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Orla Smith, editor of Science Translational Medicine joins host Sarah Crespi to talk about what has changed in the past 10 years of microbiome research, what’s getting close to being useful in treatment, and how strong, exactly, the research is behind those probiotic yogurts. When you’re sick, sleeping is restorative—it helps your body recover from nasty infections. Meagan Cantwell speaks with Amita Sehgal, professor of neuroscience at the University of Pennsylvania and an investigator at Howard Hughes Medical Institute in Chevy Chase, Maryland, about the process of discovering a gene in fruit flies that links sleep and immune function. This week’s episode was edited by Podigy. Listen to previous podcasts. About the Science Podcast [Music: Jeffrey Cook]
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Ted Schaeffer, M.D., Ph.D.: How to catch, treat, and survive prostate cancer (EP.39)
Hey, everyone. Welcome to the Peter Attiyah drive. I'm your host, Peter. Drive as a result of my hunger for optimizing performance health on jeopardy critical thinking along with a few other obsessions along the way, I've spent the last several years working with some of the most successful top performing individuals in the world, and this podcast is my attempt to synthesize. What I've learned along the way to help you live a higher quality more fulfilling life, if you enjoy this podcast. You can find more information on today's episode and other topics at Peter Tia, MD dot com. Everybody. Welcome to this week's episode of the drive. I'd like to take a couple of minutes to talk about why we don't run ads on this podcast. And why instead we've chosen to rely entirely on listener support, if you're listening to this you probably already know, but the two things I care most about professionally are how to live longer and how to live better, I have a complete fascination and obsession with this topic. I practice it professionally and I've seen firsthand how access to information is basically all people need to make better decisions and improve the quality of their lives curing and sharing miss knowledge is not easy. And even before starting the podcast that became clear to me, the sheer volume of material published in this space is overwhelming. I'm fortunate to have a great team that helps me continue learning and sharing this information. With you to take one example are shown outs are in a league of their own. In fact, we now have a full-time person that is dedicated to producing those and the feedback has mirrored this. So all of this raises and natural question. How? How will we continue to fund the work necessary to support this as you probably know the tried and true to do this is to sell ads? But after a lot of contemplation that model just doesn't feel right to me for a few reasons. Now, the first most important these trust. I'm not sure how you can trust me. If I'm telling you about something when you know and being paid by the company that makes it to tell you about it. Another reason selling ads doesn't feel right to me is because I I just know myself. I have a really hard time advocating for something that I'm not absolutely nuts for. So if I don't feel that way about something. I don't know how I can talk about it enthusiastically. So instead of selling ads I've chosen to do what? A handful of others have proved Ken work overtime, and that is to create a subscriber support model for my audience. This keeps my relationship with you, both simple, and honest, if you value what I'm doing you can become a member and support us at whatever level works for you in exchange. He'll. Get the benefits above and beyond what's available for free. It's that simple. It's my goal to ensure that no matter what level you choose to support us at you will get back more than you give. So for example, members will receive full access to the exclusive shouts including other things that we plan to build upon such as the downloadable transcripts for each episode. These are useful beyond just podcast, especially given the technical nature of many of our shows members also get exclusive access to listen to and participate in the regular ask me, anything episodes. That means asking questions directly into the AMA portal. And also getting to hear these podcasts when they come out. Lastly, and this is something really excited about I want my supporters to get the best deal possible on the products that I love, and as I said, we're not taking at dollars from anyone. But instead what I'd like to do is work with companies who make the products that I already love and would already talk about for. Free and have them pass savings onto you again, the podcast will remain free to all. But my hope is that many of you will find enough value in one the podcast itself and to the additional content exclusive for members to support us at a level. It makes sense for you want to thank you for taking moment to listen to this. If you learn from and find value in the content, I produce police consider supporting us directly by signing up for a monthly subscription. My guest this week is Dr Ted Schafer, the chairman of urology, Northwestern University in Chicago is your August who specializes in the diagnosis and treatment of prostate cancer. His high quality work has earned him the trust of people like Ben Stiller is operated on and who have spoken very publicly about his own battle with prostate cancer. In this episode, we go through all of the current and basic best practices for the screening and treatment of prostate cancer from the latest drugs to the surgical options the conversation net. Naturally leads to our volving understanding of cancer and the most exciting areas of research in prostate cancer. Specifically, we also touch on the controversy around the role of things like Tata stran- replacement in the development of prostate cancer. And even the controversy surrounding prostate screening using things like the PSA and finally if you're an MVP HD student, which realized might not be many of you, you'll wanna listen closely as Ted has some of the most pertinent and unimpaired most important advice for those who are deciding on how to thread this needle of being clinicians and scientists so without further delay, please enjoy my conversation with one of my closest friends from residency Dr Ted Shaffer. Hey, man. How are you? I'm great good to see through. It's kind of weird when I go visit my friends from residency. I see them in their grownup close and their grownup offices. It it kinda makes me feel like I failed. Well. Your office is stunning. The view over the lake in Chicago and admittedly. This might be the best month of the year to be in Chicago. But it's like we're in the elevator coming up here. And I feel like we're supposed to be doing. Like, we always did. And I'm like, wait. We can't goof off he's now that chairman of urology, we we got gotta be serious. It's true. When I when I look at looking at you here doing this recording. I can't help but just chuckle. So we'll get to all the med school stuff or the residency stuff because that's obviously where we met. But let's talk a little bit about your decision to even do a PHD. And you have an interesting story there 'cause you weren't on the typical MD HD path. Right. Yeah. I, you know, people ask me about my life. And how I got to where I am. And there's a couple of principles. I think about and their common themes that we share together. But one of the things I teach our talked to my trainees about is. You know, you never walk by an open door without looking inside. And so that's how I ended up being at the NIH doing my PHD. But even before that, I think the way my brain was built was that. I always wanted to see what was inside the open door inside the alarm clock inside the watch and so- conceptually as I move through my my training. I liked biology because I wanted to understand how things worked I loved organic Chem. Stray love putting the puzzles together making things happen. And so as an extension of that when you're in medical school in learning about the pathology of why things fail understanding out of the soil level. Just always appeal to me, and I loved the ICU I love the, you know, the physiology of the human body and how you can measure all that. And so I I think about that a lot 'cause I, you know, read in been failing your blogs in your life. How you analyse everything you do. And so for me in medical school was a lunchtime thing I went by this open door, and there is his opportunity apply for a scholarship through Howard Hughes Medical institution to really go. Study science at the NIH, and I had started college and school early. So I had a buddy I felt like I had a year to kind of play around and see what was interesting to me. And it was something that was out of the box for me. But I just you know, when you find something that makes sense, it's no longer risky to you. You're not exposing yourself to anything. It's really just. Exploration. And so that that came very natural because I'm not the type of person who likes to take on risk do different things. But for me, it wasn't arrested just leave medical school and go to the NIH. It was an opportunity when you were in college. Did you know you wanted to go into medical school? I think so. Yeah, I loved I love biology. I love understanding the way things were and how they worked, and, you know, the most complex of all those things is the human body and just a living organism a multi cellular organism is just incredibly fascinating to me. So I was always attracted to that. And so I thought that was a natural extension. But I remember when I was in college. There was a very famous anthropologist at university of Chicago who was one of these dinosaur hunters. And so I just I loved I loved the idea of just discovery I love that idea of anatomy and discovering. What dinosaurs were like and how they did that. Right talk to my father, who's a physician and. Said, yeah, I wanna go off to grad school and be an anthropologist, and he's like do what you know. But that concept of discovery innovation. Figuring things out. It's just something. I've always had in me. So you don't just go to NIH. How did you wind up in the lab of a Nobel laureate? Well, it was through a friend of mine. So when this program, I was in, you know, you went in new interviewed in in different labs, and you basically decided what you wanted to do in some people. It was an incredibly talented group was about forty medical students from all over the country. So some of these people, they're just amazing. They knew what they wanted to do. They knew what field who they wanted to work with and so forth. I wasn't sure what I wanted to do. I knew I wanted to pursue this idea discovery and pursue it at a high level. And I remember there's a guy named Jonathan Ashwell. He was an immunologist. And I thought well, maybe I should do him in allergy mostly because I didn't really understand image. Analogy very well from my medical school class. It was a week kind of class for me. So I went talked to him. And he said, you know, he's a really tough guy. Very successful hardcore scientists in at the NIH aetiology. There was just really really just amazing. And he said, listen, you just got to pick a guy is really tough. He said look just a man up pick pick something and you'll get into it. And you'll love it. And I thought you know, that that was actually good advice. You know? And so I was shopping around for somebody who was motivated who is driven and who was smart to work with and a good friend of mine who's actually here at northwestern grant perish. You should look at this. Go talk this woman pants Wurzburg. She's a post doc in the Varmus Labban. She's looking for a student, and she's really good. And so I went interviewed with her. And she was exactly what I wanted me brilliant scientists and she happened to be in Navarre slab lab. But you know, the Varmus lab was a bunch of post docs, who would be effectively. Associate or full professors at any other university. They were just incredibly smart people on I got to you know, these these individuals are just amazing. So I met her, and then, you know, work through her with him in the plan was always to she had already been offered a position as a researcher at the NIH, and she was waiting to transition to her own lab. So we yes, technically, I was a Varmus lab member for six or nine months, and but all along I was mentored by this woman pants Wurzburg, who is just a brilliant scientist, and when she was a tech in her lab at Columbia. She was making, you know, she was had covers of sell, you know, she was brilliant so herald attracted people like this in his lab group, and we stayed part of his lab group, although independent throughout my kind of experienced there. And I always considered our group to be equal, but part of his group. So it was it was a lot of fun to interact with him on a weekly basis during lab eatings just to see how he thought I mean, you know, like, you I like. Surround myself with people are just incredibly smart and by being a member of his lab team. I by the faulted that not just him, but many many other people so is really fun for the listener, of course, held Varmus in and Michael Bishop shared the Nobel prize probably in the late eighties early nineties, eighty eight eighty nine ninety something like that. Right. They basically were the first people to elicit the relationship between viruses and oncogenes is that correct? Right. Yes. So the concept of their their prize was in probably butcher this. And the the real scientists out there will kill me for. But you know, the idea was that they described that there's this, you know, you could pass on a cancer through a viral induction. And so these violon jeans was what they described. So they were an active alteration and the cells normal machinery to to induce a cancer. I've never met Harold, but I did have the privilege of having dinner with Michael Bishop once a few years ago, and it was a very intimate. You know, there's like four people there, but everyone was either Nobel laureate or will be a Nobel laureate sort of thing. Luke, Handley David Sabatini, Michael Bishop. And you know, it's just one of those nights. Like, you don't want it to end, you can't believe that you know, we were at a steakhouse, and we were sort of sequestered in our own little room, and we probably spent like five hours they're talking about their work. It was amazing. You said something a second ago that I love I didn't know this about you, actually. So this is the funding of interviewing your best, boys. Is you still learn something part of the reason you're attracted immunology as you felt it was a weakness and having spoken with a number of very good. Scientists I find that to be very common thread, the great ones seem to go towards their weaknesses rather than away from them. Steve Rosenberg who was my mentor at the NCAA always talked about the reason he did he always knew he wanted to be any knowledge is always non negotiable. But he did his PHD biophysics because he didn't want to be intimidated by these differential equations when he read papers like he really wanted to understand field of science that the didn't come you know, sort of easily to him. So that's sort of an interesting aside about you. Yeah. I was funny. I had a great mentor and worked hard, and you know, on paper had a great. A PHD. And I remember was degree granted through the university of Chicago. So again, I wasn't in a formal PHD program. There was an open door for me to do this. Great. You know, this great program not between at the NIH. I went there for year. I just loved it. I loved the research environment and from there. I petitioned the stay in additional year. And I didn't really know what it meant to have a PHD. I mean, I wasn't going there for a PHD going there to do science, but I had friends that were informal MVP programs at university of Chicago. And they were like man, you know, what you've done is PHD students would die for. And I was like, well, I don't know. I'm just doing my thing, you know. So at that time, I was an idiot, and I was kind of ballsy. So I wrote a letter to my Dina's at all I think I should be. I should be someone should give me a pin the stuff, and they said, well, why don't you fly back and much give a talk and I did near like, okay. Yeah. You do not you're talking about. And what you had public. You have actually a very similar story to another good friend of mine who was innocent. Where he basically was in the right place at the right time. Right. Was in a great lab. Very well mentor d- great project and was willing to go to wall for it and ends up getting a a first authorship in science and hater, and it's sort of like you just have to hand those in and that becomes a PHD. That's the idea, you know. And so yes, all the critical thinking and how to develop and come up with a hypothesis and tested. I did all those things. So I mean, I met all the former criteria for it. I just did it in a I wasn't in a structured way just happened to be in a good environment. Where what was the most interesting question you were asking during your time at and I well, I mean, I think immunology and really I think I was more in cell, signaling lab. And so a lot of what we did was biochemistry and the idea was, you know, well, you would take a single protein, and you knock it out or turn it on or whatever. And it would have a huge fact, I think at that time people were thinking really, very linearly. No I had. I mean, my my PHD was pretty much the most amazing experience, you can imagine. So on my floor and building forty nine. It was in the old center. This is this is before for the news lentils under which was building forty nine was genome institute, it was across the street from the NCI buildings which I think were thirty five and thirty seven or something like that. So on my floor was herald Varmus, you know, Varmus lab, I was technically in our own lab with Pam, but we shared laughs face with Francis Collins. So you know, it was just I mean, you couldn't just pick a better Florida have just people on. So at that time Gino mix in transcript dome X in this is the mid nineties this is ninety seven ninety nine. So I mean, people are just starting to do homemade microrays and looking at expression, and I remember people like take a muscle cell, and they compared to a fiber glass, and they like, oh my God. You can see these different expression changes in these homemade microwaves. And so that's when everything. Was taking off a member loose doubt. Who still at the unite-, you know, an I h who was working on. There was a Howard Huston working on lymphomas and just characterizing the different genome FINA types of them and people still use that stuff today, it's pretty mazing. So I was there when all that was happening. I was I remember when I went there, you know, at university Kogyo people really weren't on the internet, and then I show up and I go to the lab, and there's t one lines of the NIH and the internet, and I remember downloading the Clinton tobacco, you know, in reading that in detail. And so there's all these just amazing things that happened in science and happened in technology that were going on at that period of my life and that period in the world. It was pretty it was pretty amazing. So so the thing that's a long answer to the concept that when I went there think people are still focused on single, gene single change. They're still looking for the like will you have this mutation? You get this cancer this mutation you have this FINA type, and you know. The human bodies apologetic organism. And so at last count if there's twenty thousand human genes, I believe there's something like seventy three, but I could be wrong. Let's just call it a hundred round up there about L only a hundred disease states that result from single genes, right Asians. Yeah. At a twenty thousand genes. Yeah. So you know, that was the big thing that big transition in Francis Collins's really leading that where there are people hunting for the gene for type two diabetes at the time. I was there, of course. Now, we understand a complex equation. And so within immunology when I was there. It was also a transition. So it turns out that the tiresome kind. As is that I worked on my PHD are really involved in fine tuning the t cell receptor, signaling. They're really Rio stats they really find tune the signal. It's not offer on just like, you know, you have a mutation and XYZ offer on. And so I think one of the big themes of what was evolving at the time. I was there was this concept. That was a fine tuning. And I remember we would do analogy retreats in the Roseau another way to explain this. Maybe for the listener. Because of course, I hear reestablish. I think about reestablish because I'm engineer digital is a signal it's honor off as zero or one analog is like the volume button on your radio. You can go from nothing to full blast. But an infinite number of iterations in between, and that's what you mean by modulating the signal, right? And I think that that Trent that was a period of transition and science for maybe we people always thought that that happened. But people were developing the tools to begin to test that and understand that. And you think about cancer me -nology, and Rosenberg lab was a huge player on campus. When I was there, which was ten years before you were there, and they were hunting for single tumor antigens. Right. That was but then they were realizing that that it's a complicated thing in its there's multiple factors that come into the role in the play there. So for me that was maybe conceptually something people had always thought about but the tools to. Floor that the tools to to test that on multi levels were kind of coming online in science at that time. So as a pretty fun time to do that talk a little bit about a tyrosine kindness. I mean, these these are so ubiquitous in biology that and they just come up over and over again. So explain to someone who doesn't understand what that is what it is. And why it's relevant and how and maybe where it shows up. You have your DNA everybody's born with it. It's an every single cell in your body. But the skin cells in your body make a certain amount of melanin that make you darker than I am. And so within between different people, there's variability in what the individual cells do what the DNA and then within the human body, there's different cell types. And they used the DNA the code differently that code then is incredibly its modified right by exposure to the environment. And that's the genetic change and what results is a protein and so. Once you have a protein, that's really what kind of constitutes a lot of what's in our cells in our body, but they're not inert. They're constantly changing. And so one of the ways that they changed and one of the ways of the signals change within an individual cell, how the cells communicate with each other excetera is by having kind of temporary modifications to those individual proteins. And so one of the ways that happens is through this these tight these kinds, and there's different pieces of the proteins that can be modified. So one of them is a tires in kind. But there are other types of kindnesses and these are temporary modifications that happen within a protein within a cell to typically transmit a more acute or change in within the seller between two sales and so forth. And of course, these have become a very attractive target for drugs. Yeah. So one of the obviously, the the idea in cancer biology is to find alterations to find mutations to find changes that you can quote on. Quote, target to do precision oncology precision medicine. And so these are one of the ways that were beginning to think about advancing the kind of medicine in that in that special way. Glee back targets tires, and kindness, doesn't it? It does targets specifically altered fused, gene. So it's not just adrenaline tiresome kindness. It's tiresome kindness. That's altered by specific mutation within a cancer. Amid was that was house originally described? And so yes, it will it will target those AMAN have specific affect and that was, you know, work done on the west coast in part by Charles lawyers. Who's now memorial who's, you know, a an idol of mine, but he wasn't the only one involved in kind of finding the fused mutation. It's sort of one of those exceptions to this rule. Right. Where if you have that mutation which basically if I recall only showing up in C, M L and GI storm tumors. Right. Then you do have the one hit wonder, you is this drug is at least in the it seems curate. I don't recall if it was actually curative in just. Yeah. G trouble tumors, or if it was just basically could render at a chronic disease for the GI strong will tumors. Snot my my space, but yeah, it works. But it does there is resistance at develops. I think in both models now, but in general for the liquid tumors. It's much more durable. And for GI struggles. At does help to suppress growth of those tumors. Some of them do recurring come back, and that's the concepts of how we manage. And we've converted, you know, HIV aids to from a lethal disease to a chronic condition, really those basic principles of multi targeting of the particular cell, so like for cancer single agent like leave AC isn't gonna work because the the cells chain alter but doing double a triple targeting will be affective long-term approach for those just like we learned from each v management. So I'm sure today, you know, you're now that chairman of urology, so you are in you encounter, lots of residents and medical students and one of them. To you and said, hey, Ted, or I guess they'd have to call you, Dr Schaffer. But you know, I'm really thinking about doing a PHD, and what advice would you give them to select a good lab. In other words, you describe so much of your trajectory is the is your the beneficiary of having been exceptionally well mentor, and you know, you've talked about Pam now. And before and we've talked about just when you have an amazing mentor. It's like everything works out. And yet the account lists go into labs that just couldn't waste more time. They don't actually learn how to think properly they come out as dumb as they were when they went in and the field has not advanced so in his much as surrounding yourself by the right people as the best first step, you can take what guidance. Would you give somebody to you know, what questions should they be asking? What things should they be looking for either positive or negative to help them think through that? Well, I think in you've had an opportunity to interact with brilliant, scientists all along and for me, it's the brilliant scientist. It's brilliant, clinicians is brilliant people. So what are the essence of those people? That's how. I would think about it, and mentorship matters, obviously, brainpower matters, motivation matters. So, you know, why is it that some PHD's tunes are not successful? Sure. You can attribute some of it to mentorship. But I really think that it has to do with motivation and drive, and that's such a critical part of it. So then you'd say, well, why somebody not motivated why aren't they driven? I mean, I guess some people are biologically built that way. But I also think maybe, you know, if you wanted to be nicer about it, you could say we'll maybe they just haven't found what they're passionate about. Because I think that Dr passion there very soon that they come from the same part of your heart, your brain. And so I think part of that is just that, you know, have they found the right area. Now, there are still having said that there are people that are just super passionate about something. They wanna do it. And they they just can't, you know, maybe they need to kind of move along. But I think that in my experience in grad school is that there are. Usually, you can it's not that hard to identify grad students aren't successful. It's pretty easy to find out. Well, they they're missing a major one of those components. So you head back to university Gago, you wrap up your last two years of medical school at which point you have to decide what you wanna be. When you grow up and you pick your allergy yet. So I went to university of Chicago undergrads. I I spent eleven years at university of Chicago and the first four years where the toughest years of my life for sure the the undergrad I learned only one skill set in that was how to use my brain out of think how to think critically, you know. That's why we became I think friends instantly at at Hopkins was that I feel like that's how your brain is built to and you've simplified that throughout your whole career. So for me, I went there. I learned how to think I decided I wanted to pursue biology at at a deep level and I wanted to pursue human biology. So then I went to medical school now for me, I think one of the key components of having an affect. Active research career to date. I guess would be that. I had a clear understanding of this idea. Translation, so you can do science for signs sake. But to me to make really big impacts you have to be able to translate that to the human condition. So I did three years of medical school before I left. So I went away after my third year. And then I already had a year of clinical medicine under your belt. Yeah. And so for MS that's also very unusual. It's definitely different. But I encourage all students who are MD PHD's do clinical time before they do they're so that that's that might be the nugget of the podcast right there. Because I don't think I knew a single MS teepee student who didn't go straight into their PHD after the preclinical phase. Right. So for me was just so impactful to be if you say in hindsight, well, what was the distinguishing factor of the virus lab crew. They're all MD PHD's. They had all done clinical. So they knew. Really key nuances that were important questions to ask. And it doesn't you don't have to be an MVP to get that, you know, one of my good friends is his PHD who developed a genomics company that we may talk about later, and he's straight PHD, he should know prostate cancer like he does. But he really gets the nuances of it. So I did three years of my med school. I went to the NIH I did pure science amid think about humans at all thought about mice and signaling in mice and T cells in mice and so forth. But in the back of my brain is always like Kay. How're we gonna change going to think about the human condition human disease, breakdown know, rebuilding all that? So for my perspective. I had I had a jump on. You know, the other straight PHD's in the group because I had I had an idea. Now, why did I choose urology? Well, this goes back to just an early childhood imprinting. So there's a couple of facts number one. My dad is an incredibly famous urologist. My father was the chair of the department of urology at northwestern for twenty five years before I took over the job, and he's an incredibly successful. Scientists doesn't do cancer biology. And I I didn't even know he was Iran is a kid. I just knew a miss my dad, but one of the backstory's was that when I was in seventh grade eighth grade and beginning high school, we used to go visit my dad's parents they live in northern the Anna, which is about a hour and twenty minute drive from where we were and over that time. My grandfather got sick. And I have this vivid memories of seeing him. And and they're really snapshots in my brain. I recall weekly of just becoming sicker becoming more frail becoming bed bound, and then dying and I never really asked what he died of. And I don't think I was I don't think could process it what it would have meant. Anyway, if I had asked, but when I was a medical school, and I was doing my PHD I asked. My parents what he died of and he died of prostate cancer. So I was at the NIH I was doing science. I had done some clinical work. I realized what people in DC not in science. But in politics were interested in their interested in cancer biology, and they are interested in prostate cancer. I saw at other people are interested in and I had this very vivid memories of my, you know, my father migrant, my grandfather, having prostate cancer and dying from it. And I decided that that's what I wanted to do. So when I came back to medical school. I knew that I wanted to be to be a prostate cancer biologist and understand the disease. I also knew that I wanted to be a surgeon. And so I didn't to be a medical oncologist. Although that appealed to me a lot, and I'm always flattered when people think of a medical colleges because those guys are smart, they're smart. But I knew I wanted to do something I love working with my hands. So for me, the I. The of being a surgeon. Scientist was just it just made sense. I loved the biology I love, but I still love the idea of not just conceptually deconstructing something and putting it back together. But actually, physically deconstructing something putting it back together. So as a perfect fit for what I wanted to do for the listener to put some things in context at the time that you and I began our residencies. I don't really think there was any debate about what the best urology program was in the United States. I think there is a good race for number two or lots of programs that would have competed to be the second best urology program in the country. But but Johns Hopkins was hands down in a league of its own. And they only take two residents per year. So if there are four hundred or five hundred medical students graduating who want to go into urology only two of them get to go to Hopkins, and you were one of them, which perhaps isn't surprising. Did you wanna go to Hopkins for reasons other than it was the best program? Was there something about the environment? There. There that drew you to it. Yeah. It was a people. It's an amazing place that I think about think about it all the time. So I interviewed there and the chair of the department. The time was is the godfather of my field. He made all the contemporary modern discoveries in prostate cancer. And it was real simple. He looked me in the eyes. And he said, I looked at your CV. I know what you have the ability to do. And I wanna help you get there so pet well selected you as much as you selected Hopkins. I guess you can say that. Yeah. You know, it was a perfect fit because as we've talked about mentorship is just so much of everything. It's everything in life. Really? If you're motivated, and you have drive, it's, you know, even if you're not motivated, you don't have drive you need a good mentor. So for me, I showed up for the interviews. I'd interviewed all over the country. There was places I could have gone that. I could have made a good opportunity. Good experience for me to be trained. But when I showed up at Hopkins, I was like, okay. This is I got to go here. So I think it was a good fit. He was interested in having me. Train with him. And I was interested in training with him. So it was pretty heal your father. He must have must both chairman. Yeah. It's an interesting story. He I met him at a met him at a function in the fall before I started. So before I had interviewed and he was a function with my father. And so my father introduced me to him. And he said, well, you know, what you want to go into a new finish. Her medical squad said, well, I'm actually interested in your allergy. He said really, and he said will wear you applying. And I said why applied to all the great program? So and he said well the to Hopkins, and I said, I sure did. And he said, that's wonderful. And then I find out from my father that he grabbed my dad when I had walked away. And he said, I just learned that Ted applied to our program. Did we give an interview? And so I made me feel good that you know, I had gotten this interview at the best place in the country without using my father's coattails to kind of get the job. And then it showed up, and it was just an amazing. I mean Hopkins was an amazing place. I know I know you have many fine memories of the place. And I'll never forget just the pursuit of excellence is something I think about all the time. And that was really the pitted me of Hopkins for me, it was the pursuit of excellence among everybody there to be honest with you even the chairs of the departments they pursued excellence in, but it trickled down, you know, a trickle down to the everyday employee's, the physical plant people, the people who clean the floor that they had a pursuit in a passion for excellence that at the time that we are. There was amazing. I remember also being so struck by that when when I arrived, because of course, were each thinking about it through the lens of what we're gonna do you're going there because of your allergy I'm going there because of general surgery the neurosurgery. Guys were going there. But we all had this common. First year. We were all I don't remember. How many there must have been twenty eight of us doing internships in general surgery? Six of us would go on to do that track. Two of you would go onto do urology. There might have been three guys in ENT an Ortho neurosurgery cetera. But within about a week. I was like oh my God. This is like the all star game. Like these three guys that, you know, I still remember everybody's names. Like those three guys that were our classmates who went on to be neuro-surgeons were out of control. They really good. Yeah. The Ortho guys Ortho guys get a reputation of being kinda jokers. These guys were fantastic. Yeah. You know, they were everyone is just so exceptional. So yeah, you're right. It's you pay a little bit of price. You gotta go to Baltimore. Yeah. I thought was Spade. That's right. Although we both met our spouses there, so and I had my kids there. So there are some upsides to it. But the reality is that, you know, it's funny because Pat walls, my mentor. They're always talk about that. He would always say, well, it's negative. Election people come here because they want to pursue excellence. They don't come here because there's a good, nightlife. It don't come here because of XYZ they come here for that single reason. And that's a great point. I never really thought of that. But it's so obvious because I remember being so sad about having to leave California to train there. Yeah. But at the same time realizing and talking a lot about it with Steve Rosenberg was like who had done his MD and PHD at Hopkins that you only get one or two train at this. This is the phase of your life to do this. So go to the best place, you can go that fits with how much you wanna work. Let's talk for moment about PAT's work because I don't think it can be overstated. And I don't think I mean in many ways, I think Pat Walsh was a very unique mentor to use specifically. But in many ways the field of urology today is different because of him. And I don't think I've thought about this knowing that we were gonna talk today have spent the last couple of weeks thinking about this. This. And I have a hard time coming up with people in the modern era that rival him John Cameron potentially being one with respect to pancreatic surgery. But I can't think of someone in the last thirty years that has so fundamentally changed the course of one operation it's impact on one diseases, Pat. Now, am I missing an obvious example, while within urology, I think I think I can't think of anybody within urology, and the other point is I'm sure that there are brilliant out. Outstanding people that have changed operation in a way that alters the the course of those individual patients, but one of the things I think about a lot is that Walsh would always tell me, you know, you you can't make important discoveries unless you work on portent problems. So prostate cancer is a it's an important problem in it's incredibly prevalent problem. So yeah, there's probably some guy out there who came up with the best way to do a knickknack whatever surgery, but if. Doesn't have a high impact probably is not noticed. So. Yeah, I think that what he did in our field was you know, really was never been done before. And probably won't be done again. And he did it for a problem that was incredibly important. So let's talk about the state of prostate cancer surgery for men prior to PAT's work if a man had prostate cancer, what would be back in the early seventies leaving late seventies. Right. What were the treatment options for him? While at the time that Walsh was training. Very few people with prostate cancer had surgery, and that was because it was a potentially life-threatening operation. People would die from extreme blood loss. People were incontinent people were for sure impotent. Let's stop there for a second. Because this is one of those things that I think of unless you've been in an operating room. It's hard to understand why the blood loss from prostate cancer surgery could be so deadly. It's the same reason until you see a trauma where somebody is shot through the pelvis. You can't understand how. That person die people get shot in the chest, and they walk away. Sometimes if it's not through the heart or a pulmonary artery or vein and yet across pelvis gunshot. Wound is often quite fatal. What is it about that anatomy that makes it so deadly? It's the large number and variable distribution of veins in the pelvis, general and wise at the veins, not the arteries. I love I love. I love it. I do this with you. I mean, you know, the the vein is just the the wall of rain is this thick as a piece of paper. So it's prone to tear, and it's hard to repair it if you do tear it and an artery as much thicker, it has much more resilience to it, and it has to do with the amount of flow going through both of them and pressure. So so, yeah, there's a lot of anes in the prostate in the pelvis. There's a lot of anes around the prostate and the distribution the exact location is incredibly variables. So they're more like Venus plexus versus a actual vein that you can name. But if you get into the environment caveman, you're in trouble too. There's no doubt about that. I've that's happened to me a couple times. So point is at anytime, you you know, artery is the real deal, but it's just easier to control it. And oftentimes if you cut an artery, I'll go into spasm, and they won't even he'll stop leading on. And that's not true for Bain. So for one, and then also there's there's the depth, right? There's the actual exposure is really tough in the pelvis. You know, it's it's one thing to, you know, look at the kidney where even though it's in the retro. Neom. You can be staring straight in the face without too much work. That's not really the case in the prostate. Yes. So I mean the way that Dr wells describes it as that people had done anatomic studies for many many years, right? I mean for for decades before surgery for the prostate kinda was attempted to be performed, but the anatomy when you fix a body. And you study it it really compresses a lot of these sinuses. Don't really fully appreciate where they are. And what's happening and so forth, anatomically arteries preserved. But these kind of being this plexus were not. So the anatomy of the pelvis was not appreciated, but I will say that in nineteen oh four at Johns Hopkins. The first radical prostatectomy for cancer was performed by the chair there at the time. And he did it through a pair Neil approach, which is the space between your scrotum in your basic. Early. And when you do it the surgery that way, you will. And the reason is that's the closest place that the prostate gland is to the outside world. That's right. And if you do it that way, you'll void a lot of the veins that bleed just catastrophically when you approach the prostate from kind of above versus from below. And so that operation had been was in, you know, was being performed, and it was considered to be, you know, was definitely saved me in this life threatening blood loss did not occur in the problem. Was it wasn't very good cancer operation. Why's that? Well, it had to do with exposure number one. I mean, you're doing, you know, the prostate is very deep in the Pella. So for the lay people the way, I explain we'll wears the prostate. I explained to people that the pelvis is like a ring of bone and off the ring hang a bunch of muscles. And that those muscles form a hammock at the bottom of the hammock is the prostate, and so it penetrates to the muscles. And then that's where the the Eureka throat the two that you urinate through comes. Through the pelvic floor muscles. And then goes out of the body. So it's deep in the pelvis. It's hard to access. It's hard to access from the paradigm. And it's hard to see what you're doing, and it's harder to kind of excise tissue widely in that area, the exposures tough when you do it from above, but it's even tougher from below. So the life threatening bleeding wasn't there? But part of the reason that the bleeding didn't occur when you did a pair. Neil approach was because they were leaving the prostate kind of in place. They were staying away from the air where the big Baynes were. And so when you were you do that, it would be safer for the patient, but less oncological sound. So am I can't believe I'm blanking on the forefathers? Obviously, Halsted owes slur. Kelly who was the and Kelly was the gynecologist Oastler the internist halted the surge in what was the name of the urologist. The first urologist at Hopkins was one of halston ads trainees that was Hugh Hampton young. So Hugh Hampton young was a hall stead trainee. And so people probably don't realize, but many sub specialties of medicine came out of. The hall steady and era at Hopkins. So orthopedics, radiology urology, these were all sub specialties that basically were halston telling Hugh Hampton young I think we should start. A, you know, an institute our program for people with your logic problems. Now Kelly was doing some of that also at Hopkins just more on the female side. But but that that concept came out of hall stead, really assigning, Hugh Hampton young to do that in the story is that he literally bumped into the hallway until you're gonna go work on this. And he didn't really really wanna do it. Because at the time, it wasn't very sexy. But he did and said from there, he really be began the whole specialty of urology. Yeah. That sort of thing about Hopkins that never got old actually was to walk through Blaylock and look at the photos of all of these old photos of people who literally created the field of surgery, you know, the lineage there was sort of staggering. Yeah. I think one of the things that you. I'd certainly didn't. Appreciate was to really take it all in at the time. You know? I mean, I had the pleasure of being hard too. When you're sleeping, you know. I think in everage of twenty eight hours a week or respect. Right. Exactly. But, you know, the idea of what we did was pretty amazing women we had Sunday school writer love something. We would show up. When can you explain to the listener what Sunday school is you? And I might have been two of the weren't many people that probably loved Sunday school. But you and I had great it. So when you know when we were interns at Hopkins there was no work our limit. And you know, the expectation when you got there was that you'd work seven days a week. We would work eight days a week if they're eight days in the week. And so Sunday's was a day that you'll go in and you'd sit with the chair of the department one of the most famous surgeons of all time, really. And he would lead the discussion on a topic for the day. It often started with history, right? We would do history of surgery history of surgery at Hopkins. And that was those are some of my most. Favorite kind of discussions was him. Just talking for forty five minutes about somebody. And then we would present cases. And then we would talk. We would practice are suturing member. We I'm sure I think Julianne Sosa who's the Jared UCSF now is taught me how to tie square not. You know what I mean? So and also once a year, we each took a turn presenting something back to the group. I still remember what I presented on it. Presented on the war in shunt. Really? There's an operation that I never got to see because even by the time. We were residents interventional radiology had completely nullified the need for that operation. But as a medical student became obsessed with the history of that operation because of how dangerous it wasn't how complicated it was. This was an operation for the folks who may be don't spend a lot of time on the at Warren shunt Twitter handle. I know. Someone creates after this. It's an operation that was done for people with elevated pressures in the liver. And this is something that happens when people get sarosa. So this was basically an operation that would alleviate that by creating a shunt in the liver. But I still remember that and I I remember like typing it up and this was back in the day when I would cut pictures out of textbooks and tape them on and make photocopies, and it was all old school. Yeah. So that was eight to ten every Sunday morning, right? Yeah. And so those kind of things I wish I could just, you know, people say which would go back to high school, which go back to college in many ways. I mean, I do internship all over again. I would I mean, we we were there what one hundred and thirty two hundred thirty six hours a week. But Mana I would do it all over again. It was awesome. We did have amazing times. And I feel fortunate. I mean, there was just a great group of people we met you at you. And I met immediately on day one and then worked together we were together September September of our intern year. We did pediatric surgery together. And karen. Kling was our fellow. She is now an attending in San Diego. I bumped into in the grocery store like a year ago. She was great. She was in his edible. Yes. She is awesome, John Vogel as our John Vogel was our senior resident in your me. How to put an end G tube in that served me as a gastric tube for the listener is a tube that you sometimes have to put in a patient's nose down behind the farrington then into the sophists and into the stomach. This is something that is so ubiquitous in surgical care. But so wildly uncomfortable for a patient because the patient is usually wide awake. When you're doing this. And I remember one day Vogel. I remember where we were it was just at the ground level of CMC. He sat us down there in the playground and said, look you two knuckleheads. You have got to learn how to put an end G tube in without killing somebody, and he didn't mean literally killing, but he just meant torment, and you remember the vocal technique. I do still remember him telling me it was like because everybody thinks that you're supposed to put the energy to up the nose have. And he's like, it's straight. Back then things like you get the Cup of ice get the ice water Cup. You put the G tube in you put a wicked bend on it. You put the light occasion Gelian? And that's exactly the key point. Do not go up go directly back, and you curl down. And then you give them a little straw. And you tell them exactly once you hit the back of the aura ferrings take too big sips. And we and this was a game changer. Ted. It was there for the rest of my residency. I was throwing Angie tubes. If you looked at me, you got an energy to, but and it didn't hurt the thing that the listener will not appreciate is is the layer of comedy associated with this. Because this was done in what you described as the first floor the pediatric hospital, which was called the zoo. Right. Yeah. And so this is this is a brilliant surgeon, John Vogel. He's the head of colorectal surgery in Colorado, teaching Peter t a brilliant surgeon Ted Schafer just getting by in front of life sized stuffed. Animals of like, giraffes, and and lions it was hysterical. Right. It was just comedy. Yeah. That entire that might have been certainly the best month of my interns. Yep. Was fun. In terms of had great many great runs up your jokes. So let's go back to Pat, I got us a little off topic. I actually got his way off topic because we were talking about the bleeding. But there was this other enormous complication of a prostatectomy which was it virtually guaranteed that a man would not be continent with respect to urine and would not be able to regain erectile function. And so I'm guessing that many men when faced with an operation that's going to leave them in a diaper. Unable to have an erection might opt for not having surgery. Yeah. So people had radiation and radiation has changed a lot too. So it was bad radiation or bad surgery effectively. But you know, when you can actually see what you're doing just for the listener pudding doing something when it's pitch blackout bursts daylight makes all the difference in the world. And so. You, you know, you would go into the opera around with him, and he had just had a mastery, and he could control he understood where the veins were he controlled them by suturing them before they started bleeding and by doing that, you could actually see everything. And once you could see everything it was like obvious, you'd be like Hello wire people doing this or that. Now, the ability to maintain potency, and preserve, you know, sexual function was something that it's not so obvious how to do that. But he figured that out by working with some anatomist and really just studying and talking to his patients and listen to what they had to say, he also recorded all of his cases, which I do now to my studied them, and he learned how to kind of didn't know that about Pat, he would record all the operations and study them, and I didn't realize that you were doing that either. I do now it's much easier. Now for us when we hit the button, but every single case I record it, and we're working on working on with one of my residents just making a. A photo video library. So what was hard for him? And he's published and he put out on DVD, you know, his operation, you can see it on YouTube, and it's brilliant thing. But one of the things that makes doing any surgery fund is that there's so much variability in Adamy. So what I'm working on now as a video library, so ten Blatter neck's fifteen of these because there's so much variability and how the tissues present themselves to you. And then how do you handle that net part of what take surgical skill and hours in the cockpit do for you? So we're doing with one of our our laboratory were just taking all these videos, and so whenever I do case, and the anatomy was really nice for ex wires evil, while tell them pull that case. And it's in the third twenty minute clip and pull it and make short just make a clip of that for particular steps of the procedure. Was there a moment? When Pat realized he was onto something, and that this was were basically witnessing a paradigm shift, which is such an overused. Term except here. It's not at all. It's actually an understatement here, but such a paradigm shift in how an operation was going to be done. I mean, this would have been in the early eighties. I'm guessing it was well mid to late eighties or late eighties early nineties. And so it was I think he knew all along he was onto something. And he was very confident, you know, he's not a shy guy. He'll tell you that. So he was incredibly confident that he was on to something. And that what he was doing was the right thing to do and was very convinced that was convincing that when he spoke about a publicly I think that the general community was less convinced that was what he had done was really happening. But I I mean, I I saw it. You know? I mean, I I was really training there. The heyday the peak of Brady urology Johns Hopkins urology, and so I got to see it in real life, and I never saw bad surgery. That's the thing. I mean, we trained at his place, and you didn't really rarely did you see people do a ban operation. So parlor is good stuff and the bad stuff and put it on the perspective. And we didn't. Have most of the time that didn't happen there. So I saw it. And I think he was convinced of it from the get-go. So you're saying it just kinda took a little bit of time for the day to speak for itself. I mean result. So so if a patient today goes to a highly trained competent urologist and his going to have a a prostatectomy, and this it's a sixty year old man, what can you guesstimate about his probability of regaining sexual function? It's not a hundred percent and thought one hundred percent because it used to be zero. But now it's well the nerves that we preserve at the time of surgery to optimize recovery of sexual function or not Mylan aided. So they're incredibly sensitive to any kind of manipulation any kind of trauma. So, you know, one of my good friends is the hand surgeon, and he does micro vascular nerve grafts all the time and the nerves regenerate and re gained function. They do that because they're mile needed. They're incredibly protected. I didn't realize there were such thing as non Mylan aided nerves are there. Other places in the. Body where these exist. Besides the prostate. I'm sure there are I I'm below the belt guys. I don't know there in ever luminary reason that those would not be Mylan in. I don't know. But we can call Pat Walsh up when we finish this, and he'll tell me for twenty minutes when I am in Hyde. And know that. Can we record that this? Good. Okay. So that's a very interesting point that I actually was unaware of. And I can see now why that makes it that much more difficult right because you can preserve this tissue. And you can do it in a way, that's minimally traumatic for the tissue yet. It's not a guarantee that they'll be one hundred percent recovery of function or any function recovery. Right. And so that is the variable. And that's the fact that still hasn't changed like, Dr Walsh would always tell me if if we could do the perfect operation. There'd be no dispute about doing prostate cancer surgery. Perfect operation, Connor percent, cancer control and no side effects. So I think in this day and age you can be nearly perfect for kind of urinary control. You're never going to perfect. So when people say that none of their patients of your nearly doesn't make any sense because if you actually survey sixty or one hundred sixty five year old guys four percent of them will have your nearly mean. So incontinence is something that happens. It's much. More common in women particularly aging women, but it's also occurs in aging men. So to say while I do a hundred percent of my cases. And there's no airing on it's kind of it's better than the baseline. So it's hard to believe. Yeah. But you can get people up to very very close to that number. I always tell people for me personally. Ninety eight percent of my patients are totally dry where one small patter liner day, which often people just wear for protection when they're out and about functionally totally fine now for a fifty year old, man. I think there's a over ninety percent chance that you can recover sexual function. Yep. But with each deck member, you know, erectile dysfunction is a disease of the aging male. So for each decade that somebody gets older there's decline in sexual function. So he's been people say that they're totally potent and their seventy they'll tell you if you ask them, no miam-, not as good as I was when I was twenty. So there's that component of things in the other factor is prostate cancer. And it's not like, there's the prostate. There's five millimeters of tissue, and then there's this nerve bundle. There's the prostate. There's no capsule or lining encasing, the prostate. And then there's the neuro vascular bundle of Walsh named after Dr wolf. So you have prostate. The prostate itself has different zones or different regions prostate cancers develop in the peripheral region or perforate zone. So right at the edge of the prostate. So you have to Mer at the edge of the prostate, and then you have the nerve bundle. And so you're talking about one or two cruel trick of fate of of the cancer's not developed centrally. They don't develop centrally they develop Rivoli. So I understand why patients by listeners to say, why don't you don't you just you know, what I don't get it? Because it in many cases today, we I published on this a lot. Now. You know, there's prostate cancers that we pick up today are just bulkier. They're more aggressive and so. When you have a tumor that you know is going to be outside the prostate. You know, it's extra prosthetic it's involving the nerve bundle. A lot of the times. And so you have to remove part of it. You have to remove you know, the tissue around to try to clear your margins. And so when you do that in sixty five year old guy, and you take out half of his nerve on one side. It's unlikely that he'll be able to regain sat sexual function on his own. Now, these days I'd try to be very upfront about that. And I try to set appropriate expectations. We can we have special tools that we have in urology that will enable Amanda get don't total satisfaction sexually. So we can maneuver around out. So to speak. And these days many of the people I see have very aggressive cancers that are quote, unquote, the real deal. So we really have to be careful you our number one goal for doing cancer surgeries to get the tumor out. It's talk a little bit about prostate cancer because it's not a cancer that comes without its controversy to let's start with the biggest Connor is really one of the biggest controversies or things that would confuse the layperson because about every year, the advice changes on this thing called P S A. So what is the prostate specific antigen PSA is a protein it's made by the prostate. And it's normal function is to liquefy semen. So it's highly expressed in the process of the way, I explained the process of people the best analogy, I can come up with his if you think about it like a sewer system, you have the main sewer leaving the city, that's the urea three that's the tube that we normally urinate through. But this channel also deliver semen out. A tip of the penis off this main sewer are slightly smaller sewers had go to different neighborhoods within the neighborhood. There's a sewer that comes out of the individual house and the individual houses in this analogy are prostate epithelial cells, they make components of the semen, and the semen is used to give nutrients to the sperm while it's trying to fertilize an egg to enable the sperm to penetrate, the cervical mucus these different functions PSA is a protein that breaks down the semen and liquefies it and people think it's an important for for this whole process of fertilizing egg. So that's what it does. And if you look in the semen, the PSA numbers are hundred million per m l mean, the numbers they mount of this protein in the semen is astronomically high. So that's what it is. That's what it does. So how do we use it as a tool to screen for prostate cancer? While we check the values of. The PSA in the blood. So since the prostate is sexual gland. If you check the values of PSA in a eight year old boy, it would be zero because there's no testosterone. And that boy, there's no sexual development that boy. And therefore, there's you know, there's some but affectively no before puberty there for a little levels of testosterone. There's no effectively prostate epithelium, and there's no PSA as a boy goes through puberty to become a young, man. And then as he goes through the aging process, his prostate develops, and the then it starts to produce PSA as part of the components of the seamen. Now, there is a certain amount of leakage of the PSA fluid into the bloodstream, it's not quote unquote supposed to leak into the bloodstream, but it can and as the prostate gets bigger. So think about this concept of this underground sewer system, the New York City sewers, right? They're getting older. They're getting leakier. And the bigger the prostate gets in the prostate gets larger as we get older some of these pipes get leaky. And some of the PSA leaks into the blood. So it was discovered in the eighties that there's this prostate specific protein that you can pick up in the semen, and you can also see in the blood, and so it is not cancer specific it's prostate specific, and is actually very good biomarker for prostate size. The bigger the prostate. The more leaky it is so to speak and the leakier it is the higher. The numbers can go in the bloodstream. So there's two variables that can progress over time the size itself, which can you could talk about that independent of size. So to thirty year olds one guy's got a five grand prostate. The other guy's got a hundred grand prostate just to make sure him you should see a difference. But also to guys with the same size prostate that are two decades apart you might see a higher PSA in the older. That's right. So if you do, for example, like we were always taught in residence, even though I wasn't urologist you still once in a while have to you know, we still do your algae rotation. If I recall, you wouldn't check a PSA on a man right after doing a rectal exam because in theory that could artifice have raised the PSA presumably by creating more of an insult and increasing that flow Shing, some of it into the blood the blood, Jim so what can make the PSA rise. Besides just having getting older and having a larger prostate. Well, if you get an infection in your prostate. So think about that like you got your city you have received or network, and there's an earthquake all the pipes are rattle bit, and they all are extra leaky. And that's what an infection is not infections in the prostate or either all are none really they're not focal. So the whole prostate gets more leaky in the PSA number can go way up the other way to think about it as if you have a cancer and the the analogy would be low. There's there's a city block that has the pipes. You know, the sewer systems clogged. There's more backflow into the bloodstream, and that's how he pick it up. That's not really how it happens. But that's a good way for patients think about it. So what is a normal PSA? Well, a normal PSA is age adjusted so normal PSA for a forty year old is around point five two point six nanograms per mil for fifty year old normal. Meaning this is the median for all the population for fifty year old it's one, and so it kind of goes up stepwise by decade. So there are age adjustments that we do for the PSA number. Now, what are PSA numbers that tell you? You don't have a cancer. There's no PSA number that is one hundred percent, no cancer. But there is proportional rise in cancer detection with rising PSA numbers. So the Ridgely the cutoff set at a PSA of four we do, you know, we think about things more based on the individual scenario. So if you're a younger person if your PSA more than two point. Five that usually considered to be abnormal and may want you may need further work. You don't need a biopsy right away these days in my opinion. But unique further workup so depends on the age of the patient and depends on how also their prostates so many guys will go and when they get their PSA check. There's another thing that gets checked called the free PSA. And then a number is reported, which is the percentage free, which is obviously that if their PSA is three and their free PSA as one the percent free is reported thirty three percent. What is that mean? These are different ways for urologists try to find tune this prostate specific antigen test to make it more cancer specific test. So again PSA's just goes up when you have an every man has it's not cancer specific so percent free. PSA was the first way that urologist began to look at what what's the chance that a PSA of four is coming from a cancer versus a PSA. Four coming from just benign overgrowth. So remember, there's a lot of factors in play. One would be if you had a man who's prostate volume was eighty grams that big and his PSA was four. Well, that's of low ratio. That's something called PSA density. How much PSA's made per gram of tissue. So you'd say well that guy it's very low chance at he has a cancer. That guy would also have a high percent free PSA. So percent free PSA is another way to just look at what how much of the PSA's produced from benign cells versus cancerous cell. So if two guys have a PSA of four and one has a free of one so he's twenty five percent free. And the other guy has a free of three which is seventy five percent free. What's the different physiologically in those situations? Well, there's less bound PSA in the lower percent free, and that's more often associated with prostate cancer. So that just a correlation. So it's not. Like, it means that in other words, you we can't infer what? 'cause I I would I would have assumed that the binding protein is in the periphery. It's in the plasma right? Yeah. It's it bound up when it comes out of the epithelial Celso and just how it's processed. So PSA's process is not a full length protein when it's born in. And so the other way that we now so just for listener. So we have absent cutoffs PSA four in older man, two point five and younger men, but they're all really case specific in my opinion percent free. PSA was the first way to say, let's try to find tune what the PSA means. So a high percent free PSA's associated with the big prostate less of a chance of prostate cancer. A low percent fee PSA is associated with a higher likelihood that that PSA's produced from gland with prostate cancer in it the other variables that we use our PSA density. So that's highly predictive of what's going on in the prostate. So. Easy threshold or cut off for for for you. Peter. We talk on the phone about some of your patients percent, free, PSA density, more than point one. It raises a little bit of a red flag. A PSA density of more than point one five that raises a red flags think about it and median prostate volume for a sixty year old guys forty grams. So forty grand prostate PSA left corner four it's probably it's it's pretty safe a PSA of six six that raises red flags in you know, this mural in patients that okay guy, probably has something going on. So that's how I think about it. Now think about the eighty grand prostate with PSA a four, oh, you have these patients in your practice. They don't have cancer on average right percent free PSA helps with that. There are two other new tests that yes, so you got me onto the four K two years ago. And I really consider it a game changer for the guys like me who were in the peanut gal. Lary? So I don't you know, I I make it my job to know as much as his knowable with the time that I have about every possible disease. It could afflict my patience. But that means I need to spend as much time thinking about colon cancer as I do coronary artery disease as I do prostate cancer. So for me the four K which again, you didn't. I mean, you did me a great service. Not only did you get interested in. But you introduced me to Andrew at Memorial Sloan Kettering, I'm blank on Andrews Landreau, Vickers Vickers. Yeah, amazing guy. And I mean, the guy couldn't have been more generous with his time. I mean, just gave me the schooling early on this topic. So good, and we put together a patient hand out on this thing. And he even edited it for us. I feel like not an I'm worried not enough patients understand that. And I'm worried not enough primary care physicians understand the importance of the four K test. Can you explain how that has changed the way we do things? So this test or looting into and there's another test that performs equally well called the prostate health index or ph test. These both leverage off this idea that prostate cancer cells make PSA differently than benign prostate cells. And so the four K score is the fork calico tests takes PSA percent free PSA intact PSA and age Kate to it takes those four prostate specific proteins produced, and it has a calculator really just discriminate between a cancer cell and benign cell P. H I uses the similar concept. It uses something called minus two pro PSA, which is PSA for all the scientists out there, plus two amino acids on the five prime side of it. So minus two pro PSA, right? And you you measure those specific PSA base proteins in the blood and the four K scores. Great because Andrew Vickers, and Hans Leah developed it with this other great urologist, Peter Scardino memorial. And what they they looked at was. Will what's the chance at this person is diagnosed with and has high-grade aggressive lethal prostate cancer, and it gives you a percentile chance. So when you get the four K report, it's actually really nice report. It'll say two percent chance twenty percent chance and so forth. And so now as you start using this in your practice, they may now also give you the PSA. So you can see the PSA, and then you can say wait a second disguise PSA six but his four case cores to it's safe. What I really like about it is. And so when we do our usually with our patients in their second year sometimes in the first year, but using their second year, we do a cancer screening program where we kind of walked them through every single cancer that you could possibly die of. And then we go cancer by cancer risk by risk. And we it's very lengthy process on the back end for the patient. We simplified it takes about ninety minutes to go through it. But for the males when we come to this. I always view this as one of the better, I said, I wish every cancer had a test like this because. As we'll come back to, you know, pretty much every guy is gonna die with prostate cancer. But fortunately, most men will not die from prostate cancer. But their job is to figure out when a guy has prostate cancer as you alluded to earlier resist the bad one. Yeah. Or is this the one that if you around too much, and so what I guess Vickers in his team have been able to do is figure out that there's now enough data that you can basically turn this into a binary test. You know, which so that the so PSA would be a continuous variable. Right. And when you want to test the sensitivity specificity, but continuous variable you have to use something called a receiver operating characteristic curve, and it becomes quite complicated. Because the question becomes what cut off, and as you alluded to it's very difficult with PSA because it has to be age and volume adjusted so now it's a three dimensional receiver operating characteristic, Irv where you would have a different a UC area under the curve for each point in time and volume that becomes almost inconceivable. And yet the the four K has basically allowed us to say the following. If you're four K score is less than seven point five percent. And I might butcher the numbers a little bit. But that's right number. If it's less than point five percent, the probability that you will be alive at the probably that you will die of metastatic. Prostate cancer is one point six percent in the next twenty years. Yeah. That the the lifetime of the patient, and that's based on this data from Andrews partner, a co developer Hans Lilia where they had this incredible database, you know, mouse Weeden so they could track and then the verses if you're greater than seven point five percent. I think it's like sixteen or seventeen percent chance in twenty years. They that's the the binary office seven point five percent. But it's a continuous variable. But above that, it's continuous. It's not like if you're bub that. Yes. Fifty so berries based on the number. So where are we today? Let's take us take a journey backwards in time in the late nineteen eighties. Forty percent of men who. Who were coming in with prostate cancer had metastatic at the time of presentation. Just like a lot of cancers other cancers we diagnosed today, and that was how it was then every there was an epidemic of deaths from prostate cancer. We're getting a better hand on how to control cardiovascular deaths. People were coming in with aggressive, advanced cancers. Prostate was one of them we Tom. Steamy took this P S eight test, and he I made the observation that you could use it to actually follow men after their cancer treatment. And if the number went up gosh that meant that their cancer was back. It was the game changer. Right. This is the first time this was ever done. And then Bill Catalina who's one of my partners here. One of the godfathers in the field. He said why don't we use it to screen people to pick up cancers when they're early incurable? Not when they come in an advanced. So the chain what year was that? That would have been nineteen ninety to nineteen ninety. FDA approval. So they cut they set up arbitrary cutoffs. This is what this idea of mass screening took off. And you know, it's been sold to the public like will the urologist route there just to make money. This is what we are doing to get rich. No, it wasn't that it was because at the time the test was developed. It was the first biomarker for cancer pick up a cancer early. If you pick it up treated in cure that patient now over the nineteen nineties and early two thousand what we realized as well, guess what we're picking up a lot of cancers where treating a lot of cancers number one were increasing in reducing the deaths from prostate cancer, reducing the incidence of metastatic prostate cancer at presentation. It was forty percent in basically nineteen ninety forty percent of men coming in with prostate cancer metastatic at the time by two thousand it was four percent. Now, the skeptic is going to say this is such a controversial topic. So it's so good that we're. Doing this the skeptical say, well, that's just lead time bias. I mean, all you did was catch a bunch of men earlier. So you have a much bigger funnel. Right. Right. So by the way, the same controversy exists on mammography. So I can't wait to actually sit down with Ted Schafer quivalent of breast cancer at some point. Because I realized that an episode like this is probably a little bit more geared towards male listeners or probably the female listeners who have males houses or people that care about going through this. But it's interesting to watch the rise of mammography and the rise of PSA go through this parallel thing and Kohanovsky though to a slightly lesser extent that really being the big three mass employed screening while it's and it's been written about Al Peter you've written about this. So Peter Albertson is a nother Hopkins alum, he's Charon Connecticut, and he's an anti screener effectively for prostate cancer. And he wrote about this, and he showed that if you just look at incidents of metastatic prostate cancer incidence of metastatic, breast cancer. There's no change with implementation of. Mammography? There's a huge drop in the incidence of medicine prostate cancer with implementation. So why is he anti screener? Well, he just he was historically. He wrote this paper and showed that there is a huge difference. So now with screening you have increased detection, and what we've learned is unlike let's say pancreatic cancer where most of the time if if you picked it up early if you did nothing it, you would die not everybody who has prostate cancer has a lethal variation of it. And so initially we developed a biomarker to pick up all prostate cancers that was the PSA blood test. We pick them up we treated them, we reduced deaths. We also over treated people people who had a cancer that would never have been lethal in their lifetime. That's the dying with the dying from. And this is something you and I used to talk about nearly twenty years. I remember sitting in the cafeteria because you know, even though you know, you. We were still interns, and basically two knuckleheads you knew you were going to do this. And you were always head and shoulders above everybody else in terms, which when I said, I remember asking like, I don't get it. Like, why do some guys get prostate cancer? And it seems to be relatively uninteresting like, yeah, they and another guy though at it and they're dead in two years in it's his devastating pancreatic cancer. What is it about the biology of that because it strikes me as more a function of the biology than the environment? You're the host. But but I could be wrong, of course. But I remember talking about the Salahdin and really coming away scratching my head thing. I don't but clue what's going on this disease. I mean, I'm still scratching my head about it. Because that's my whole research program is all about his will what's the molecular biology, lethal prostate cancer? So we'll talk about that in a second. But to circle back to our story. So we diagnosed many men with prostate cancer, we treated men, and we save their Lisin reduced deaths from prostate cancer period. It's not debatable. But along the way they. There were people that were pulled in and were treated who did not need treatment. But you know, there's a lot of smart people who've studied the biology of prostate cancer, and we realized that not everybody who was diagnosed with that needed to be treated from it. And so the four K score and the prostate health index help us a dentist by men who have life threatening or lethal can't potentially lethal prostate cancers. And so those are great screening tools. They're not considered or the government doesn't like them as first line screening. So you should they recommend you regular PSA blood test. If it's at all abnormal. Remember seventy percent of men have normal PSA's. If there such a thing, and by the way, what do we have a sense of what percentage of those men can still harbor a lethal prostate cancer? Well, Vickers would know that data and they published on that. It depends what you say normal and not normal is you know, below Amina PSA below three. There are still men that have if you just do one test, it's assuming it's not. A lab area miss. Yeah. No, no below three. I still think the Fourcade data says it somewhere around I wanna say ten or fifteen percent. So it's not it's not a single digit and other big opposition in the screening world is the quote, unquote, unnecessary biopsies, and I say, quote, unquote, not because I'm diminishing or minimizing that, but the idea is like a prostate biopsy as trans rectal procedure for most men, it's a morbid procedure, it's not comfortable and just as it's not comfortable for women to have a needle put into her breast and the fear is hey were doing too many of these I want circle back to that. But my view on that today is diffusion weighted MRI, and you know, the is that we have today have have really cut back on those biopsies, but I wanna get your. That's just my take as a non urologist with my patients, but I wanna come back. Also, the government said in two thousand eight I for people over seventy five and then in two thousand twelve for all men that you shouldn't do PSA testing. And when the internet. Scott. Go ahead. Did not do it. I mean, it's easy to not do it. Right. You just don't do it. So what would you predict would happen? If you stop screening for prostate cancer while you would predict it would go up, and it would depend on the time horizon of the disease. So if you stop screening for prostate cancer, you'd predict that the detection of prostate cancer will go down right year out looking for, but you're gonna have you're gonna have a greater number of late presenting diseases or lethal disease. So we published and some of my good, friends and urology published that yes that in fact has occurred. So if you look at starting an OA or in twelve when these two big shifts occurred since that time, there's been a rise in the incidence of more advanced prostate cancer. So the cancer's that are picked up today. Even with the short, you know window where we stop screening aggressively with the internists that there's now more aggressive more lethal disease as of today, I still believe that the formal recommendation for screening for prostate cancer. Is each physician and patient should discuss together. There is no formal recommendation because we when we go through each cancer with our patients, we show them what the ACA with Cancer Society says the US taskforce on preventive services, the NCI the New England Journal medicine did a review on every cancer. And there's one other one other oh, the CDC is the fifth body to weigh in. And we show them. Here are the recommendations from all five of these for every cancer. And I remember when that shift changed to for prostate cancer. There's no more recommendation while the recommendation is talk about it with your doctor pass the buck besides the I think the American kademi of family practitioners, and they don't recommend PSA screening still. I'm not sure why. But you know, that's a different discussion. But the bottom line is that almost all the guidelines now say it's a shared decision making process, which I think makes perfect sense. That's how I view mod modern medicine. Yeah. It does it. In theory, makes great sense. What I worry about Ted is theirs. A bunch of patients they get caught. They don't have doctors like you or me who are willing to be able to have had the luxury of the time and the ability to educate themselves to do that. Because I still see a lot of patients that show up and they're not getting screened because their doctors basically saying, well, obviously, this is quote, unquote. Controversial, you know, I sort of remember hearing that we shouldn't have been screening. So we're not gonna do it. And that's that's sort of my fear with these things. Well, I think I think shared decision making it require also. So then to me conceptually, it makes a lot of sense in reality. What does that actually mean? Well, that's the next question. That's the next unknown. Right as well house. Our shared decision making process, how does it occur? And when a patient sees you that's different than when a patient sees an average internist, let's say, and it's different. When a patient doesn't see any doctor. So, you know, the idea that there's the bus that rolls up that just does your bloodwork and send it back in the mail. That's terrible. I mean, I did that when I was a resin they pay me fifty bucks. Go man the bus and do that. That's not really doing that patient, those individual men any, you know, any they're not helping those people because you don't know their whole health history. You know, and all that. So I experienced that. And you know, I got into it with Otis Brawley about screening, and you know, he raised that point in. It's valid. I did that when I was rather than because I was told to do it. And it wasn't that. That's a mistake just bringing up the bus and doing blood tests in the WalMart parking lot. That's not a good answer. Having a discussion with the vision is their internist is a good answer because I have many patients where the bus parameters, by the way, eight men between eight any guy who showed up literally any duty shows gonna free PS. Yeah. You know? And then they'd send it how did I not know you were doing that? I did it once or twice, you know. And I was a lab year. Resident they'd say go ahead. And, you know, do you want to earn fifty bucks? And I drove to some civil war town in northern Virginia. A cool town. You know, did it you know, on a Saturday for half day. And I did you know, and it was. Like, you inside you say, okay, I get it was worth doing. Because now I understand how bad that wasn't. What a mistake that was now, Conversely, I have pay a lot of patients that role in their super healthy sixty eight year old guys with TSA's of twenty and have a bad rectal exam, and they had a PSA when they are sixty and it was three, and you know, and they'd come in. And I had a couple experiences where you know, the spouse is just hysterical because she's like, you know, how could this guy the her husband's internist just stop the test and not discuss it with us and to be clear where is the screening recommendation on rectal exam. Well, it's variable. I mean, I think rectal exam adds value many of the kind of intern. It's society's say that you don't necessarily need to do it. I do think it requires experience. But I think it's part of the physical exam. So you should do it. If you do it enough, you'll get an idea for what's really bad. And what's not, you know? And so I I have a lot of really good internists that still do. It. They do a great job. And so I think it's regional and it's also varies by the country. I I could probably use a tutorial on it. But I I do it a lot. And I realized that it's can you insert like a zipper noise. I'll show you how to do it. I want the technique, but I can see that. If it's something you're just not doing frequently. If it's something you would only do on someone who shows up with a high PSA, you're not getting the wraps. Gotta sorta know what normal feels like. Twenty year old. Let's art. Yeah. You know, when you listen, you don't need a twenty year old process. And but you listen to the heart of everybody, and that's how you detect pathologic prom. You got all of those you did trauma. You got to see a lot of normal prostate. So I think that the guidelines have come to a medium. Now, the pendulum was both ways. I think that prostate biopsies are these days a relatively safe procedure? They're not overly traumatic for men. There are some that have complications. I think that that's a little bit overly dramatized by people who are anti screeners. The other thing that urologists are doing today is now doing transparent, Neil biopsies. So they're not trans rectal anymore. So so if a patient's listening to this, and they need to go and get a prostate biopsy. One of the things I always tell patients is you should always, you know, it's one thing to know what the average complication rates are this risk of infection this risk of leading. It's also important to ask your practitioner their personal risks because medicine is not homogeneous. Quite heterogeneous. So what would we say nationally would be the risk of infection or bleeding from a prostate biopsy? Well, I tell people most men have some degree of bleeding after the biopsy when you when you have a Bob movement. There may be a little bit of blood. Let's say bleeding that rookie Eire's. Right. So they're showing the if you talk if you talk to if you go on blogs about non anti screeners, they'll say, oh, you know, eighty percent of men have bleeding in the rectum and hunter percent at blood or urine. Yeah. Sure. May there may be a little bit of pink Nisa redness or do microscopic exam on the year, and there's blood that's ridiculous. Of course, you can have it. But is it requiring admission to the hospital? We wrote a paper on that looking in the Medicare population the numbers, it's hard because you look at these big data sets to no granularity. They say about seven percent of individuals will be admitted to the hospital or seen at the ER within thirty days of a biopsy that number seems high to me, I tell people at our institution we monitor by ups infections. It's point four percent drought. So somebody shows up at northwestern. Knowing that seven out of a hundred guys are going to be back in the hospital month, and you can say actually, it's in our hands. Yeah. Our series. It's Ford thousand if you better with an infection. I would say that you know, it's probably about one one the two percent show up at the ER something for an evaluation. They may be have because you can have some problems urinating 'cause your prospect can get a little bit swollen. So overall, it's it's low at you, tell them the result and the as you looted to before in my practice. You know, I don't by everybody. I by people who I think have clinically significant prostate cancer. So I start with the P H I test. We have it within our system here. And so I use the forget that there's any reason to to switch from one to the other you pretty agnostic. No, the Hans Lillian Andrew Vickers show that they perform identically in the same serum. What patients so the four K was developed on a cohort of what sounds like pretty homogeneous patients. Right. What was the H? I developed on what was their cohort similar? I mean, most of these tests are done. In developed in Caucasian men. I wanna ask you do. We run a riskier. If I have an African American patient, and I might can I be misled by his four K, should I be well, that's a good question and the opco team just published a paper based on validation cohort of VA patients where there is fifty percent African American and it performed as well or slightly better. One of my partners. Here has a prospective trial. I'm it's him and myself looking at PHI African American men and the early Tako messages, it looks like it performs as well or better. So so this gift with me you don't normally get this in biology. This is exactly the kind of tests that can go awry because you can get fooled by differences in leaving example. Right. You look at non alcoholic fatty liver disease. Nafil d I mean, if you wanna study that disease in Hispanics, and then try to make even a the mildest inference about what's going on African Americans your host. I mean, they're they're they're not even the same disease. In fact, even diabetes is quite different across races to think that something is ubiquitous. Has prostate cancer. Even though it might be a different disease because I know that African Americans were gonna talk about this. I'm sure have different versions. But even from a screening standpoint that they could be you'd have one tool that is so good in both yet. There is fortuitous. Yeah, they're good tools. And then so after if there's an abnormality in the P H I R four K score. Then I moved to an MRI. And then there's been good day. Can you just because I mean, we talk we geek out on this stuff because I'm super nerdy about what type of MRI to do for what thing, but for a patient listening to this Ted who's going to go to their doctor, and whose doctor is hopefully cooperative enough. What do you recommend because not all Emmys doing the trick here? Yeah. I mean on paper what you want a multi parametric prostate MRI, the most important phase the most important parameter in the multi parametric MRI is actually the diffusion weighted imaging which is the most operators dependent. So it really requires a skilled technician and escape. Killed interpreter. Radiologist to look at those DWI images, that's the most important one. So we do get patients contrast. But people showing you can get a lot of value out of just non contrast DWI based the one we use. No contrast, but it's their DWI's exceptional. I've sent you the images I think if they're Schaefer approved I'm happy. They're very good. Yeah. T one t two DWI an multiplayer MR is if you're listening to that. And if you and if your doctor refuses that I think those are the kinds of things that make me think you need another doctor because at this point and look your insurance might not cover. You may have to foot the Bill for that. And that's that's horrible. Well, wouldn't cover that? That was true. But there's recently reported a large multinational prospective clinical trial, looking at the utility of Mariah used for screening for prostate cancer. And the study was half the men got an MRI of their suspicious lesion. They got that lesion biopsy. And they increase detection of high grade cancer reduce it over. Detection of low grade prostate cancer. So it was a quote, unquote, positive study. We haven't had problems in the mid west Illinois getting 'em is approved. But that randomized trial based out of reported out of the UK that really has changed a lot about what companies are approving for Moore is for screening so rate to here. So so if somebody has an MRI if there's an Adra malady on the MRI, I'll recommend a biopsy. Now, there's a lot of data that says you shouldn't just sample the suspicious lesion that you should do the suspicious lesion plus doing a Sexton. Bob Sierra, kind of what I tell patients is right left top middle bottom that adds value. Not just in the detection of cancer. But if someone is gonna move to surgery, for example, and I don't do a biopsy in ninety year old guy. Even if they have an abnormal Marai, do it. If I think that person's gonna live a long long enough to benefit from treatment in those scenarios. I do those systematic by because I want to know exactly where the extent of the cancer and one of the problems of them arise it it doesn't. Actually, see the true boundaries are true. Borders of the tumors within the prostate, very well. So they're often especially the DWI because it's not really an anatomic. Yes. The way a t one way to images traffic. So if you take if you take the lesion on T to for example, it often under sizes the tumor by between five and ten millimeters. So pretty significant for prostate, which is generally pretty small. So so I do those to get a better roadmap. Put it all together. Now, talk to the patient what the treatment should be. So my album is if you have an MRI done, and you have an abnormality you need a biopsy if you have an MRI done, and it's negative no lesion, but you're wissies your quiz for the day. Peter, but what is high your PSA densities high? So you have nothing suspicious on 'em are, but high identity you need a biopsy and sorry in that situation. Ted do you further stratified by four K? Well, I have done the four K R P H I up. Front which was high enough? So you're already talking about a subset of patients who have a high, and I think something's going on because twenty percents. So then you're gonna use the twenty time. Moore is false negative jot it so the now you're using the prostate density, and we you and I actually shared an Email exchange over this about six months. He has density is so easy. And it is so good. So high PSA density, usually, I would say more than point one five depends sometimes point one depends on the age of the patient their scenario, they need a biopsy anyway, and you know, twenty percent time MRI's are negative. But if they have an MRI no lesion hype. Yes. A and a lo PSA density. They don't eat a biopsy. So we published our series on that. It's not a, you know, it's not a randomized trial. But what we showed was that we looked and compared the doctors at use that algorithm. And those did not you reduce biopsies by about one third you reduce detection of low grade cancer by about one third, and you actually don't compromise the detection of high-grade disease. So again, you have. Tools building off of this very simple PSA blood test to I think offer people very sophisticated screening for their prostate cancer. We've talked about that a bunch. Yeah. So let's talk a little bit about the biopsy because every patient here who's had a biopsy or know somebody was at a biopsy there. There's this word Gleason. Yes. What's your Leeson? Yeah. Could be like a t shirt. So Donald need to do a fundraiser here that could be the urology fundraiser north lot of things put on t shirts. Yeah. I mean, let's take a step back. So as you know, one of my best friends from medical school, my roommate for medical school. Matt McCormick is now a an excellent urologist up in Reno, and I just met I've couple of weeks ago, and we were kind of just we have a patient in common by total luck. So the patient came to see me and he lives in Reno. And I said so funny, my roommate for med schools up in Reno and names, Matt McCormick. And he's like, Dr McCormick is my doctor. I couldn't believe it will how what has small world. But I remember medical school. Like one of the things that drew Matt to urology because we all saw it. Matt was going to be an orthopedic surgeon. There was just like the most amazing athlete in the history civilization. This guy's going to be an orthopedic because that's what you expect your athletes to do. But then when we all started are doing our rotations. He sort of fell in love with urology. And I think a big part of it had to do with two three two things. One was it's a field where you can't take yourself that seriously. Like in the end. It's it's a funny funny field like it's there's there's just a lot of dick jokes. No way around it. And if you find that if you don't think that's funny, like you're not gonna wanna be in that you gotta make it funny. And the second thing was the patients are so grateful, and again, I think if you're a medical student in you're listening to this. You've gotta be able to think about what kind of patients you want to interact with that has a lot to do with your chosen profession. I remember there were people in my class who loved being around older patients, and they wanted to go into cardiology for that reason because they're like, look my bread and butter the patient. I mostly gonna see is going to be like, my grandmother and my grandfather. And that's that's why I came to medical school. That's what I love. And that's what I wanna do. And there's just something about that urology patient as again urology abroad field because there's male urology, female, urology cancer, non cancer. But but for the most part as you said, you get to fix things in people that are causing them real trouble. And again, I'm not minimizing the stuff that I was in. Trysted in which is like pancreatic cancer. But when you take a person's pancreatic cancer out, they don't necessarily feel any better. That's true. They usually feel worse because it's a big huge operation and Celikkol. Can. I mean, I think that there's a lot of urology that. I mean, look the patients that we take the people in urology are great, you know, and so going to work every day says the blast. I mean, everybody's smart. Everybody's fun. They don't take themselves too. Seriously, that helps the patients are wonderful people. They're incredibly grateful, and then urologist, also, you know, we own the diagnosis. So a lot of other surgical specialties. Let's say colorectal surgeon example, very fuel the diagnoses come from the clinical surgeon, and therefore if you own the diagnoses, you own the pre-treatment, the the predigested work, you do the intervention and you follow the patient afterward. And so one of the nice things in urology is that you have this great longitudinal care with patients. And so many of my patients followed me from ball. Damore, and you know, my nurse her Marie who's fabulous. She she hates me. Because you know, I'll I'll have like a fifteen minute return double book, but it's one of my old Hopkins patients, you know, I'm in the room for two hours. And she's like what were you doing in there? I'm like our talking about our kids, the Goto, the whatever, you know. And so that part of it really makes it super fun out about the goat. Yeah. I love to go. It's yeah. So in trying to get goats goats are trying I'm not winning what they don't. They're not allowed in your town. No. I just I can't convince the family to get the go. Oh my God. You gotta go to pygmy goat cutest thing ever. They're so cute. They stink. But they're super cute, and they're incredibly smart, and they're very social. So they do not like you can't just get one vote. They really they actually they they do terribly if they're just by themselves. So anyway, so, you know, that's the fun part about your allergies. You get you get these patients. So they all have a may every I mean, I I love just talking to my patients. Dr Welsh he had a way to to do a history and one the second thing he asked what they did for living. And it wasn't the kind of a checkbook check. It was just to say how you're gonna talk to this person. And for me. It's I like to ask the max, I love just learn about what they do. They're so many cool jobs out there. You know? So, you know, sound engineer for a big theater in Chicago this or that it's just awesome super cool yet you've had quite an Austrian career. That's not even close to being over. Which is also includes I know, I know you don't think much about this. And I think it's more of a nuisance than anything else. But you've also now basically become the urologist to anyone in power that seems to need just as Pat was basically when we were at Hopkins every VIP on the planet came to Hopkins, and I can't even as a general surgery resident rotating three Raji, I can't believe the people that walked through that hospital, which was also true in pancreatic surgery in, you know, all sorts of other surgeries. But and so of all of the sort of people, I don't I again, I I don't wanna use names because I don't know how many of them have ever publicly talked about at the. One who I know his public talked about it as Ben Stiller because of course, you and Ben went on Howard Stern together. So how did you even get introduced to Ben Stiller? And I know Ben was very private about this couple of years. You guys went if my remembering correctly, it was probably a year or two after his surgery that you guys even went on the show together. Right. Yeah. Was two years or so after that in and I met him through his internist this great really one of the best internist I've ever interact with Bernie Krueger, you telling me like, I don't know who he is. I am saying the audience Bernie's great for the listener head introduced me to Bernie four or five years ago when I was starting to practice in New York, and he said Bernie's the best internist I've ever had a referral from probably because he trained as a medical oncologist. But he said, he's really freaking smart, and he knows his stuff. And if you're going to be in New York, you've got to meet him. So you introduced us. I went to meet Bernie, we hit it off like in seconds. Yep. And he just said why don't you just come in my office? And so to this day, I still sit next to Bernie, Bernie's great. So. Bernie was taking care of Bandon. Bernie was a guy who did all the right stuff. He did. He did the blood work, and it was abnormal for him and his his age and got up in New York. And then he came and met he met with Dr walls because Dr walls wrote this has mazing book, Dr walls guide to surviving prostate cancer, and Ben had gotten it. And so he came down to meet with Walsh, but Walsh wasn't operating anymore at that time. And so we I'm that's how I met him was through Bernie and through Walsh. I have a copy of the book for you, by the way, because I convinced Dr wells to do a final edition of it just came out in may. It's really really good. So all the listeners out there. It's a great resource. So that's how we met and then he had interviewed with the bunch of folks. And he decided to have surged with me, which was I was honored to be able to do. And then he did great. And so we he's been an amazing person for the field because he's not afraid to talk about his journey and what he did. And he really he's an amazing person. He's just a down to earth. Good guy. So. For me. I've you each of my patients as VIP's, you know, I really honestly my heart-to-heart do. And so yes, I'd take care of people who are, you know, important in many, different professions and walks of life. And so it's fun to help all of them. And it's fun to go on Howard Stern with Ben Stiller. That was a great experience. So by the way, you know, it sort of occurs to me when you say this that you were still relatively junior as urologist you'd probably only been out of your training for six seven years when you operated on Ben did that ruffle any feathers at Hopkins that that you became the heir-apparent. I I mean people tell me did, you know, I never really thought about age in that way. You know, I have always pushed myself to to be the best surgeon. I can be and always tried to measure up to Pat Walsh for one of my other mentors assist guy. Balch carter. These guys were the brilliant surgeons at Hopkins. And so I to me it didn't matter that they do. Doing it for twenty years and I had done for one year. I wanted to be as good as they were just like, you know, you the same way. And so that's how I always viewed it, right? And so and it was just the environment. I surround myself with. So for me when Walsh said, you know, listen, I want you to become my partner and Benchley want you to take over my practice when I started quote unquote, as his partner he was still top of his game. And was the was the man I benefited from that because he was so busy. I, you know, he would refer me cases. And at the very end of minot our relationship or time at Hopkins, you know, he was an operating more. And so I if he had patients needed surgery, do it and everybody I think on the outside thought that this is this easy thing. It was a gig. But listen when a guy you operate on not only reports to you how he's doing. But how to Walsh how he's doing? Then that's serious. You got to be on your game yet. It's like an eternal fellowship never left. Right. So, you know, he would call me and say, you know, selling so says incisions crook. And I'm like, oh my God. You know? So like, you know, you couldn't get anything. And so it makes you better, right? Definitely makes you better. So let's go back to the t shirt raffle thing, and what's your Gleason? So what does this Gleason score? So Donald Gleason is a pathologist. He was a pathologist in many people, including the folks at Hopkins were coming up with the way to grade prostate cancer. So we grade cancers, and that's a way to measure how they are. And usually cancers are kind of high-grade low grade or a one two three kind of system and Gleason came up with a way to grade prostate cancer based on the appearance of the gland. So if you go back to our knowledge or discussion of the sewer system, effectively, you know, there are these channels that the prosthetic fluid comes down and out of and these channels will grow abnormally in in a cancerous state and so- Gleason was describing how these channels appeared under the microscope now one of the interesting things about it was. Unlike a lot of other cancers where they would describe the rate of cancer based on a high power view, like a very, very close view, Gleason graded his prostate cancers and a lower power view. So he got a better sense of the Roman architecture. It's an architectural thing. So it's the tree not the leaves. Whereas a lot of grades are the what is the leaf look what's the edge of the leaf Lindley. So so he did it. And so the way he did it was he said, well, what's the most common looking abnormality? What's the most prevalent abnormality on the view on the of tumor, and then what's the second most common kind of glandular architecture. And so the Gleason some is those two things the most prevalent and in the next most prevalent and that went from and so it was a one to five scale. So the lowest Gleason score originally lease other ten combination. Yeah. The lowest Gleason some would be to the highest Gleason some would be attend. That was how it started out. But then over time so meaning one plus one. Or five months five. That's right. So overtime at evolved in the lowest Gleason, some would be a six three plus three was kind of typical read. Meaning because if you're already at the point where you're doing a biopsy, you're not gonna see ones you're shouldn't be seeing ones and twos. If you're doing a biopsy is at the thinking, I think that there were some general organizational 's architectural features that everybody just agree were low grade, not aggressive, and yes, you could occasionally, you know, occasionally, even how concede see on final pathology report Gleason with some pattern to in it. And they would try to explain to me the subtleties of the difference patter to an apparent three. I think most pathologists called a they would just call it a three. So that's where it was for a long time. But there are some subtle differences in the Gleason, some that actually have real big differences for what the patient's outcomes would be. And so in two thousand fifteen late two thousand fourteen the international society for your logic pathology. Just so we're talking about dork central here. I mean, you know, real, you know, real super geeks bread. Really good the holidays. They are kind of. Yeah. They got together along with rocks, radiation, oncologist, medical oncologist urologist. We need a better way to to transmit this information to patients and to internist in a way, they can understand. So now, there's a great group and the great group goes between one and five the original kind of old school Gleason some of six that's a one a Gleason three plus four equals seven is a to a four plus three seven is a three a four. Plus four equals eight is of four four plus five equals nine or five. Five is a five. So this step wise Gration into five bins of aggressiveness called the grey group, actually, translates very nicely into step wise clinical outcomes glaucous. So that's the new kind of way that we talk about a talk about my. She's just a great group. So you're a group one two three four five. So do you do any other testing do use like type or any of these other genetic testing algorithms to further strata fi or to those only become things that are done post surgery to determine Edwin care? So I think that they can. Yes, a good question. So I generally speaking don't because I think I know what the patient what they need. So what only my that? Well, you taught me when we are in terms, you know, don't order a test. Don't do a test unless you know, what you're what you're going to how it will yet. So funny. I was just having discussion with a patient yesterday. Yep. Don't order a test. If it will not alter your management, right? So I don't do a prostate biopsy in ninety five year old guy. Who's got an L that I don't do it. You know? So, you know, I don't urology concept to the coronary. I see you, you know. So I don't do the test unless it's gonna change by recommend for the patient so prostate biopsy, I'll do it. I think I change something. So I don't do the Tesla's that chain something I recommend. And for me. It's there's not many cases where it will change what I recommend. So meaning what do I mean by that? Well, again, we don't actively treat all prostate cancer today. People who have great group one prostate cancer. Generally, we recommend active surveillance monitoring the tumor to see if becomes more aggressive versus and to be clear. These are patients who these are the quote unquote, Gleason three plus threes. That's right. And were saying we're going to actively monitor you and would your once you have the pathology in your hand that that grew that Greg report the googlies Gloria is anything before that matter anymore. In other words, does it matter in your thinking that this guy had actually four K of seven point five percent versus twenty percent. Yeah. Does matter and Murari results matter to this is the ultimate basin experience. Yeah. You know, that's why the genomic test. It's funny if you measure new compare genomic test, and there's a bunch of amount their head to head with PSA density, PSA density, performs pretty much identified. Well, right. It's pretty amazing. And do you get the grams? I mean, the MRI does tell right there until you get that. Can you get that alter sound catch and has a Namara we measure the ultra at the time of the biopsy will measure, but the you know, generally speaking, we get it off the mariah's what I use. So a Gleason six I generally recommend surveillance unless they're super high volume six, and I know in my brain that and that's independent of age. So a forty year old. I mean, we have a mutual patient who was a Gleason seven, I believe at the very young age like forty five correct? Yep. Did his age being forty five versus sixty five change the way you managed him. Well, so he came in with a single core. Seven really wanted to do surveillance, and that would be one opportunity to say. Let's do a genomic test on this on this individual. And let's see how Gress of a tumor looks under the no under the true microscope, the molecular profile the tumor, and so we talked about doing that and his biopsy. The molecular test was favorable. But you don't forget about those patients. You actually, follow them active surveillance. So we re biopsy them, you know, after repeat MRI, and he had a lot more. As m r I was actually pretty favorable. This was an MRI invisible. Even and he had multi-core seven. So we then we took him the surgery that very well. Yeah. I I always think of his case just one of those examples of I don't know what the term is. Because I don't wanna use the term precision medicine because that's become so stupid and meaningless. And I don't even wanna use the term multidisciplinary because it really wasn't multi-disciplinary was mostly Schaefer disciplinary. But it it. It's just the nuance of the fields. Just that's that's the medicine. That's that's the that's the hard part. That's the part that you don't necessarily. Figure out in residency so easy. I think to go through residency learning the technical stuff learning the surgical judgment. You know, what do you do if this person's got a post operative bleed versus in infection? Who do you sit on who do you take back to the those are very important skills? But this is like kind of next layer judgment stuff that I mean aside from talking with your colleagues and surrounding yourself by people who are you try to surround yourself by people smarter than you. How do you continue that evolution of learning? We have a what I call adult only journal club every fried every other Friday morning. So it's all the oncologist, and our group Maddox rat on urologists, your logic oncologist, and I call it a dull only because it's not really for the residents. It's during their teaching conference, and we just pull articles that come up every day. So I- every Friday morning. I get a feed from the H about new prostate cancer articles any article of prostate cancer in it. I get that link. It's about one hundred eighty two two hundred papers week. I. Review that list and any looks good. I pull it and I'll look at the abstract era, pull the paper. And so I send those to the group and on Friday two days from now will go over my prostate articles, plus my partners bladder cancer articles or kidney cancer, because I I don't read those. So I have them tell me what's important in those fields. So that's how I it's really fun. Because it's just like, you know, what we been school again it's being in school. It's decide of continuous learning. So that's how I think about and try to keep on top of at meetings are okay. But you know, I think that people get bogged down in just the politics of a meeting so thing reading reading what I try to do most of slits pivot to another topic that's germane to prostate cancer, which is kind of a two topic that goes hand in hand the first the role of testosterone the second of the role of dihydrotestosterone. So we can explore this in any order, but I wanna definitely touch on the notion that is there a real or perceived effect of patients who are on five zero dictates inhibitors. So for the list. Males make a hormone testosterone just thrown is converted via an enzyme called five after reduc days into a very similar molecule called dihydrotestosterone abbreviated DAT. Dat is actually any slightly more potent steroid and in men who fifty times more potent. Yeah. So the in men who are susceptible to baldness DHT, drives that process D H T also probably plays a role in the enlargement of the prostate is correct. Most of the five for duck days enzymes in the prostate. So yes, reducing Anderson's in the prostate by reducing effectively. Reducing DHT production reduces the size of the prostate. So a lot of guys take medication to reduce DHT either to reduce prostate volume size of something called benign prostatic, hypertrophy or to re minimize hair loss, and it's usually the exact same drug given it slightly different doses. And sometimes even come up with different names for the same drug. So proc-. Car is financed. Rated five milligrams. And I think pro-peace says the one milligram nets. Right. Okay. Now, I remember many years ago, and I don't I'm sure this has been revised one hundred times, but maybe ten years ago, maybe less, but a paper came out that said look in guys who have suppressed DAT levels when they get prostate cancer. They're more high-grade is at my remembering that correctly. And there's been definitely case reports of that. It's hard to really study that over I gotta yeah. So what is the current thinking on five algebra dictation habituation, and that relationship to prostate cancer? Well, there's was a very large randomized trial to see if you could take that medication with the idea that if you reduced the relative amount of Andhra Jensen the prostate by preventing the production of his potent androgen DAT. Could you reduce the risk of prostate cancer in those men and the answer was if you took that medicine that reduced potent Anderson? Hugh could. So there was a oatmeal study. This was in men starting out who did not have cancer. That's right. So it was called the prostate cancer prevention trial, and it was over seven years at the trial is conducted in Thompson was the PI on the trials of big study. It did reduce the chance at a man would develop prostate cancer overall, you know, reasonable amount of time. But one of the problems was that there was increased detection of more aggressive cancers in the men who are taking the finance. Right. And so then the question was, well, what is that? From is it inducing, a more high grade cancer, you know, and whether or not that's true or not as or is it selecting for it because any cancer that comes out of a low DHT environment. Well, yes. So I personally think that what you were just saying as is true. So yes, and there's case reports that people with low testosterone, or for example, people with low PSA's because PSA is only made when there's testosterone around, for example. That those individuals have more aggressive cancers. Now, this is what I've been focusing on in my lab for like the last four or five years now. And so one of the cool things we did in this collaboration with this company genome DX in this great, scientists alight of an she Oni was to look at the biology of prostate cancer, how grass if they were and compare the gresh Innis of the prostate cancer with the Anderson output of the tumor another nuanced way to normalize things a bit. Yep. And so we had this ipod uscis that the tumors that had the most amped up Anderson, signaling the most Anders output because prostate cancers and ginger tumor that they would be the most aggressive, and I say that way 'cause you know, the answer stieg's act posit the tumors with the lowest Anderton output or the are the most aggressive tumors. So it's somewhat relates to PSA, but not entire. Fairly like there's not a is on a true, you know, linear correlation. So the high Anders output tumors. They can be aggressive, but they are not as aggressive as Alterra low once's by modal distribution. And this is a good way to segue. Talking about these molecular tests because this is a commercially available test from genome DX might tell a funny story about ally. Before we go down there. Sure, I've told this story before but now we get to put a name to it. So I hope he doesn't like like I said, I'm telling it was it was allies the guy who called me one day when I was in the airport, and he's like here. My wife just got me this book. It's it's it's a great book. And you're in it. And I was like what I had no idea what he was talking about. And he goes you had called biggest tools. I was like, wait. Do you mean tools of titans? They'll say, that's it. That's great. I know I've stories, but so to this day like anytime talking with Tim Ferriss, like I'm like, I expect to be referred to as the biggest tool that is really he called me too. And he's like, dude, I'm reading this book. But he didn't call biggest tool. That's awesome. That's really funny so allies start of this company. That was Juno, Geno, Mickley transcript I'll make lease so looking at the Arne levels within prostate cancers. And so he has a commercial product. That's very very good to just tell you the aggressiveness. It's basically genetically score. It's more sophisticated that, but that's what it helps you to do. But when he when he looks at each tumor. He captures about one point four million data points on each tumor. He uses twenty twenty one of them for his test. But we use the other one point three nine nine nine million of those of those data points. And so we developed this algorithm. Look at this. The thing that's pretty cool as we've been able to model and show with allies grew. That you know, because it's one thing to have a kind of prognostic biomarker like your prognosis is good or bad. But. Precision medicine is really the can of the predictive stuff. So we've been able to take all this data. We've been able to show that these low. Anders output tumors are the most aggressive tumors now. Hi, Andrew output, very high air output tumors are also passive, but as you would imagine the tumors are sensitive to different drugs, so high air output tumor, they're exquisitely sensitive to energy deprivation, which is one of the mainstays of treatment for metastatic prostate cancer low. Anderton output tumors are not right. They're not dependent on it. They don't use it as their fuel for growth, and we've been able to model other compounds that they are sensitive to and so were moving those things into clinical trials is sexually pretty exciting times. So what is the current state of the art or the current thinking on testosterone replacement therapy? And again, I'm referring to this in the in the confines of what we'd call physiologic testosterone placement. So you've got a guy who's walking around with a free testosterone at seven. Grams per deciliter on a lab where the upper range would be twenty five and you know, he's replaced two twenty my reading of the literature says I'd have a very hard time. Making the case, it's that's increasing risk of prostate. Can't with that. And I think my data suggests that the tumors that we don't know how they develop but the tumor where we segue like five times. But the ideas that our data shows that the most aggressive tumors are the ones that have low androgen output does that mean that they developed in a low energy state? Maybe we don't know that. I don't know. But, but for sure it's telling me that I don't like you said, I mean, the literature that we've discussed on the phone many times. I don't see any clear evidence said physiologic replacement of testosterone is gun to accelerate or cause a cancer to develop. What do you think the role is of Estra dial in this some have argued that as Estra dial is going up that may be playing a greater role in prostate cancer either through its? Direct interaction or indirectly through its receptors. I think I don't know the answer to that question. But I do know that it's not just a testosterone thing. Remember when we talk about benign, your logic conditions, testosterone values decline over time and over simplified the whole PSA discussion earlier so remember that PSA's rise over time. But at that same time testosterone values are lining. So I do think that a lot of the prosthetic growth not cancerous grow Senator necessarily, but but nine growth are influenced by the ratios of TD, so to speak testosterone estrogens Anderton's estrogens which wanting his it seems to me that you're at your highest risk when your testosterone is going down your estrogen going up. Yeah. Now the question is what's the lag time yet? So at in real time. Yes, that's true. But we know that all cancers prostate cancer for sure. Among them is something that occurs from mutations of the DNA from decades prior probably so yes at the time of diagnoses, there's probably higher Esther dial lower tea, but I think about it like what happened to that in that patient ten years beforehand or fifteen years is there anything about the mighty Qendra in the processed. The prostate has so many odd things about it. And we're gonna talk about the difficulty with immune surveillance in a moment. But is there anything about the the mitochondria within the prostate that are unusually sort of either ramped up or ramp down relative to other epithelial cell derived tissues? That's a great question. And I hope you know, I try to ask request. I say that because we just had last Saturday. We had our kind of prostate cancer working group meeting where all the kind of, you know, deep thinkers get together got together on a Saturday. Just about to say the fact that she goes through this on a Saturday just another bit of evidence to like the level of obsession here that I love. Yeah. So we I re roped in this brilliant radiation oncologist named David Geiss works on hormonal dependency and breast cancer. And what he focuses on is on the Maya Qendra. And specifically these superoxide dismutase is that really get rid of reactive oxygen species. And so he has a whole model, and he knows about aluminum be breast cancers, and how they can become resistant to Tomasa thin and so forth, and it's driven by basically, the might Conroe and still mitochondria in the prosecutor follow the Warburg effect. Do they become more? Do they do they favor an aerobic metabolism? Over oxidative phosphorylation. I I it's hard people don't we don't know. You know, people don't know a lot about the metabolic environment of the prostate. I've had a lot of thoughts about where what about the? I mean, it's it's a very dense, Oregon. There's not a lot of blood vessels in. It's on a big blood supply. You know? And so I thought a lot about just for example, are there regional differences in the P H within the prostate and his dad what's causing these because I think about in relationship to these Andrew independent tumors. My my brain is defaulted this idea that will the high A R output tumors are ones that are occurring in oxygen rich parts of the prostate. I mean, I don't know why just assume that you know, and that these lower air output tumors are occurring regions the prostate have lower PA. Oh twos. Different P H is. And they're forced to use alternate growth pathway. It's hard to test that you know, I've thought a lot about it. There's nothing published on it. Really? It's hard tested, but the sky David guys. Has a lot of really interesting data looking at the tune in pathways through might Akon rea- regulating. The homeowner dependency are hormonal regulation of prostate cancer. It's a brand new area for him. So in other words, the tunes, which of course, can either turn on or turn off genes. The idea is in this is certain to or a different, sir. Three sort three. I see. So it could be up regulating or down regulating production. Basically, he has a certain three manganese super oxide dismutase pathway worked out, and it regulates resistance to Tamaki if an aluminum breast cancer, so and he's made these observations, I publish this and sell and I want to say, oh seven or eight on certain three in brass, but he had some data in there and prostate. So I kind of we hang out with the money wanna king out with like a deep thinker. So he has his preliminary data, and he has more interesting data that there may be a role for this. So I do think that there's something. About metabolism in the prostate. I think it's hard to study. You know, it's tough. It's hard to model at an amount at all. Like, you can't do it you cannot model in a mouse by do think that there's some good people on campus who think about it and are going to be able to study. Well, he's he's the guy. You know? I'm seeing Chen del tomorrow, who is a mutual friend. Didn't you go to med school with? I mean, he was in grad school when you were in med school or something he says that he was my TA and undergrad, but I just note, you know, known him. I think we've figured out I've known him in nineteen I met him in ninety three or ninety four. So he's really one of my oldest friends. I have you know, anything should know about now. But well, I know, of course, because we played Patty cakes on Easter Island for awhile. And well, do you know what his nickname? No. That's the thing. There was a nickname. Yeah. What's his nickname? Well, just for the listeners. Knob deep is this. He's about what six foot three suave good-looking. Yes. Good looking guy long hair. So it's nickname was swab deep. I mean, I've ever seen the ta ta class where there was it was like ninety percent women, you know, had questions for him afterward. You know, awesome in med school. Great. And did you also go to school with Matthew Vander head? I did he was a smart kid my med school class. Yeah. Matthys I know Matthew, obviously, not as well as you. But I don't know him that. Well, I just know him and relate broke up in the field of cancer metabolism. Yeah. I'll be I gotta get up to Boston to see Matthew who actually works and collaborates very closely with another very very close friend of mine for medical school may Mark Palmer, who's a medical oncologist, Mark. Yeah. He's great. I love that. All like, all of these independent circles of my life, have overlapped and prostate cancer and cancer in general. Yeah. What is the most exciting area of research that that you think of with respect to prosecutors specifically, maybe I'll even prime the question by saying immunotherapy seems to finally becoming into its own a little bit with some cancers. But of course, the prostates kind of a weird immune protected odd organ like does amino therapy play a role in this. Or are we talking metabolic therapies or read? Resolve gonna. Be coming down to earlier detection of lethal cancers. Certainly early detection cancers is important. I think the most exciting stuff in in your logic on college is really moving beyond these prognostic biomarkers to predictive biomarkers. And so there's a lot of really cool new things that are, you know, great. So there are some predictive biomarkers at you can pick up in the DNA of tumor or the DNA of patient, particularly Braca. One Brock to ATM lost. He's different kinds of DNA damage repair pathways. That people didn't really think matter for prostate. We now know within the last three years, they really matter. So I didn't. That's that's news to me. I I never really understood the BRCA one BRCA two should be looked for in males as well. I mean, I did from breast cancer standpoint. But not from a prostate cancer standpoint. Yeah. So so there's a one of my heroes in in your logic on colleges is this guy Pete Nelson. He's at at the hutch and Seattle, and he published a paper, and they look. At the germ lines of men with metastatic castrate resistance with the most end stage prostate cancer, and what they showed was that. In contrast to the general population of men that mutations in these different DNA repair, pathways or significantly enriched and individuals who had metastatic prostate cancer. So about eleven to twelve percent of men with metastatic, castrate resistant prostate cancer mutations. Particularly Brock to Braca one ATM RAD fifty one these different pathways that are involved in DNA damage repair. If you look in the tumors of men with metastatic, castrate resistant prostate cancer, it depending on where you look over one third of the tumors. The cells will have mutations in these pathways, which makes them incredibly sensitive to park in addition. So that's a huge game changer. The other thing that people now look at his kind of the total genome scorer the alterations in the genome of the individual cancer cells will that make them more sensitive to immunotherapy? Fear. Not that's more coming online. But the idea that there are things in the semantic DNA of the tumor cells, and in the germline of individuals that you can use to screen for not only, you know, prostate of breast pancreas excetera that's a huge game changer. And then as we touched on earlier, those are not just prognostic biomarkers, but their predictive of drug response, which is pretty amazing. And then I think allies test the version two point. Oh, or the beta version of it which has a lot of these built in biomarkers at predict responsive drugs that now are being tested in clinical trials with with the idea that let's test the ability to predict response, it's pretty mazing. Stop actually. So obviously, you specialize in prostate cancer the field of urologists so much bigger than that. Right. We haven't even talked about renal cancer bladder cancer, and to do so would only be to do it an injustice. You know, given that we've been talking for a little while. And I know you've got a hard stop here in about twenty minutes. I wanna talk a little bit about benign stuff. So I'll tell you personal maybe someone embarrassing story. But it sits good illustration of of this. So when you were treat at the extra large peanuts clinic at happens is the Mike the peanut insert or. Yeah, reductions exactly see those are the kind of jokes. We can only tell in the euro. So by two years ago. I remember calling Ted. I don't what's going on man. Every time I p like it's just burning like crazy. I did a quick check. I don't have a UT. I never had a youth. I'd seems unlikely I would have been fumbling around. And I'm wondering I must have prostitites. Right. And I guess my question is Ted. What anti-biotics should I take and our member I was actually in Baltimore at the time. But I was heading up back to New York because I was going, you know, working New York that week where I spend quite a bit of time. And you said well, first of all you're in luck. Because my dad wrote the paper on prostitites, and it's I forget what year it was. But it was in England Journal medicine, and I downloaded the paper. And I I read it on the train ride up to New York or maybe it was still in Baltimore. Because I remember you had any you've written me for some flow Maxwell what the long and short of it was a came away from reading the paper. And I said, well, my takeaway on this as I need a prosthetic massage not an antibiotic and you said, Yep. So go ask Bernie to give your prosthetic. Massage and I had been in pain. And he we had he did that to get a sample from the prostate because when you do a urine urine check for infection. You're sampling predominantly the fluid the urine in the bladder. So I said, yeah, find your urine cultures negative, but let's check your prosthetic fluid fern infection and think it was clear, but it was clear, and here's the amazing part of the story. I had been suffering for a month. And Bernie being the great Bernie like he didn't just give me a little bit of a prosthetic massage. I mean, he eviscerated me I was one of those Chevy Chase moments. I was like using the whole fist there Moseman river. I actually I will say it was one of the most painful things that ever experienced. This was this was a different level of of pain because it wasn't the rectal. It was like the prosthetic massage to generate the various sensitive. Yeah. Yeah. Especially when you're inflamed as I would later come to realize, well, here's the most amazing part of that story within about three days. Everything was. Better. Yeah. I didn't need a single antibiotic, and somehow that massage probably, you know, somehow turned over some of that inflammation, or you know, there's something. Yeah. I mean, we had you on some anti inflammatories. And we had you on some other symptomatic stuff. But yeah, I mean, definitely, you know, so we don't really call it prostate is anymore. We it's kind of binned into kind of this chronic pelvic pain syndrome, kind of concept, but within that concept, you can get acute bacterial prostate Titus. That's what happens for people after prostate biopsies, and they get very very very sick high fevers went oh, three one four like bad stuff. That's an incredibly wear thing. But what you can get basically, non bacterial, prostitites inflammation in the prostate. We that's the thing. I think a lot of people don't understand Itis, means inflammation. That's right. You can get with an infection. But Itis does not imply inflection so process height as mass. Titus these things don't necessarily have lie that there's a bacteria that can be sterile. Right. So people will have, you know, acute inflammation in their in your prostate. Which is what I thought you had on the phone. I said look have Bernie do actual culture of the of the prostate. Then typically for most people that goes away. We don't know what causes it. You know, we don't know what is that's causing inflammation. That's what my father who's very prominent researcher in this field. That's what he works on. But we know we can we try to treat the symptoms and ride it out. And then we, you know, we try to just risks that we prevent kind of from coming back and so forth. So some of the things that can cause it, you know, we talked about this, you know, constipation. So if you one of the ways, it's easing constipated just going to a transcontinental flight cause dry, and you know, just they'll those little subtle changes make a big difference. So so those things come into play now that falls within this greater scope of something called chronic pelvic pain, which is. I know a field that is you know, has some work in it. But it's still evolving. It's really just been recently described. My father was one of the people described that was some other folks. And so, you know, that involves, you know, just burning or pain in the you know, that you re throw in the bladder women used to be called interstitial cystitis women. So some foods will trigger these things. We don't have a good handle on at all. So we try to manage the symptoms. And then from there, we try to just prevent what's the state of the art with using injections within the bladder about talks to alleviate women who have interstitial cystitis discussion about the. Yeah, it's not we do use boats in the bladder for people who have you know, hyper Krant contract till the bladder. But we don't use it for people who have interstitial cystitis for people. There are people that have deep-seated infections in their prostate that we can document or sometimes we can't document, but we have a suspicion of them. And in those individuals you. Can you can actually directly inject antibiotics into the prostate or an in fact, my my feeling is that actually the typical night Nitis for this persistent factions actually the seminal vesicles, which is attached to the prostate. So what you know, we'll have individuals who have recurrent bacterial infections same bacteria same sensitivity to the drugs. So they don't become resistant. They're equally sensitive all along to be a bacteria that you aren't clearing that's outside of the field of scope. That's right. And so in I feel like those are often or you can you can't get the concentration high enough into into that tissue. And so they're those cases will do intro. How is it difficult? You do that transact delay friends regular, but it's you know, it actually works under Alday sound guidance and how easy to hit a seminal vesicles, sue, breezy, even your even you can do it, even I do that's it across the street. I was going to ask you about. That's thanks for bringing that up. I was gonna ask you about injects you need to do come to share with me. When that the awesome. I'll actually been on the robot. Have you know, we gotta do get out, man. How many going back to that for a second? So we didn't really get into the deep surgical technique. But I do wanna linked to any videos that we can. But what percentage of your prostatectomy do now use the robot for verses open hundred percent your hundred percent robot now and MOS one hundred percent robot, obviously, so most men now getting their prostate removed will do it the the robot. I mean, I think that there are very few people out there that actually can comment on which one is better, you know, robot mercy's traditional open, but I've done I don't know fifteen hundred opens and twenty five hundred robots. So I have a good idea for which ones are better. And was the last time he didn't open case three years ago two years ago. Is there a party that sad that like if you went back into an open tomorrow, you wouldn't be as good I wouldn't be as good. But even when I was good robot. It's I I'm better using the robot. It's just incredibly precise. I'm just a super Taipei guy. You know, you get four arms to control island two hands. Right. So you can just retract everything. Exactly. What we want the magnification the optics are just unbelievable. And you would just you just die. It's just like the Davinci. Yeah. It's like we're in twenty x loops you think about you know, you had two point five that used to walk around with. I, hey, hey, hey, I up graded the three point five those are tough. I had from four axis and is harder min the, but it's amazing. Right. Depends on the case. But even but even anything where my loops were every open case I did. But you know, even the difference between two point five and three point five a big difference. So think about ten x I just put a four x magnify on. My Bo so you have a clarifier in that sits in the peop-. And then you have like a magnifying that sits on your scope, and I've been shooting. Probably up to seventy yards and kid. And then I went to a two x and I was like, oh, this is good. And then I went to the four x, and I I just don't know if I could ever go back. That's the thing. I was one of my mentors, surgical mentors Sky Bow Carter, and he always did his cases what you know without loops. And then he's in Pat made him switch. And so we would talk about it. And he said, you know, it's just literally different operation. And so people who do open prostates without loops I what they're doing. 'cause I mean, you know, you just see everything right? You see it all now think about the robot? I mean, I can act out individual little arteries at our one two millimeters has made it difficult to teach residence. It's easier to teach them you gotta come come by tomorrow. Doing a case. It's usually talking to have tomorrow must pose to do that not at seven AM night. Boy doesn't roll out of bed before nine. Take you up on that. Yeah. There's a lot of other stuff. I want to talk about I know we're getting real close. You've got a hard stop in ten minutes. Now, do you know anything about male contraceptives this atomic that? I is there is there male contraceptive on the horizon outside of a Secta me. I mean, the only way to really prevent sperm production is to block testosterone in the testicle. So that's the way to do it. And there's a couple that are coming online. They've been tested in small groups of men. I don't know if they're really ready for prime time. And I don't know of men are ready for that. You know, what about bass activities, they work. What's the reversal right on them? If you need to worry about that. Well, I mean, I have a partner here. Bob Branagan who's you know, he's one of the he's one of the top three guys in the country. And you know. Yeah. If it's the right if it's if the Secta me was done correctly, the first time, you know, by professional so to speak, so not in the parking lot. There's there's a surgeon. I'm not gonna have professional who else is do. Invest sect Amies out there. GB guy who just think about there. Yeah. Okay. Not saying to them if there was a urologist him. Yep. Nickname Khodadad hands of death and destruction. Anyone any Hopkins resident from our era listening to knows exactly who we're talking about. And that's right. So as long as you don't have a Khodadad. Yeah. You can they can be reversed. But the reality is eighty percent ninety percent. The Peyton c is. Yeah. I think it's over ninety percent for a well, a good micro, vascular era guy, who's deciding who sort of waffling on this. It seems to me that donating a bunch of sperm putting sperm into into Bank. Yeah. Having a really good person. Do the vests ectomy is a short fire way to just go ahead. I mean, most of the time, you know, you can have. I mean, you know, the reproductive technology is just ridiculous. So, you know, individuals who have kleinfeld Thor's where they really almost have no no sperm production who are told ten years ago. You can't have a child. Now, you can you. Can do these procedures under the microscope and find individual nests of sperm within the testicles of these men and allow them to have kids which is had no clue sung with Klein filters could do. So. And then of course, you're doing it anyway because you want to be selective for writing. You're getting the right Chromos. Right. So so I I mean, I think there's nothing wrong with us ectomy. It's very effective way to do contraception. I think you know, if you're single and you're dating around I think you should also use protection, not just contraception. So to me, so this'll be are public service announcement not to be confused with the other PSA this'll be. Yes. PSA on on them. Yeah. I think not just for protecting your not having children. But for all the other reasons to do it is there anything else that we can talk about him five minutes. That's not going to get one of us in trouble. Well, there's lots of fun things that we we can talk about like, watches or pens or cars yet you and I have shared. We don't never since isn't going to work cut. It. All right. So on each of those if someone could someone walked in the door today and said, Ted, I'll I'll buy you any watch you want, you know, within a reasonable price frame. Don't just pick the most expensive watch. But like is there watch you'd love to just have sitting on your on your desktop when you walked back into your office, courtesy of some Santa Claus. I notice you're wearing a beautiful hulk today, I do I wear that on my non-clinical days. It's I do like it. I didn't I didn't wear it a lot. I would say I'm look I'm in the mar this always ask you, I'm in the market for an elegant dress watch. I've never I've never that's the thing. I I have to say that, you know, I'm pretty satiated from watching these days. I'm good. But I I don't know. I I wanna elegant dress watch. But I could travel with it, and it would have GMT. That's my challenge to you. Oh for heavens sakes, you had to throw the GMT see if because I want to be able to wear a dress watch to a meeting, and I want to be able to go the meeting change my time zones. You know, I wanna go to the meeting. And now have nobody know what the watches, right? 'cause you know. Yeah, I can get that in a Rolex, whatever. But it's you know, it's sometimes it's nicer does not, and I will take this on as a personal challenge. If you're willing to give up the GMT, I'm really I don't have it. I might never have it. But I'm really obsessed with two Vacheron out. There one is the altri thin and the other is the nineteen twenty one which is a remake of the famous driving watch. Yeah. Those would be, but you know, you're not going to get a second time zone on either those. I just think you know, you travel a lot to right. It's so nice just know where what your times on his at home. And that's why like about that. I like that. That's my newest thing by love that. So I'm looking for a GMT watch. Because that to me is like so important. So so if you could get home to San Diego and find any car in your garage. What would it be? It's a tough question. And I seem you mean a car that will only be driven on the street is not going to be on the track. I'm not taking the tracks. For you for I for San Diego y-. You know, you've definitely got me more and more interested in in Porsche. And I think that the nine eleven turbo, you know. So when I don't let's just say I could if I could get an early jump on at nine nine to nine eleven turbo. That that might be. Yeah. That great vehicles that engineer. Yeah. They're they're really special cars, and they're so drivable. I mean, there are other cars that I know you and I have driven. We we have friends who have beautiful cars that have given us there for eighty eights and four fifty eight and all those things, and they're they're incredible. I mean, I I actually I love the four fifty eight. But you just you're not going to drive that car every day. And there's something else that comes from it, which is is I guess, I just deep down always feel a little self conscious. Pulling driving around in the bright red Ferrari, and I don't think you feel sell. You don't think you don't have that same level being self conscious driving around and certain other cars, but but that said, you know, the four eighty eight is a blast Seattle. I have a long torso. Yeah. I can't. Get the seat. Right. So I'm not looking at the head the head the pillar. Yeah. So, but it's a great. It's a great car. They're great cars out there. But as a daily, you just can't I mean, I you know, that nine eleven turbos are pretty amazing. Yeah. I've never actually driven a McLaren. I don't know if you haven't. But I've heard those are really I I I have a couple of friends that have them, and they always have an open votation to go. Visit them at MacLaren's in other cities. And those look like really special cars, you know, part of that's emotional to have emotional connection to McLaren because of Senna. Yeah. So I don't like the son of though, I don't like the looks of that car. I think things going to be just a beast. I cannot wait into these. But I mean, it just doesn't you know, I like the functionality that they put in our cars, you think that the Senate looks better or worse than the P one. I think that P one looks better. But I haven't seen either them in real life. I seen seven twenty in real life, cool car. Look great aero cars. He won in in person once in New York City of all places that never understood that lot. Yeah. Right. What would what would possess? You wouldn't matter. How much money you have? What would possess you drive? He one in Manhattan. Yeah. It's crazy. Just like it's almo I knew somebody who had had a law had a nine eighteen and a p one and he sold one of the three because he said just wasn't fun to drive around. Let me see if I can guess, I know maybe the LA Ferrari, the P D's P one because it's just too much of a race car. So he said that you, you know, on the set on the track it's just ridiculous. But the he said that he sold it because on the streets just we couldn't even begin to enjoy it while it's so cool, though, actually think all of those hyper-cars like I love watching Chris Harris take those cars around for the listener, certainly the last generation of hyper-cars were those three cars the Royal. Ferrari, the Porsche nine eighteen in the McLaren p one only one of them ever broken minute thirty on Laguna Seca, do you know, which one I would guess the P one? But I don't know. No. It was the nine eighteen went one minute. Twenty nine seconds point eight nine seconds by eleven one hundreds of his second the p the nine eighteen broke a minute thirty goodness sake, the only production car to ever do. So now, my favorite little ended tell you so which so the nine eleven turbo ass is faster than the nineteen at the ring. I know so unbelievable on the leave arrival. But then of course, there are fifty thousand dollar track cars that will go a minute nineteen run that Laguna Seca, which again is the always the great thing for people to understand the difference being trackers streetcars, Ted. This was awesome. I know this was a bit more of a male Centric episode. But I think one guys will get a lot out of this. But also, I think, you know, for women who know a man who's going through this or we'll go through. This. I mean, I think there's a lot here and will be sure in the show notes to link to a ton of the stuff that was discussed would be great villa linked to any videos have on your on your surgeries, if people want to learn more about you. I mean, obviously at northwestern the website will, you know, linked to your bio, your CV and all that Dr Edward Shafer get all the links, but an M R, northwestern, medicine dot dot org. Is a good way to find me DR. Dash Schaefer dot com is another way to find me. Okay. Do anything on social media? Are you? I'm my handles at Edward Shafer. Okay. Cool. Ted. This was awesome. Thank you for making the time. And for your your hospitality with insights. Yeah. Thanks, peter. You can find all of this information more Peter Tia, MD dot com forward slash podcast there. You'll find the show notes readings and links related to this episode can also find my blog at Peter TMD dot com. Maybe the simplest thing to do is to sign up for my subjectively, non lame once a week Email where update you on what I've been up to the most interesting papers, I've read and all things related to long jeopardy. Science performance sleep etcetera. Unsocial you can find the on Twitter Instagram Facebook, all with the ID Peter Attiyah MD, but usually Twitter is the best way to reach me to share your questions and comments now for the obligatory disclaims, this podcast is for general informational purposes. Only does not constitute the practice of medicine nursing or other professional healthcare services, including the giving of medical advice and note, no, doctor patient relationship is for use it as information and the materials linked to the podcast is at the user's own risk. The content of this podcast is not intended to be a substitute for professional medical advice. Diagnoses or treat users should not disregard delay in obtaining, medical advice for any medical condition. 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Invest in progress was comprised of many grammatical errors the ad comprise many grammatical errors, the portfolios are bigger groups of companies and the companies do things that help the world. Yes. But it's about the direction, you know, one thing comprises little or. Things. It's not little things rising compressed. Yes. But comprised of is just a kind of a bastardisation. It's fine. The English language is it's it's a it's a living breathing thing is this still recording. I hope not this is hamlet. I wonder we listen to. They do. Good evening. Washington. He's saying. We're my furloughed workers at. We're the essential ones. All right. Calm down. You snot nose brats. Where the non-essential people. I get it. Is great to be back in Washington DC, mostly because it reminds me that I am glad that I lived here when Barack Obama was president. I got caught behind Pence's motorcade. Knew was him because of the Handmaid's. That's so stupid. It is weird. That commander Waterford was the designated survivor. Not as bad as Rick Perry. We have a great show for you tonight. We have a fantastic panel. We're also going to have a special guest Senator accused in Jila brand is here tonight. We are here in the moments after Donald Trump delivered his third best. State of the union. Well, the first one was a joint address to congress shut up shut up this show will be released on Saturday based on what we saw no one will give a shit about it by the time. We get to Saturday. It's only been twenty four hours, and I already forgot that Trump talked about the Black Panthers. He actually didn't. But you weren't sure. Because you for a second thought, you forgot or that you zoned out or second until Senator gillibrand side, and then you were back in it. Trump state of the union to me it feels less important than a traditional an actual president state of the union. And it's true. It does feel like it matters less, and I think it feels like it matters less because it matters less. And the reason it matters less is because he does less the job and his words carry less. Meaning there was that story that revealed that a whole swaths of his schedule or now taken up by executive time, which means watching cable news and eating quarter pounders, and it's like I could do that job. You know, there's always this difference between what a president says. And what a president does there's always a space between their promises and what they actually leave and the language. That's just true enough not to be alive. But there's never been not in our lifetimes a president. Who means less of what he says is less willing to tell the truth who lies about so much so often, and what's interesting is to see that. There is still a price for that. And the price is it doesn't fucking matter. What he says in the state of the union, and it just doesn't matter. It has no connection to how he governs. Your state of the unions are supposed to sit between what comes before. And what comes after it? It's supposed to be something that organizes the government's thinking that lets us know through the president's words what the president plans to guide his administration to do over the next year. Does anyone believe that? That's what we saw. So that's a no. Look the thing about the people in the box. It was strating the points. It's a silly thing. I believe in education. There's a child up there who's very stupid. We have to fix it. But this year was also a specially stark first of all he does his usual thing of using a terrible tragedy that affected a family to malign an entire class of people. But he also had World War Two veterans up there, and he had Buzz Aldrin up there, and it's a little bit like look up there. There's the America. We remember the good one the one that was against the Nazis. That's the proud America up. They're not like what's down here with me. And this and a bunch of people shouting USA at the worst person in the country. I will also say that Buzz Aldrin almost punched me in the face once. That's real. President Obama the the good president. He was going to deliver a speech about the space program at NASA. And I worked on the speech. So I was on the trip, and I find myself in a van with Buzz Aldrin, and I should say that even though Buzz Aldrin, I do believe almost punched me in the face. He is not the villain in the story. So we're in this van, and it's actually, you know, there's some contradictions here there's some competing versions of events. But basically what happened? So I mean this van and it's me and our own Chowdhry who is a did a lot of the great videos that Obama produce when he was president and Bill Burton who is a great communications person who now works for Howard Schultz. So we all yeah. I mean, it's obvious. How we feel about that? We don't need to dwell on that. And I'm so excited because it's buzz all trend. I mean, the man has walked on the surface of the fucking moon, and that's still something only Americans have done. You know, we can say that for at least another six or eight months. China puts a flag on our fucking moon. I'm gonna lose it. I'm not joking around. I know I shouldn't mean that I know is just a symbol. But if they put a flag on our fucking moon. I'm gonna lose it. Dr moon. We were there. I are moon. Our moon. So I'm so excited to meet, Buzz Aldrin. I'm in the van of sitting in the ROY turnaround, and I tried to make conversation. It doesn't go very well. And I realized that hindsight, you know, the guys like a daring gruff pilot. That's not my speed. I don't I can't relate to somebody like I can try. What are we going to talk about? Anyway, I will say at some point in the conversation, Buzz Aldrin pointed out that he shared a publicist with Barbara Streisand. Now. This is where the story there's competing versions about what happened next. All I will say is someone in the van said that makes sense you have so much in common in many ways, you're like the Barbra Streisand of space. And when I say that both Aldrin turned a shade of red. His eyes went so white and so wide, you know, they're the television now that they have HDR it's so that you can see more kinds of colors, you can only see the color that Buzz Aldrin turned if you have a properly set up HDR television with the latest HDMI cables, you need that proper two point two handshake. That's for no one. Now. I, of course, immediately in a way that's too uncomfortable to describe apologize said it was a joke and a silence settled over the van like a fart. And we in that van sat in total silence for the remainder of the ride to Cape Canaveral. I was in a van with a man who walked on the moon, and I ruined the ride to Cape fucking Canaveral. The point is state of the union. State of the union. Anyway, it was terrible. It will mean nothing, and that's the price. He pays for being a liar. Also, I don't know if it's the LSD talking, but the only part of the speech I liked is when Nancy Pelosi unhinged her jaw and eight Mike Pence. What are you applauding? Also, let's just look at this shit. There is going to be peace and legislation. There cannot be war and investigation. It just doesn't work that way. We got beat by the stupidest bucket assholes. That is some marquee, Mark. And John C Reilly in the fucking day. New Ma of boogie nights snorting coke and trying to record an album is the dumbest bucking shit. I have ever heard. If it wasn't so stupid. It would be terrifying. It was stupid. You'd hear the words. Which are I'm going to start a war. If you people don't stop investigating me. Then a godforsaken rhyme is that. A presidential speechwriter. It's not actually easy. It's a really really hard job to get really stressful. Hard job to do. Work on it really hard trying to make it lyrical, but not to lira coll-. You wanna sound majestic, but you still want to sound like a human being memorable phrases? But nothing too cute. You want soundbites nothing sounds to political you read speeches. You think about what Ted Sorensen would say, you searched through the the old states of the union, you think about lines fucking asshole show up. All right, obviously, the person writing these speeches is C, plus Santa Monica fascist Stephen Miller. This speech writing was so bad. It's like, let's put the racism aside for a moment. That's how bad the writing is Joe badger racist. Writing us to be for the racism to be the second thing you notice. You can either have war and investigations or you can have peace and legislation. What kind of godforsaken choices that? Unbelievable, whatever it's the only thing will remember and we'll forget into week. All right enough on Nuff about this speech. There's a lot more news to get you. I wanna bring out are fantastic panel. She is a writer comedian youtuber you can pre-order her book. Obviously. Now, he's welcome back friend of the pot Accua Hughes. We do. Next up. She's the co host of Showtime's the circus, contributing editor at the Atlantic and author of future pace. Please. Welcome back, Alex Wagner. They do now. Oh, hello. Hi. Is it starting now? It's nice to see you John nice to see you. And she's the New York Times bestselling author of who thought this was a good idea at a very special contribute or could media's hysteria. Please welcome back. Eliza master, Monaco. You have banned. All right. Let's get into it. What a week. As most of you know, right now things are not looking great for Virginia. Democrats. We're recording this mid week. I don't know where we're going to be when the show comes out on Saturday. Scandal is moving through the upper reaches of that government. Like the black face plague. I don't know what this means. But it says here some Democrats have taken to marking their doors with lamb's blood. I don't know what that's going to do. I don't even know what it means. I think it's something about helping the reporters pass over them. Route north of is under pressure to resign after photos from his nineteen Eighty-four medical school yearbook surface showing people in black face and KKK robes, then Lieutenant governor Justin Fairfax who would succeed Northam has now been accused of sexual assault by college professor accusing him of misconduct in two thousand four and if the governor the Lieutenant governor and the AG after them the fourth in line for the job is a Republican Kirk Cox, you became a house speaker after a close race ended with a name being drawn out of a fucking bowl. If Republicans take over the governor's mansion while controlling the legislature, the damage could be monumental, especially to healthcare, reproductive rights and congressional redistricting. Akilah you're from Kentucky. The reason I'm asking you is everyone in Virginia government going to be brought down by a black face scandal. Until we have to pick a new leadership with that song where they put people in mass to sing. Yeah. Yeah. It's going to be exactly like the show. I mean, listen, I am from the south. And we we've been new up schism. It's never surprising. When those terrible cub cap kids got sort of like found out my nephew is one of those kids. Yeah. The one black kid, I'm not proud. I had to cuss him out. And I'm like in Kentucky, even the black people are racist. That I'm like, I'm listen. This is going to be fifteen more people who are like we didn't know we did like a all white remaking, the wiz. Like, I'm waiting for it. I'm ready. Olisa? Yes. My being punished. This started in part because route Northam was defending Bill meant to protect women's health and rights around third trimester abortions his words were taken out of context. Mischaracterized referring to him as advocating for infanticide. A lot of this is what stirred up the interest in searching through his records. What about that controversy so galvanized the right because it seems like it has set up me, and it even reached Trump state of the union. I mean, it's kind of like the red meat. They were all hoping for right? His explanation while taken out of context also wasn't like deft here, we have this man. Who's trying to say I mean, be clear what they're talking about his been in effect since one thousand nine hundred seventy three since Roe v. Wade this is not some new democratic like let's aboard babies in the third trimester. It's hot trash, but he does this. And then they all latch onto and they're like he's trying to kill babies and the third trimester. The right. So just gleefully tries to paint women who support safe and legal abortion as the same women. Who are like, you know, what we're just going to go to brunch today and decide if we're going to abort babies for no good reason like they act as if that is is very casual decision that women are just walking around talking about it is like one percent of all abortions that happen after the twenty four week, Mark. And it is for non viable fetuses or women. It's not something that's done. Like, oh, I'm not feeling like this was a good idea anymore. And so they've been looking for the right has just been looking for something to really sink their teeth into. And so he got caught up in this. And they're like we're gonna take him down. And then all of a sudden it ends up in Trump state of the u. Union, and I tried to look back, and Alex may or akilah me. No, I can't remember the last time abortion was mentioned in a state of the union. You know, I mean, I really think that this was like a moment where we went really backwards. You know, especially by president who wants was pro choice. Correct. Right. I mean that is part of the irony of Trump that is. You watch that clip and sure it wasn't a perfectly articulated sentiment. But at the same time, he was discussing something, really, hard and painful, and he's a doctor. I mean, the reason we're in the middle of the scandals because his medical school yearbook was insane and racists, but it did go to medical school. He did go to medica-. And it was a reminder to that in this abortion interject though, because I think you know, there is a long and very ugly racial history relating to experiments, try it out medical experiments tried out on black Americans. And one of the reasons why the north end thing is the fact that it was in a medical school yearbook is so ghastly is because here's someone who's taking Hippocratic oath. Yes. And is in the middle of their medical school education dressed in black face weather. Michael Jackson, or in the photo in the yearbook at the precise time that he is supposed to be sort of entering the sort of peak of his ethical education and given the. The racist history. That America has it makes it particularly fall in and around the sort of medical profession. Keila? So obviously, I don't believe north. I'm going to handle this more poorly. First admitting to it then denying it then threatening to moonwalk during the why. And then almost saying like, well, you know, when I put the black face on you can't use too much shoe polish because that stuff is hard to get off. And it's like, wait a second. Dude. How do you know that one conversation I've seen on this place called Twitter is this conversation that basically says that the one thing that's not going on as an honest conversation about the fact that this kind of racism was prevalent, the reason they believed it was acceptable because they lived in a racist culture in a racist school where it was totally acceptable. Do you believe that if he was more forthright if he came out there and said, look, I have learned a lot in my time in public wifi, obviously regret taking this photo. It is racist. I was part of a racist institution. I mean is there any value to him saying something that is more truthful now whether or not it gets him out of this fucking morass? I mean, yeah. The thing is like the keyword is now like have you like you did a great speech for him a week ago when all this stuff happened? I mean, we. We all just sat back and watch this guy. Like, you said he didn't know if it was him in the picture. He didn't know if he was the hood or the black face like I'm like damn recently about hard for white people like God, I was doing so much. I could have been anybody like it. Also, like, how racist is it that you think all black people look the same even when you're in black. Now, you know, if that's you ask seven people like was it. There were other black face people who weren't in the photo. I don't know. I think you're absolutely right. Like, he should have come out and said that and even now like, I don't think it would hurt the Democratic Party because I think look everybody's worried right now, here's the brass tacks. Everybody's worried because it was like all right. All of these Democrats are going down. We're gonna end up with this Republican guy that nobody wanted a fishbowl didn't even really want like someone probably looked up piece of paper. So he got chosen fine. I highly doubt that we're not gonna find a black face picture of him. I mean, come on. But it's a Republican. He put it in his campaign. He's running. He's he's stumping on black face being human, right? And I think if we could just have honest conversation now. Like an hour or like years from now like let's just say it like guess what America is racist. It has been racist since his inception. Black people came here because it was racist. It wasn't like we came here because it was chill like. Yeah. People do black face. They made a lot of money on like every movie before nineteen fifty was pretty much just that. So we could all just say like, hey, it was chill. And like we're sorry because it's not Schill anymore. That would really make up for all of it. 'cause like black mart surprise I want. You don't like white people are like a Tim McCray. Would that in this economy? As a black person. I'm like, oh, you're surprise. That is I mean, I feel like what you see happening in Virginia is throws into sharp relief. The choices that black voters in particular have to make like bay new, right? Even north. That's are like twenty twenty Stanford. This we've been but also if you look at who north and was before he was elected, right? He wrote into office saying he was going to be some kind of advocate for civil rights in progressive sort of reformer, but his record is not that he was not someone that had a position on taking down confederate statues until after Heather higher was killed in Charlottesville, and it became clear that there was a right side and a wrong side of history. And then there was a very astute political calculus about how to ride into office by gaining minority votes in a particular moment, which is not to undermine. I think the importance of embracing a more progressive stance when it comes to race. But north is not some champion. Right. And I think black people in Virginia, particularly the we're probably like, okay, we'll vote for him. He doesn't you know? He's not saying they're good people on both sides like some people in office. Amen. But like just to amend your point. That's how black people feel voting all the time. Right. Like, we don't vote in America. Like this. We're like, well, at least this guy's not lynching people like it's really like that. And I just want you to keep that energy. When you think about this situation. I do think though like we are operating as citizens in a democracy where there are huge questions on the table and raging debate about systemic and individual racism, right? And to have leaders of the sort of progressive side of the aisle who are so clearly morally compromised, I think is really complicated in this particular moment when a lot is being asked in terms of ethical and more moral clarity. And that's why I don't know if north can actually stay in office at or should stay in office. So let's talk about that for second because it so the photo breaks, and there's a media it call on him to resign from a lot of different quarters. And I think we could pretend otherwise, but it is hard to ignore that part of the rationalization was it's obviously important that he'd go. Important message because there's a substantive and genuinely good reason obviously for him to leave office, but it would be wrong to pretend that it wasn't on also on people's minds that don't worry. There is a Lieutenant governor. Who's a democrat is an attorney general who's a democrat. And then the story breaks about Justin. Fairfax. What are you guys make? I mean this letter we're recording this on Wednesday, Vanessa Tyson, a professor put out this incredibly wrenching. Compelling detailed statement, outlining when she came forward who she told why she came forward to allege sexual assaults against Justin. Fairfax why she felt compelled to release the statement in part because she actually didn't want to be part of this. But she felt that he had been making false statements about her and also points out that she is a lifelong democrat at actually doesn't want to say anything more than this. It's an incredibly compelling and difficult letter to read what was your reaction to seeing that letter today. I mean it all smacks. A lot of Dr blazey Ford. Same law firm to fame. I mean. The same offer same situation. Same earnestness same like, no one seeking the spotlight. Like, no woman was like, you know, how I'm going to get famous. I'm gonna accuse someone of assaulting me. Like, it doesn't work for anyone like, where's Dr lazy? Like, if you think about this woman. The example, she looks to is Dr blazey Ford what happened to her. She came forward against her will she was basically outed. She did what she thought was her patriotic duty. She came forward before Cavanaugh was actually the pick. And then she sat in front of congress and testified, and he's a supreme court Justice. And she still has protection she's still in hiding, right? So why would any woman think you know, what this is a fucking great idea? And she did it, right? And she did it because she became consumed with the fact that this person was literally going to fail up. And so I think that we should start from a place of believing women. Because there's nothing to be gained. By coming forward with something so painful and sharing it with the world, which is what she's done. Can. I just say one thing though. I mean, I I talked to Deb cats Christine Blasi Ford's lawyer right after Cavanaugh was confirmed, and I don't think they think of it as a lost. I don't think they think Christine Bazi Ford is just a kind of victim who lost in the whole cow confirmation thing. I mean, I think they really think of that hearing and that confirmation process a turning point in women having solidarity with other women in taking into consideration victims accounts in sort of the way, we treat narratives around sexual predation and sexual abuse. And I'm not saying in terms of incentives. I think more women like this woman. That's right now against Fairfax. Feel like you know, what like cabinet Gabby on the supreme. But it matters. It does matter and but what she didn't think it would be easy. She didn't do this. Because she thought it would be ready or Sean new on that it would result in what she wanted it to result in, but she was brave. And so that's why I think that we start from place of believing women something that you want said to me, John, which I think about all the time. And I don't even know if you remember saying this to me, but we were having like sort of a Frank discussion backstage about like, I don't even remember what the scandal was at this point. There's always scandals right? You said decency. Only matters if decency matters to you. And that's how the Republican party seize it where it's like, yeah. They flaunt their black face. They flaunt their horrible things. They don't give a shit, but like Democrats care, and so it's going to be brought up all the time. And it's going we're going to be held accountable for our problems because we actually care to be better in what I guess, I'm struggling with in all of this right now, or it's like, you know, obviously, there's nothing that you can say about somebody you fucking sexually assaulted somebody. Okay. Everybody's done. Black black-faced is what we learned today on Twitter leg every person who's ever been in office was in black face at some point. And I think that that is not something that you can just walk away from. But it's also like listen, there's a whole generation of white people. In this country who thought it was fine forever. And they're still alive, and they're still in office, and whatever. And so it's like, I guess what is important to me. Is that we don't like I do worry that we're going to get stuck with this shitty. Lake Republican guy. He's like, yeah. No. I think like face is great. But let me it doesn't matter to me. And so how do we rectify that as a party like, I don't even know? So there's no risk of an Jamal. Boo is written really eloquently about this in the times of a focusing too much on black face because it's so literally racist, right? But you know, we just had a president that gave a state of the union that demonized refugees and had a specifically if not explicitly racial narrative, which is based in part in racism, and and and who then decried anti semitic. You know, the celebrated World War Two veterans and the triumph over anti-semitism. But at the same time embraces of form of white nationalism, which has its foundation and a brace of anti semitism. Right. But we get we start talking about black face and who's going to stay in office because a black face, which is a problem. Right. It's not good that everybody in Virginia apparently is in black vase. But but off good there is, hey. Hey, Virginia people, it's not bucking good. It's not it's not like where you wanna be as a democrat or as a person in America. But Steve king is allowed to spout racist sentiment for sixteen years before the Republican party decides to do something about it. And what black they should lead? You is a deeper conversation about okay, what is racism, and what is racist and who's embracing it, right? Hardest. Block base to fight is the black face in their hearts. There was poetry poetry come back. Okay. Stop. Don't go anywhere. 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And then you realize to drink some one, you know, what I mean reinventing the drinking space. Thanks Reno back down. Thanks again to burrow as well. For supporting this show. We love you, bro. And we're back. Now, it's time for a game called okay song. Clip in the panel can say, okay, it's not but any point to comment. The green new deal is wildly popular new program that is being spearheaded by Alexandria Causey. Cortes. Who refuse to lend me that Cape? It's coming back to Zara. So you can order it soon. I looked it up. And over on FOX business. Stuart Varney interviewed a fascist version of Bill Nye the science guy to talk all about it. Let's roll the clip there's ignorance there's willful ignorance, and then there's willful and malicious ignorance that is Alec Jerry. Andrea Cossio Cortez. This is demagoguery. It's about time. She'd be called out. Okay. I like going on the AFC sucks channel to say. It's about time. Somebody said that sucks. Choosing. When did Orville red marker gets so angry? Girl when they started making skinny pop. Warming climate change the environment as a stalking horse for socialism. They can't take away all your money and accomplish this. But they will. But that's not what. These fucking people. I don't know. Docking haunts facility journalism. Goes worth pointing out that it's interesting the tropes, right like Braga. Obama was like a secret socialist with a grand plan. Right. He was a secret Muslim, socialists. That's can it's been a while. We could finally talk about it. I saw the birth certificate. Yeah. He's a secret America. Okay. Okay. Just making sure on the same. No. That's why it was so sneaky, but but like Braga mom is a secret Muslim socialist who's been plotting since the time he was at Occidental to take over America institute. Socialism probably from out sandal, he didn't really get the idea until Columbia. Let's be honest, but the. I really probably not to Harvard Law School. That's where he really that's where it all clicked. But with AO see she's just dumb right like Braga Obama gets. You have a secret master plan. That's why he's a socialist. But the only reason AFC is a socialist ignorant. This is again, and again any thoughts. Let's keep rolling it. And the green new deal is going to be part of a many of the presidential campaign presidential candidates campaigns. Well, think about who we're talking about. This is the party not to change the subject that wants to tell us a fortieth week abortion is not a faith in fantasize bit rather. Just joyce. Birth. Is that baby not abortion? But you know, when you get the when it comes out like it's here become out at three weeks. Yeah. Yeah. You really can't pull the plug at that point that maybe I'm in your house up there. Also, my feed me, I'm losing the thread with this. Bizarre Bill Nye, right like he widely what to do with abortion. I I don't really think that that's a say it's like it's like rage autopilot where you start like. Eight any name thing where it's like I want people to have equal things. And also these people want, what are you like, socialism abortion, black people all things that? Also, his friend is English. And I'm wondering why he's so invested but contain. That's. What Brennan to worry about similar rant on Brexit? Yeah. Was he Brexit this interview? All right. It's no longer believes in core American values, and it also shows us what's going on with immigration, basically what you have time. Okay. Okay. Stop. I've forgot the cats as I was like, wait stop. Okay. Okay. Stop. As I said before we went from socialism to abortion. And now, we're on immigration. I just feel like this guy was in his own thread, and I don't get invited on news shows. But this guy because he has a bowtie gets to be on. I just think it's fucked. It does it says that he's a professor emeritus. Yeah. What does that mean? I think it means that you're not just look listen. You can call yourself a professor, but you get ready get the fuck outta here. We're sick of you. Sick of you where we the turps. What's is that the turps? What does that a tortoise? Turtle terrapin takes class with this guy applaud if you taken a classroom him. Are you lying? Applaud if you've taken a class with him. And you're not lying buyers. What did he teach? I heard five different kinds of things he doesn't teach science business. Let's keep rolling it. I'm sorry. I talked to you the Cortes are Latin American values. Okay, south. Yeah. Yeah. Yeah. Oh that was subtle. I o sees bringing Latin American values. I just wanna see like have either of them ever been even close to Latin America, do they know can name one Latin Americans online like I just feel like if you're going to say values be specific borough like spell it out to simulating them. They are simulating us, and they wanna bring the kind of socialism got destroyed Venezuela, and frankly, Mexico. Okay. Yeah. It's over, but okay. Just to be clear Venezuela's problems are because America, okay? Just to be clear. I guess those are American values. He's referring to. But I I'm I'm I'm sleep whatever they're coming over the border bringing opioids and Latin American values in their caravans. It's just like a super what is the latest Taco Bell burrito. I don't know what it's called. But it's like these wrapped up every like mongering dog whistle into one thing. They're bringing their Latin American values in the trucks from mad mad and they're coming up plus the border, and they are turning rights bringing they got coming over that border. They got socialists textbooks. Some of them are gay. There are gay one's socialist gay one's bringing Medicare for all. They're all wearing white capes. They look fabulous in a rent lipid czar. American though, they're letting them. Clothier? What's next clapback? Huge Twitter followings also just remembering that, FOX businesses like they're they're minor league ball, you know, it's where they go when they're just not ready for the big time. That's where Lou Dobbs is currently in Scots. That's I think technically they upgraded Lou Dobbs to a single room. At Fox News because his insurance covered. It technically being a host on FOX business is covered by Medicare. Which is again ironic right because they hate Medicare. But then it's considered technically a long term care facility. And that's okay. Stop. We come back. I'll sit down with Senator Kirsten gillibrand. Don't go anywhere. Love it or leave it and there's more on the way love it or leave. It is brought to you by Tommy John. If you're big Valentine's Day surprised because it's a bouquet of supermarket Rosen drugstore chocolates. Then the only surprises that you think Tommy will find that memorable. Rethink. 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So don't sleep on these gifts. That's Tommy John dot com slash L. O V E T for twenty percent off only at Tommy John dot com. Tommy, John dot com. And we're back. He's the junior Senator from the great state of New York. He's a leader in the Senate on female equality in the metoo movement. She's running for president of the United States. Don't call her. Kristen please, welcome Senator Kirsten gillibrand. Great. DC crowd loves you love to you. Mary amazing. I love them too. Lot of love. So Trump state of the union. Yes over it was a night where he truly spoken sentences. At some point. I now I was struggling to pay attention, and I did drift in and out, but I did look up, and I saw that you issued a very layered and multi tiered sei, we do have a clip. So for the people listening if they haven't seen it. I would say that there is a kind of I'm movement. And they shift in your seat. And then there's a side that follows is a fantastic fantastic Cy very impressive. What was on your mind? I would have to say bad word. But it was basically, are you kidding me? Because that's all he just kept bloviating on horrible things and saying divisive hateful things over and over. And you just get so frustrated. You can't compose yourself. I believe that it was at the moment where he said the economy, it's the hottest right now. People are talking about how hot it is whatever it was it was so offensive, and I couldn't put my mind around it. So whenever I see Donald Trump in a forum like that like, you know, we we've sort of gotten a bit used to it. But it's still very sad. Right. It's sad to see this person. It's depressing to see a person standing there this person who doesn't belong there's unfit on qualified. You know, there's been a lot of talk about Russia's interference about unfair coverage about the role of misogyny, and racism and galvanizing Trump's base undermine. Ending Hillary Clinton. You know, here we are two years later this completely unfit person is standing there. Do you believe that those explanations for what happened in two thousand sixteen are enough to explain how we got here or do you see other vulnerabilities in what made it possible for someone like Trump to be elevated to this job? There are deep Gulnara abilities after the election. It was obviously crushing moment for many of us, and I really had to figure out. Why was my state so red on election day? So I made sure I spent a bunch of time in the places that were red upstate New York. Parts of Long Island, a lot of the Hudson valley, and listen to people and the truth is a lot of people really did feel left behind a lot of people throughout the state felt that no one was fighting for them, and perhaps not fighting for them for a very long time. It's shocking to know that a good number of union. Members voted for Trump Democrats are the party of workers and the lesson. I took from this was we need. To spend a lot more time listening understand what's actually going on in all our communities, and then fighting for everyone and one of the reasons why I'm running for president is because people need a voice, they need someone who will take on the corruption and the greed in Washington that dominates everyone and everything you need to be able to do what's right, especially when it's hard you need to fight for other people's kids as if they were your own, and I think for too many people they feel like that wasn't true anymore. So. This is the question. I like to ask people from New York actually asked us of one that always struck me about Donald Trump is he I'm from island. It's what we get really. And to me Trump actually reminds me a lot of despite his sort of silver spoon upbringing. He sounds to me like a lot of the people that I knew from sort of working class Long Island, this kind of tone that understood how to relate to people, and I think one of the questions it's been asked is there's been this silly kind of bifurcated debate. Like is it about white working class people or is it about racism? But do you think Democrats have learned any lessons about Donald Trump's appeal? Like, what what do you think what I guess I'd say what changed for you? In terms of how you approach campaigning based on the fact that someone like Donald Trump was able to get through and how interest how you talk to people. Okay. Well, Donald Trump ran is the great disruptor. I mean, he's the one who promised he would blow up the system any lied to the American people and said, I'm going to blow up the system, but I'm gonna blow it up for you. And that the system is rigged, and it's raped by the political and the financial elite, and I'm not only gonna blow it up for you. And I'm gonna fight for you. And then let's build a wall 'cause he wanted to add his own racist dog whistle. Message to divide the country. He's continued to spew that hate over and over again continuing to divide the country, and this moment that we're in is so important because if we want to restore our democracy, if we actually want to direct democracy, if we want open government, if we want to actually have a voice in our own country. We're going to have to fight back as hard as we possibly can. Because he promised people. He would change the system for them. He he didn't mean it. He's not going to do it. He lied to everyone. But if Democrats don't take the message that we need to change what's happening. The fact that legislations written in the dead of night, the fact that you can't take on the opioid crisis because you won't take on the drug companies. The fact that you can't have healthcare is a right and not a privilege because you won't take on the insurance companies. The fact that you can't keep community safe because you won't take on the Anna array all of that has to do with greed all of it. Let's talk about some of that greed. There have been a certain over caffeinated billionaire has recently taken. You know, he he called supporting Medicare Medicare for all un-american. You can't paint on access to Medicare. You've signed onto Bernie's Bill for a single payer plan. One of the debates we've had recently is around what happens to private insurance should ending private insurance as we know it'd be a Democratic Party goal. And do you think it's an urgent goal? Yeah. It is a goal and an urgent goal. But let me explain I ran on Medicare for all in two thousand and six in my upstate New York to to one Republican district. And the reason I ran on that message was because I listened. I I traveled around the district. Ask people, what's on your mind. What's your worry overwhelmingly, they said, I'm worried about access to healthcare? I'm worried about being dropped because of a pre existing condition or too much deductible or co pair or monthly premiums. And so I said, well, how would you feel if you could buy into Medicare at a price you could afford with that work for you that it'd be open to you. No matter what Medicare for all. And they said, oh, I would love that. And we explained will clearly what will happen is you'll create competition in the system because the for profit insurance companies their obligations to their shareholders not to their patients. Their goal is actually to make money every quarter pay their CEOs millions of dollars, and they put a big enorm-. Mus fat in the system enormous cost in the system because their priority is their returns and their profits. You do not deny you an extra day in the hospital or a certain medicine because they will make more money if they do not because it will make you healthier. So describing this to the district, and the people who live there was something that they fully understood said, yeah, we'd love more competition. We'd love a not for profit public options. So that's what I ran on. When Senator Sanders was working on his Bill. I asked if I could write the part about the transition because to me the quickest way you get to single payer the quickest way, you really get to Medicare for all is you create a by an and so we wrote four percent of income for the first four years anyone can buy in that as a price anyone can afford. And if you think if you're just a middle class person who works hard, you think about your own budget four percent of your income is less than you are paying today for whatever private insurance you have. And so what's gonna happen is you're going to have enormous competition. And I don't think four profit providers will be able to compete. Because they have to have that layer of fat. They have to have that shareholder value that have to have that quarterly profit. And so through competition, you will get to single payer, and you will get to healthcare and all the money that you spend on it going directly to the providers. You don't need the middleman. So I don't think they're gonna compete. I don't think they survive this process because they are too concerned with their own profits. So one more question about this. On the one end. I think there's been this criticism the left that there's a lot of Democrats out there that are trying to blur the difference between access to Medicare and truly single payer and at the same time. I think that there's some concern on the part of people that are proposing more access and public option type programs that someone a lot aren't worrying enough about the transition period. And you've talked about this transition where there's access period, but a new CNN poll found that among people who support a national insurance program, they do not support completely replacing the private insurance system. Do you think that even in a system where there is a period of time where people can buy in? Do you think that we're talking enough about the political ramifications? Even if it's the right thing to do the political ramifications of telling people that they're private insurance may go away to tell anybody anything, I think if you just give them a choice of having a not for profit public option whose goal is to make sure you are healthy and have the medicine you need and the care that you need instead of an insurance company. That's goal is to make sure that their share. Holders. Get a quarterly profit. It's not even going to be a close decision. People are going to choose to give the money directly to the doctors to the hospitals to the healthcare centers, not to the insurance companies and the truth is you don't need a middle, man. You don't need a middleman if you believe that healthcare is a right and not a privilege, which I think the majority of Americans if not all Americans believe if you believe that healthcare should be a right and not a privilege, then you should make sure you have universal access. That's affordable. The quickest way to do that is Medicare for all having the not for profit public option. It gets you to single payer fastest if there's a private sector market, that's still working. God bless them. That's their issue. Our issue is universal coverage that is quality and Affordable Care for everyone. I don't think there's going to be a role for an insurance because if you want if you want to go get plastic surgery, you can pay for that. That's good. That's good. So that's the. Extra stuff. That's there for you. If you want you pay for it. But in terms of is I'm just going to offer me. I'm just going to get this just a little. Yeah. It terms of health and wellbeing that should be covered in a Medicare for all structure, so your Medicare. So when I get this tightened up you can pay for that yourself. Shame. I I like Senator gillibrand. Okay. So obviously, you know, the Democratic Party is facing this incredible turmoil out of Virginia not only the scandal around black face around governor north on and the attorney general on Wednesday. A woman accused Virginia Lieutenant governor Justin Fairfax of sexual assault. Professor, Vanessa Tyson. Cinci issued a statement it's graphic and wrenching describing the assault. The shame. She felt the fact that the metoo movement spurred her to reach out to the Washington Post in two thousand seventeen you've taken strong stances on sexual harassment sexual misconduct sexual assault in the military. The Senate Judiciary you've done it. Even when it was Democrats. You spoke out against Senator Al Franken. Do you believe based on? And you as blowback for that. Based on what you've learned so far. Do you believe that Justin? Fairfax should resign. Well, let me say this. I I think what Dr Tyson did in coming forward took enormous courage, and you could tell from her statement that it causes her grave grave trauma to relive the worst moment of her life. The reason why we talk about believing survivors as something that's really important is because for her to come forward with this story of her life. Now, I just have to be received by us. It has to be taken very seriously, and it has to be investigated. You have to take these allegations seriously. So they can be investigated. And that's why we want to talk about believing survivors because if you don't take that first steps to say, okay, let's investigate. You're never going to investigate the problem with sexual assault in this country. Is that institutions do not believe women? They will want to put it under the rug. They want to blame survivors, they want to retaliate against survivors. Whether you're talking about a college campus or you're talking about the US military or you're talking about the NFL there's so much institutional bias against a survivor in favor of the powerful every single time. So I think there has to be a full investigation. I thought her story was was deeply disturbing and credible. So there must be an investigation. Okay. But it sounds like you'd wanna see where that investigation goes. So you did receive blowback for your decision to call. An Al Franken to resign. How do you weigh calling for the resignation of Democrats knowing that say in the case of Virginia policies like access to healthcare the protection of rights under Roe v? Wade voting rights all these things could be at stake with Senator Franken there were eight allegations that were corroborated of the time and the eighth one happened to be a congressional staffer. And as someone who has been at the forefront of these movements and issues for seven years. I decided I could no longer be silent on the issue, and as a mom with young boys and the conversations I was having at home with my fifteen year old THEO where it's like mom, why are you being so mean to Al Franken? Well, my heart rate starts beating very loudly and very fast and say, listen, THEO, let's be clear you can't grow women anywhere on her body without her consent, and you can't forcibly kiss a woman without her consent. And it's not okay for you. And. It's not okay for Senator Franken to that had a lot of clarity for me at that moment. And it doesn't mean he wasn't entitled to whatever process. He wanted. Those were his decisions. But the question you ask is a broader question, which is when the consequences are about somebody love when the consequences are about somebody who's good at their day job when the consequences are about the party, and your priorities, and what's going to happen next at the end of the day. The question you have to ask do you value women because you're saying all those things are more important than women and survivors, whether they're male or female, and I don't think that's okay. I don't think you can make these deals with the devil to say, oh only this once or just because because that's what's happening every day in the US military. I can't tell you the stories when you meet a service member who has been brutally raped by someone in their own unit. Not only disbelieved by their commander, but then retaliated against because they came forward that person's life is destroyed for sometimes forever because it's not just the first betrayal of being raped or assault. It's the second be trail of being betrayed by the institution that you love. And so for all of these allegations, all the ones you hear over and over again, you have to be concerned about the institutional bias against the not powerful against the survivor who tends to be more junior or less powerful. And so two a commander. They think that survivors disposable. And I need the one who's accused because he's so great at his day job. I've literally been reading documents and information about when a commander decides that we have to make sure this is no longer part of his record because he's so good at his day job. It's just goes to do you value women, and do you survivors? And I think it's hard. But that is when you have to do what's right, especially when it's hard. Thank you, Senator gillibrand before we let you go. You have agreed to play a game with us guys. Give it up or center. Now, it's time for a game called Queen for a day. Since twenty twelve Grover Norquist's conservative activists in the only person ever to be visited by three goes on Christmas. Who learned the lesson that tiny Tim is responsible for his own. Fucking problems has asked Republican candidates for office assign his pledge committing them to his core values, no taxes, no elimination of tax deductions. No rules. Just right outback steakhouse. And since I consider myself the Grover Norquist of liberals attracted to Darren criss. Stop it. I'd like to start my own pledge for the next two years. I'm gonna print presidential candidates down on the issues that matter to be most you have agreed to be the first to face the gauntlet. I suppose the idea is you're going to be Queen for a day. You're going to set whatever policies you want will you honor these pledges? Are you ready ready on day one? Do you pledge to eliminate daylight savings and never let the American people see dark before five pm? No joke sleeper issue. So I wanna be clear. I'm not saying we don't daylight savings time's. I'm saying we jumped forward one last buck in time. And then that's just time. No. Why why so important because I'd rather be darkened the morning. I don't want it to be dark in the morning. I get up early. I work out at six. It's not helpful to me. It's less helpful to me. I have to get up at five thirty. It's really dark, and I don't like it. And I get my ass out of bed, and I go do my spin class. And I do my polite es and my yoga, and I'm in bed by ten for filibuster too, bad and clear day. If you're waiting for someone to back out of a parking spot, and the person is just sitting there with their car in reverse. Can you hit the horn? Yes. Correct. What are you doing? You can tap. How do you feel about people who back into parking spaces are they wise planners or full psychopaths? I am terrible at going in the front way. Anyway. So I'd be mad in controversial. But correct. If it's up to you wench in McDonalds, stop serving hash Browns and switch to French fries. Never. They should have hash bounds. All day long. Wrong. There should never be a time where you can't get fries. That's the correct answer. Let's see it says here agree or disagree. Is it? Okay. To say how why are you limiting the hash Brown on time. Honestly, I I mean that my point was don't limit the hash Browns. I don't understand the subject to do with the temperature of the friar can't have both asked Brown and the fries, that's fine. With me that's fine with me because different different. He'd love. Preferences compromise wall start unity. All right, agree or Desi or not by partisan. No. But on this issue. We crossed the divide. We. The common ground. If someone is the host of a weekly political podcast, which is widely successful and popular how often should their partner listened to an episode. At least once a week. I've moved once a week and go back and do the faves overtime. Yeah. Rex is that it's not not happening. It's not happening. He's very busy. We can you talk to him. Will you finally put a stop to this madness and force a vote on a constitutional amendment capping the number of Grinch movies at no more Grinch movies? I think they're kind of cute. I like them. I like I like all kids shows. The take that back to Iowa. All right. How many times can a person order delivery before it becomes legally? Sad. This. There's absolutely no limit. All right. What is the line of demarcation for upstate New York? Where does it begin Albany? It begins at Albany Albany. I'm sorry. It's not it's it's Hudson valley before Albany, you if you're in Albany, you're an upstate or above you eat. It's got all the need above follow up. The Hudson valley's the Hudson valley, it's not upstate as president Yorkers would say Westchester is upstate. Let's and I mean people in New York City. Let's talk about those snooty Westchester people for a second. As president. Would you do anything to stop Westchester people from sticking their fancy noses up about Long Island? I'm I'm sick of their ship. I, you know, I really I think we should treat others the way we want to be treated. I don't think people want to be treated the way people on island tree people. So it's sort of a tough issue. I'm not saying there's no heroes in this story. I'm from Long Island. What do you think should happen to the people who locked certain gay nerds in blue recycling bins in one thousand nine hundred ninety eight what should happen to them? The people who are people who I'm not hypothetical. Do you think that MRs Malan has paid high enough of a price here involvement or her complicity her silence? Standing by. Go I needed. I'm being hug. Thank you. Thank you. Don't worry. Needed that. She cares about all our kids. All right. I'm not doing this. I'm not doing your all right? Last question. When you're at the airport and people start lining up in a big clump way before their group has been called. Should we be allowed to subtly bump into them with our Rowley bags? You got it you'd one Queen per day. Once again, everybody, please give it up or Senator cures in Jila ground. Thank you so much here. We come back a game about lobbying. Hey, don't go anywhere is more of love it or leave. It you coming up lead or leave. It is brought to you by simply safe. No one should feel safe at home period. Fear has no place in a place like home that's been simply safe's mission from day one from day one. Did it have? I think four extra words a riddle in there. You may have seen their commercial about a during the big game this year believable. If you didn't you can find it online. Simply safe blankets your whole home with protection. I think this is the big game of podcasting. Don, jR, hunts big game. Yeah. He does. He's a prick around the clock professional monitoring, make sure police are on their way when you need them. Their security sensors are tiny blending in with your home. So you won't notice them the verge called simply safe the best home security, and it's a wire cutter topic, we have it in our places, and I really like it I used I just checked the SimpliSafe AB moments ago, and I think it works. Don kills like Cougars and rhinos elephants and thinks he's the worst human me spit couple. But don't forget the scariest game evolves. Man security as more than three million. Simply safe customers already know, it feels good to fear last. Protect your home today. You'll get free shipping on any system. Order just visit SimpliSafe dot com slash L. O V E T that simply SimpliSafe dot com slash love it to protect your home and family today. Simply safe dot com slash L, O V E. Tommy, would you mind helping me because love it or leave? It is brought to you by the New York Times got crossword out got up. All right, ready set. Let's go love it or leave. It is brought to you by the New York Times crossword, you listen to podcasts. Well, obviously you look for smart ways to spend your time when you're not listening. Hi this play. The New York Times. Crossword many puzzles crews have another clue downtime the mini puzzle. Only takes about two minutes or less. If your love this clue was what I you minutes of most podcast and the answer was ads meta. Order meta Rory yourself anytime anywhere, you can fit it in every day. There's a new puzzle with fresh clues that keep you sharp. Wow. What was that twenty eight seconds? You pre record and to share facts with you all you enjoy short battle of what's with yourself for a friend issue. Saw it in the fastest time. Have a couple of minutes. Discover wordplay every day play them any puzzle for time. Well, spent download the New York Times crossword app at NY times dot com slash puzzling. Get involved too, great part of my day. Damn right. And we're back. American democracy. A beautiful and proud system where every single one of our voices council sane, and where we can all influence American policy so long as we put our heads down put in the work in form a multimillion dollar lobbying group. For the third year in a row. The amount of money spent on lobbying in DC is on the rise in two thousand eighteen almost three and a half billion dollars was spent on lobbying and over half of all active lobbying. Arrangements involve at least one revolving door lobbyists. That means the lobbyists used to be a member of congress aggression staffer or other high level federal worker, I feel like I saw like thirty people sink in their chairs. While Trump promised to drain the swamp and even signed a flashy executive order, restricting lobbyists from taking high level rose and the administration the White House has routinely. Wade its own ethics rules in secret. So nobody knows how many waivers were issued. That's weird that doesn't sound like him. There are so many lobbying groups working in DC for so many causes. We don't think you'll be able to tell what a real lobbying organization, and what a fake lobbying organization sounds like. And so we'd like to test your knowledge in a game. We're calling K street or nays street. Would any lobbyists in the house like to play? Hi, what's your name? Stacey susie. And are you a lobbyist? I am. I work for trade association to guess. So long. Yes. Expert in lobbying issues. Okay. I believe you. Okay. It all it all checks out your job. I'm going to say the name of an organization you have to tell us if it's a real lobbying group, you'll say real or if it's a fake lobbying group and you'll say fake, are you ready? I am. The American dehydrated onion garlic association. Correct. The balloon the balloon council to Slough correct, right wrong. It's real it's real years to slow the US association of reptile keepers real correct association of makers of little plastic pizza tables real bake American racing pigeon union, real the American vaping association rail. And did you see that one of those pens exploded and killed a guy? They let let on fire and his tug it and we've on video when he went to the. Be careful with your vaping. It's not just making you look terrible. The cheesecake consortium fake fake, the institute of makers of explosives real breath, the national candle association real correct the center for American Mbebe once. Thanks. The fuck Jerry counsel for the abolition of intellectual property. That's big noodle partners. I don't even know what that is a real. Bickell people. The Boehner boys Travis. Kettle corn advocacy United. Hey, it's fake. You gotta you didn't listen to them. Proud of you southern shrimp alliance. Real correct, spider strategies. Real real the healthy hog alliance Faye Bakker getting it. The national association of foster grandparents program, directors real, and I'm sad therein. We're rooting for them. That's a good group. I think I don't wanna find out that like they're just anti climate change or something that it's fake. But when you tell me that is an organization of foster grandparents, let them in let them have the meeting. I want them in the me. That's that's not tobacco. The US dry bean council. Right. God get it together. Drive. Dr try the US dry pea and lentil council real. Real. The stronger America through seafood, real correct? The low carb council rail bake. The independent lubricant Manufacturers Association. That's real the bottom end. The Baja men. Hey. You've won the game. Thank you for all of your work. Republicans. Donald Trump's big legislative successive two thousand seventeen was their tax overhaul hall, which slash the corporate rate to twenty one percent. And in two thousand seventeen business groups spent big on lobbying by the end of two thousand seventeen it was found to be most lobby issued of the year nearly fourteen hundred groups lobbying on the legislation that's K street or nay street when we come back the red wheel. Don't go anywhere. Love it or leave it more on the with love it or leave. It is brought to you by the cash cash. We. Love the cash as work. So it's as simple as an easiest way to pay people back getting paid back. I recently had a conversation with someone I consider a friend his name is Spencer while and I explained to him that there's the growing and ever more complicated involvement. He has had in the cash up ads. In fact, someone we went to college with Santana one dollar on the cash shop, and he's like, I have a feeling this is your fault. A woman who went to college with both of you came up to Tommy and I at a bar last Friday night. Yes, she knew Spencer. She was like, hey, this is a little forward. But I went to Williams. I just go with love it and Spencer. You said Spencer is not real that's the code in. We're sticking to our story. And so if you download the cash out today, and you put in the code either pod, safe SAVE or Spencer SP, and are or Spencer is not real because he is my imaginary friend, you get five dollars and five dollars goes to Jose. Andrey's who has been feeding people affected by hurricanes and storms, but also people who were affected by the natural disaster known as the inner workings of Donald Trump's broken brain goes to world central kitchen does the world's. We're not just like, hey, thanks for don't you. Don't give money. Famous chefs what the beak little. Yeah, we don't we, you know, he he he makes good money making home phones and hormone and foams where sometimes hormone foam. Have you ever have a you have a, hey, what am I? Empire. You take ham for a menu is somehow you make a foam out of. Hey, okay. You want some cotton candy, but it's tastes like ham. Guess what turns out a lot of fucking people. Do the point is we're switching to the cash app or not using the other payment apps anymore. Use the code pod. Save or Spencer or Spencer is not real. And if you know Spencer in the real world text him, and you know, tell whatever the fuck you want. And we're back. Welcome back. Our panel akilah Hughes, Alex, Wagner, Elissa master, Monaco, or the rat wheel. Hi, guys. Now, it's time for the rent wheel. Here's how it works. We spend the wheel wherever it lands. We talk about the topic this week on the wheel. We have Elizabeth Warren DNA test. We have jumbo slice. We have the Rams clashing uniform. We have the queen's Brexit evacuation plan. We have arguing on Twitter. We have the bachelor we have an aunt Arctic cavern, and we have Marie condo. Let's spin the wheel. It has landed on jumbo slice. For those listening. There's a grand tradition in Washington DC. There's this place called Adams Morgan and they're. And there is a strip of interchangeable disgusting alcohol rooms where I spent a significant portion of my Chinese. I don't even know what places still exist. The brass ape. I know what it is is it's still there. It's not there was replaced by another place. That's the same. What's there? Now. It's gay. Oh, that's an improvement. That's good. There weren't a lot of gay places on that strip. It was the duplex down at the bottom. Then it was just straight nonsense all the way to the McDonalds. Here's the thing. People listening at home in this part of town called Adams Morgan there is a kind of pizza that is served at several places and it is called a jumbo slice. And all it is is a insanely gigantic and disgusting pizza pizza. Only technically edible between the hours of two and five in the morning. And here's the thing. Managing a piece of pizza. The size of a window drape? Is hard for the soap remind dead. But it is downright impossible for drunk legislative correspondent at three in the morning. Just getting Greece and red pepper flakes all over there pleaded non wrinkle dockers khaki. With that sheen. That comes from the formaldehyde bet makes it the kind that doesn't stain. I am so hungry for jumbo slice. So is it Keeler, and they are delicious. But they are stupid. Is that awful place still there where they line up? I've been there. I know what you're talking about. I'm very rarely hear if they have signs about how you can get weed. But you can't get we there. Yeah. I don't know about. But it's pretty cool. That's gonna update has nothing to do with Amsterdam. All right. Well, this ended quiet. Let's Bennett again. It has landed on the bachelor, which was adjusted by one Elissa mastermind me. Okay. So I there some of you out there that every Monday night when I'm tweeting about the bachelor, you're like Elissa, you're better than this. Disappointing. Like, honestly, I'm not better than this. And I love it. But that's not my rand. So this bachelors on season like twenty two right yet this week. We find Colton and the many Hannah's ABC. Target about how they are frayed. They're putting walls up and my personal favorite. I can't watch the man. I'm dating date other women and like I just can't it's twenty two years. It's the entire premise of the show. But the real thing got me this week with something I thought we were going to avoid which is when the bachelor corinn's into that place of humidity. Do you know what I'm talking about anyone who watches about suddenly, there's not one arid island and all of the Bahamas, and they find the one humid place where like Colton and all the girls are just like sweating, and it's like girls watches for twenty two years, you the bachelor is older than you. Why are you bringing silk? You're sweating through yourself. You are comfortable you're not having a good time. And so the thing that keel, and I were talking about backstage is like as someone with IBS. It's like those two nerve. Purpose people sweating to death. It's like, you know, that that porta-pottys getting a lot of work like a lot of a lot of action. It's terrible. But anyway, that's my brand. I'm just sad. Like, why can't they find Arad even batch in paradise? It's like why is it so humid in Mexico? It's not this Umid in Mexico. I don't like watching people sweat. It makes me uncomfortable. It's like that movie broke down palace member with Beck and sale and Claire Danes member. They were the drug new. I remember the movie what the fuck are you talking about? They were always just so hot looking in sick. And she had the Roach in her ear. So it's like just stop making me. I'll just piggyback on this for a second that whenever old time movie, and they're in New York City, and they're all in just thick wool all the time. I couldn't have made it. They're everyone's in wool. It's time to go play tennis better. Put on my wool tennis. Always my warning. It's an actual fiber. But it's so much thirty layers where people colder back, then let's spin it again. Landed on Marie condo suggested by Alex Wagner. Con Mari method. Yeah. Okay. I you whoever just hooted is sick. I initially embraced this concept because I was I'm I guess I have suffered from obsessive compulsive disorder. And I was like, I don't actually, well, maybe I do 'cause I initially embrace it. And I was like this is great. I'm going to get rid of everything I own has anybody realized that this is like material anorexia like just like get thinner. Lose more stuff. Lose more stuff. What's that you through a your wedding album, get rid of your child? It's like it. Never ends. Right. There's something sick about getting rid of all of your possessions. And it's so nefarious how it begins its start with your t-shirts. Then go to your husband, sentimental t shirts. Now. Now, go to your books is it hard. Does it spark to I know get rid of it? And then by the end, you literally throwing out like heirlooms and jewelry, and nobody has keyed into the fact that this is also wrong. We are nothing but a collection of dust and stuff. That's what human beings are. She is trying to deny an up route our basic humanity. I say, no more. A lot about a lot of things that she did have pickup pundit the dog and asked me if it's sparked joy, thankfully, the answer was yes, I didn't follow up. All right. Stupid. All right. She hasn't angel. Thank you. Let's put it again. Landed on Arctic cavern suggested as me by Keila that was me before I started doing gigs. We'll see. Only serious rare. We ever done the history of being on your show who. Okay. Well before I start. I'd like to say as a hoarder, it is the best thrift ING right now. So get out there. People are just denying themselves of so many gyms my home looks amazing. And that it does every all my chairs. My sofa my chair my love seat to to rugs. Probably for a person who lives alone. I have like thirty chairs. It's excellent. Also, you said it's twenty seconds season of the bachelor. It is the sixty nine album from now, that's what I call me. We. Nice. So all right. It's cavern. So the other night during the Super Bowl, I got really bored. And I was like, you know, I'm gonna do I'm gonna start reading other shit on Twitter. And I was a little bit stone, admittedly, and I found this article on NBC news about this cavern that is under the big sheet of ice that we are hoping doesn't tall. And they have these new cameras now that can look through the ice. And the like, oh, there's a big asshole under there like it's not more ice. It's just water. Like, we're just like it's like an ice cube now on a Cup of water in. So they're saying that like if the ice falls in all the way all the water on the coast is gonna come up. We're all gonna die. And so I just wait glacier Antarctic. There you go. See this is what I'm talking about someone not during game that knowing the drunk right now, there wasn't a child in my son expert. And and they good choice. Good spirits. I'm like, eight months pregnant. So you guys like if that wasn't readily mayor. Right. Exactly. Basically, the the radar that they're using shows that the ice loss is dramatically more than anybody thought and this glacier alone could rise global sea levels by two feet around the world, which would be the end of New York City and also love it early. Yeah. And so, you know, so it would it would mean. So we'd be leaving it live from Kansas is. We all over. We'll be. I mean, look, I'm not for it. I'm just saying we'll be fine. I'll be fine. I plan on not moving from my home as it's happening. But suffice it to say as a stone prison that really alarm me. And I think that, you know, can I hear about global warming, which you should you live on earth and only rich white people are going to Mars. I want you to be clear like black people do not get invited to Mars. There's no fucking way Oprah and no black people. That's it. So we gotta stay on this bitch. Like, can we please just like stri to be cognizant, and that's my rant? One more point about the Rams jerseys. The helmets navy and the uniform is Royal blue. We are from Los Angeles right ton of costume designers, including gay costume designers. I don't know how we draw on the talents of LA to help with things like the Rams helmet. And the fact that Stacey Abrams was too far away from the people in that shot. We can talk about it. Let's be honest about it. She was lit too much from behind. It looked like a green screen Jews too far away from those kids that panoply of American diversity that carries the message that Rams jersey look stupid. And it was a hard thing to find out on the same day that Los Angeles had a team called the Rams and that helmet didn't match their uniform on the day of the Super Bowl to find that out. Let's end on a high note. Obviously it sounds seeing Trump standing on the house floor. But what's exciting is that we have someone like Stacey Abrams to lead the response. And how great how great would that sea of women and white jackets and capes that I wish I could go off. Trump is the baby boomer's supernova an explosion of the past. But the future restoring him in the face, which was very cool, and we spoke to Senator gillibrand and seeing this democratic field take shape it's worth remembering that, this primary may get heated, and there are big important debates inside our party. But at the end of the day, we share our mission and we're on the same team. That's why crooked and swing left are teaming up to launch unify or die of funds that will go to the eventual democratic nominee. So that when our candidate leads the convention in July twenty twenty and faces an onslaught from Trump the cokes probably Putin in the Saudis. Let's be honest. She has the money to fight and to win. And so you can go to both save America dot com slash unify to donate right now. Let's give our candidate the best the best chance. She has. I wanna thank our incredible panelists akilah Hughes. Alex. Cnor master Monica Senator Joe around and Peter Pan, the nationals do and take you all for coming out a great night.
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