it it's about
engagement and getting them engaged in lifelong learning
I know these are all catchphrases but I really it does have actual meaning yeah
and I mean as a med student you know a lot of the value you get is not from
your faculty or from your books it's from your peers right like the people
that I really trust today are the people that I studied with that I grew up with
essentially my cohort and so if your cohort isn't enriching your experience
that sucks and if you're not enriching theirs you know you're you're kind of
the reason that it's making it suck for them so I think that that's an important
piece is that when you start med school or nursing school or anything you have a
responsibility to your peers to do your work and that's not just to yourself but
it's to your peers and if you can kind of frame it that way then you're not
just letting yourself down when you don't prepare you're letting everyone
down now the problem is that so many people get caught up you know in bad
classrooms not understanding some basic thing yeah that's not the hard part you
can cram that part the part that you shouldn't be cramming is the discussion
in terms of how it applies to someone you know and that's what it should be
like our videos are just like yours that are short videos I want them to be short
because I think that that's the easy bit you know it's easy to just understand
the new guidelines but what's hard is you know understanding how it applies to
a person and saying okay here's a 17 year old person comes in with blah blah
blah what would you do that's the part you can't cram away well doctor to say I
really appreciate your taking the time to meet with us and to talk with our our
med cram subscribers and viewers out there I think that we are together
making it there for its one video at a time absolutely
thank you so much Roger I appreciate it