Perspectives on evidence based medicine, career mapping, and interesting side gigs

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Hey everyone, welcome back to the TechLink Health Podcast. I'm Govind Chandram, and I'll be hosting this episode with Dr. Rodney Samaan. Today's episode focuses on a range of topics from evidence-based medicine to ways to harmonize professional life with personal interests, all in hopes of creating a healthier future. Today's guest is Dr. Payal Kohli. Dr. Kohli is a non-invasive cardiologist With interests and expertise in advanced echocardiography, nuclear cardiology, and women's heart disease. She is trained at some of the world's premier institutions, including MIT, Harvard Medical School, Brigham and Women's Hospital, Massachusetts General Hospital, and UCSF. She holds board certifications in internal medicine, cardiology, echocardiography, nuclear medicine, and vascular ultrasound. In her spare time, she enjoys writing essays reflecting on the practice of medicine and promoting patient education through lectures. She's also a TV personality as the NBC local KUSA on-air medical expert and also as a health expert on the show Daily Blast Live. It goes without saying that Dr. Coley is very accomplished and has an impressive background. So without further delay, please welcome Dr. Payal Coley. Dr. Coley, thanks for joining us on the podcast.

Thank you so much for having me. It's my pleasure to be here.

No, it's great to hear from you. You know, with everything happening right now with COVID I'm really interested in hearing a little bit more about your background. And how COVID has maybe affected your clinical practice?

You know, I would say COVID has impacted the practice of medicine so fundamentally that this is something that no amount of training can prepare you for. So whether it was medical school, residency, my first fellowship, my second fellowship, or my third fellowship, none of them really prepared me for what we're dealing with as physicians during this pandemic. And I think there's just so many layers of how it's impacted us, not just as physicians, but as human beings. You know, the way that we think about each other, the way that we interact with our friends and family, or with our neighbors, or with our colleagues has fundamentally changed. So for my practice of cardiology, I try to be a glass half full kind of person. So I have really tried to be focusing on the positives. And one of the things that I've noticed is that it really has facilitated improved access to care. So my hypertensives, or my heart failure patients, or my AFib patients who I'm titrating medications in, I used to see them once a month. And now with virtual medicine really facilitating access to these patients, I can sometimes see them once a week and really feel like I'm able to keep a close eye and really get them to their target doses very quickly. And of course, reimbursements are something that we don't like to think about as doctors, but it is something that is part of our lives with RVUs and productivity tracking. And if you're in private practice, obviously that's how you get paid. So the fact that they're now getting getting reimbursed for these telemedicine visits has really facilitated, in my opinion, access to care. I also think that virtual medicine is a little bit of a double-edged sword because in one way you get to see the patient in their home, in their environment. You really get to see who they are, what their barriers are to care, how they live. Of course, the physical exam, when that's the other part of the coin, is something that we miss. So that's where I think remote monitoring devices which is my background in technology, has really got me excited about using a number of startups and a number of recently adopted remote monitoring devices to really help deliver care to my patients. So telemedicine has been a big part of how COVID has impacted my practice. And then personally, as a physician, I think I have just become much more appreciative of disease and about health and just how much we took for granted what we had before and how much it makes us realize not just the importance of what we do every single day, but the importance of what we're fighting for, which is good health That's great.

You've been able to integrate a lot of the newer technologies into your clinical practice. One thing that often comes up, and it's an old concept, but it's increasingly on the forefront now, is this idea of evidence-based medicine. We're living in an age where facts are open to interpretation, and I'm wondering a couple of things. One, what's your journey into evidence-based medicine been? And 2, how have you been able to deploy that principle in practice?

Yeah, that's a great question. So I have to say, I'm one of those people who's always worshiped at the altar of evidence-based medicine. And again, being a scientist to my core, having been at MIT, then Harvard, and then Brigham and Women's, MGH, and UCSF, those are all programs that are very heavily oriented towards evidence-based medicine. So that's something I never really questioned. It just kind of became part of my evolution into becoming a physician. But I think the COVID pandemic has really brought to light why evidence-based medicine was such a fundamental teaching for all of us as physicians and why it is so important for us to continue to base our decisions on evidence-based medicine. Because whenever there's uncertainty, as we've seen during the COVID pandemic, people have fear, people have unpredictable behavior. And the moment that you stray away from evidence-based medicine, which is really what's happened during the last several months in our country, that's when you start to have dissent, you start to have systems falling apart, and the outcome of it all is that you get more disease and illness. So I think the last few months have really solidified for me what I've always kind of believed and taken for granted, which is that evidence-based medicine is really the holy grail of how we should practice medicine. But the other opportunity that I've had is to be able to bring this evidence-based medicine that I so strongly believe in to my patients. And I think one of, again, the silver linings of this pandemic is that patients have really started to appreciate the complexities of medicine and also appreciate and understand a lot more about their health, their wellness, and about what the evidence is for what we're doing. So I feel like my patients, as a result of the pandemic, have now become a lot more sophisticated in the questions that they ask, in the way that they challenge me, the way that they've become engaged in their own health. And that allows me an opportunity to really provide them with that evidence-based medicine so that they can really make an informed decision when they're thinking about their health. So again, I think that's a real positive that's come out of this. And through my job as an on-air medical expert, I'm really able to translate the evidence-based medicine that we use at the bedside into kind of language and education that's digestible for the everyday person with really take-home tidbits as to what they can walk away with. So I continue to be a strong believer in evidence-based medicine, and I hope that this has really reemphasized this for All of my colleagues and all of our patients as well.

This is Dr. Samaan. Thanks for coming on the air. I do want to talk a little bit more about your on-air experiences. I'm sure people have told you before, like, are you going to be the next Sanjay Gupta? Is this a fabulous, fun time, or is it tons of work? News TV is definitely a different world and different, perhaps opposing interests in terms of what you're trying to portray besides medical information. It's entertainment in a way. So tell us about that dichotomy and how you deal with being on the air in your practice. How does that all work? How did you get involved in that? I think people would be interested in learning more about that.

Yeah, so my family teases me that they're going to start calling me Sanjeevani Gupta, which is the female version of Sanjay Gupta. So because we're both Indian, and Dr. Tara Narula is another Indian cardiologist who's also involved at CBS medical expert. So, it is kind of funny. But, I'm glad you asked me that question, Dr. Saman, because I think I had never ever imagined that I would be on TV. And, if you told me exactly a year ago at this time that I would be leaving my hospital-employed position, which was very much coloring within the line, and I would be on national television every single day as an on-air medical expert, sometimes doing 10 or 20 television appearances a day, I would've said that that's impossible. So that's not ever something honestly that even crossed my mind, but it just sort of happened to me. And I have to say that it's one of the best things that's happened to me. And I really encourage people to start to think outside the box as they think about crafting their own careers and what they're really looking to get out of their life. It was getting to me and it had sucked all the joy out of being a physician. And, being only 4 years out of training last year, I was shocked somebody like me who so fundamentally identifies with the practice of medicine, that's such a big part of who I am is being a doctor, was starting to not enjoy being at work. So, that's when I really thought to myself, I have to do something different and I have to do something that makes me happy. And, I thought really about what my kind of talents and skills are and how they could be applied. And, That's why I decided to start my own private practice earlier this year. Part of what I do is write. So I'm actually a writer now that's doing a lot of freelance writing for a number of different publications. And then the other part of this was the television part, which again sort of happened serendipitously. My predecessor at the local NBC station here in town, Dr. John Torres, got picked up by national NBC. So there was this position open and they had actually already interviewed 50 candidates for it and already almost extended the offer to one. And then at the very last minute, they approached me. It was 2 days before Christmas last year. And they said, do you want to come and audition for this? We think you'd be great. And it was these TV people that I had randomly met at some fundraiser event. And really, it ended up being the perfect fit because it all felt very natural. And it felt like something That really awoke in me a passion because I'm very passionate about educating my patients and about making sure that I communicate with them and about explaining things about their disease to them. And that's really what a TV position is. It's just sort of taking the information that we tell our patients on a one-on-one basis and crystallizing it so you deliver it to the masses. But I have to say, it was a whole different skill set. And just like they didn't teach us about COVID in medical school, they don't teach you how to be a TV doctor either in medical school. And a little bit of it is being articulate, a little bit of it is being brief and succinct, and a little bit of it is making sure that you're really accurate because every word you say is on camera forever. And if you say something that you can't later back up by science or by data, you know, you've just gone and put your foot in your mouth and you've really compromised your credibility. So it's definitely been a learning curve, but it's definitely something that I think for the right personality type who thrives in that kind of an environment would be a really good part of a comprehensive, fulfilling, and satisfying career.

That's great. That's great. I know we talked before about this. There's quite a bit of work and research to take a story on air, and I'm just wondering if we could peel back some of that in terms of what that looks like.

So, you know, it's been really interesting because during COVID You can imagine there is 500 different angles of topics you could talk about or things you could educate the population about. And when I actually first started this position, it was in January before the pandemic had started, and we were going to be spending a lot of time talking about disease prevention. Because if you think about life when life is as usual, what's one of the most important messages that you want to give people is about chronic disease prevention, management of coronary artery disease, diabetes, cancer screenings, making sure that they're doing all the healthy lifestyle choices to prevent obesity, those types of things. But as soon as the pandemic hit, obviously the focus of the things we were talking about very much changed and it became significantly more what we call newsy, which is like what's hot, what's the latest headline. But to try to take information that's hot off the press Whether it's a new study on remdesivir, or it's a new finding, this antibody cocktail that the president is taking, with very minimal data, and still be able to sort of construct a story around it that's cohesive, scientifically sound, and succinct. Because an average TV spot is about 3 to 4 minutes. And that includes the introduction and them asking you questions. So really, your questions have to be limited to about 45 seconds or less. In order to really be effective and not lose people's interest. So it's a challenge. It's a challenge to take incomplete information, have a very limited time, and take topics that are very complex and really try to break them down into more simple, understandable, digestible bites so that people can walk away from your segment saying, oh, I got a take-home message from Dr. Coley.

It certainly sounds like going on television is more of an art that requires A lot to master and many iterations. And I'm wondering, for some of the viewers who are earlier in their career, do you have any recommendations for those who are looking to color outside of the lines, to use your language? What does it take a physician to go to the place where they are finding that their career is less satisfying to then push the envelope? I'm curious how— they can proactively develop these skill sets? Any advice or recommendations you have for those individuals?

You know, I'm so glad you asked me that question because I really think obviously when you're hitting a wall, that's when maybe you're the most creative. But I think if I had to do it all over again, you really want to be proactive about your career choices and not reactive. And you want to make sure that you are carving out the career that you're supposed to— excuse me, the one that you want rather than the one that you're supposed to. Because we're so used to going through the process one foot in front of the other— undergrad, med school, residency, fellowship, and then a job. And, and then it's the job that everyone's getting, and you make the decision between academics and private. And that's really the only decision that we ever think about making. We don't ask ourselves, do I even want to do full-time clinical medicine? Do I want to do startups? So I've actually done a fair amount of work with a lot of startups as well, and I'm an advisor for a number of startups based in Boulder, Colorado. And so that's another Yeah. So, there's another way in which you can really kind of scratch your intellectual itch and feel really satisfied without necessarily doing 100% clinical. And I used to love clinical medicine, because it's our bread and butter. It's what makes me happy, is seeing patients. But I have to say, the administrative burdens on us as modern physicians have made a 100% clinical job very challenging, very tedious. And very difficult, honestly, to sustain with the types of productivity targets and stuff that are set on us from top down. So I think to your question, Govind, my biggest piece of advice would be to start thinking about what you want in your career early, to try to connect with people outside your bubble who can expose you to ways in which you can apply your medical knowledge that doesn't necessarily have to be 100% clinic or 100% hospital and clinic every day, but ways in which you can diversify your life. So my typical week has a combination of the TV job every day. I do a segment or 2 every single day. And then I have clinic patients 2 or 3 days a week. Then I spend a little bit of time doing procedures in the hospital. I spend some time writing for the publications. I spend a fair amount of time doing educational lectures, doing talks for primary care physicians like CME talks, doing some consulting work for industry, giving some speakers bureaus for industry. And so to me, that's the perfect mix of all the different ways in which I can prevent myself from getting bored, prevent myself from getting burned out, and really be able to maintain a number of different skill sets simultaneously.

Very interesting. It's almost like we need a course or a fellowship In media or medical reliance of information for residents. I don't know if there's anything like that.

I don't think there is, but I think it would be very valuable if there was because like I said, it is not a skill set, number one, that's natural for everybody. So I, as part of my job, I spend a lot of time interviewing other physicians. And then when we're done with the interview, we sort of decide what soundbites to take and how to synthesize the segments that we're And of course, there's obviously the stress and the nerves that come with being on live television or what have you. But even besides that, to your point, Rodney, there's just a lot of finessing because the way that we communicate information on television or in a radio interview or what have you is very different than what we do in our everyday lives. It's different than how we have conversations. And sometimes our mindset as physicians is more is better.

Right.

You know, the more information we give, the better, or the more scientific it is, the better. And again, on television, that's not always what appeals to the audience.

So how do you challenge your editors or producers on a story?

Yeah, that's a really good question because a lot of the stuff that is a little esoteric or it's in a pre-publication. And so I've been very fortunate because the company that I work for is very much interested in really portraying the facts and the real truth. So oftentimes I'll have a reporter approach me about a story or about something that got put on the internet and asked me to comment on that. To your point, it's really, really valuable to make sure that the science you're putting out there is, first of all, solid. So you don't want to be talking about something esoteric or something pre-publication or something non-peer-reviewed. And that's where my background, I think, has really come in handy because I did a fellowship with the TIMI Study Group, which is a clinical trials group. It was a clinical research fellowship.

Wow.

And that's given me an extremely solid foundation for deconstructing science. Because when you see something, what makes you realize whether it's good science, bad science? What are the questions? What are the limitations of the study beyond what the authors have just written? Because part of your job as an on-air personality is to not just regurgitate what's already been said, but it's to add your editorial opinion. And that can be challenging sometimes. I have to say that that has been one of the challenges in this position because you really got to put your nickel down And sometimes when you put your nickel down, it's not what people want to hear because it's not politically correct or it's not trendy at the time or it's not the message that they want to hear. So something as simple as wear your masks and masks save lives, that's not a message that everybody wants to hear. But I think that's the difficult thing is you have to stick to the science and stick to the truth, even if it makes what you're saying a little bit unpopular. But make sure you're sticking to the right science because that science has to be vetted. solid and thorough before you will go and put your name on it and start kind of presenting it to the masses.

Great points. And obviously there's political discussions now about masks and whether certain medications work or not. And in some ways doctors were silenced, in other ways they've been amplified by COVID. And I'm wondering about your thoughts about where doctors fit in now, given what's been going on in terms of who do we listen to?

Yeah. So, you know, we started the pandemic with doctors being heroes. And unfortunately, I have to say that as things have gone on, in my opinion, I think that's changed. And doctors have gone from being heroes to being questioned, to being mistrusted, to being doubted. And I think Dr. Fauci is the perfect example of that. He has been giving a very consistent message all throughout the pandemic about what we ought to do. And in the beginning, there were Dr. Fauci socks and Dr. Fauci cupcakes and all those other things coming out. And now— You're hearing that he's got a security detail because he's having death threats against him. So I think, I think it's been an evolution. I think, again, it started out in the beginning when we had no other options and doctors were the ones actually saving patients' lives, that we were the heroes. But then there started being a mistrust of media. There started being a mistrust of science and a mistrust of physicians relaying the science. And I don't think that's all that unexpected given the course of things in the pandemic. I mean, there were a lot of mixed messages. We had our Surgeon General saying in the beginning for people to not buy masks, and that was driven by a few things. One was obviously they wanted to conserve the masks for the healthcare workers. Number 2 was we didn't realize the extent of asymptomatic and presymptomatic spread that was occurring with this virus. But because that message changed and because it changed so much in the public eye, It didn't happen behind the scenes. I think the public has really kind of started to question what physicians say. And I think another reason for that is because the scientific process is messy. I mean, as you all know, we do our ups and downs. We say, oh, something works. Oh, now it doesn't. Oh, let's give an aspirin for primary prevention. Oh, never mind. Let's not give the aspirin. So we do a lot of this as more and more information becomes available behind the scenes. But the pandemic for the first time has really brought this into the public eye, to the forefront. So every decision, whether it's hydroxychloroquine, chloroquine, steroids, remdesivir, testing, it's all happening out in the public eye. And I think the next big test of science is going to be the data on the vaccine is really going to also, again, happen very publicly. Does it work? Doesn't it work? Is it safe? Is it not safe? So I think it's been a bit of a journey. I do think, however, at the end of the day, it'll come full circle. And once all of this is behind us, I am really optimistic that people will re-embrace medicine, their physician's advice. We've had a lot of people starting to question vaccines in general now, and that's been an unfortunate consequence of what's happened. But again, with those public health messages and the media messages being consistent, I think once the dust settles, I really hope that things go back to how they were or even better.

Those are some really good points. And I think first, just a plug for TechLinked Health and the podcast. This is the idea behind these conversations that we're having is that more doctors go on these podcasts and talk about what they're doing and how important it is that we value science and education and getting the word out. So thank you for those points. I have to just comment on the Fauci point. The history that you put together of that we were respected and not so now is Really interesting, I think, and so true. And you're right, science is very messy. So I think it's great we're talking about this and letting patients understand this a little more. I think that's important, but your points are excellent.

Definitely. I think you're spot on. And I think that sometimes it takes the worst circumstances to really help us sit down, pause, reset, and reevaluate. And I feel like 2020 has been in our lifetimes the biggest, most challenging year, whether you're talking about the pandemic or you're talking about the wildfires raging across the country, raising questions about climate change, you're talking about the violence, you're talking about the race riots and protests. It's just been one thing after another that has really challenged, I think, humanity as a core, with obviously the biggest common denominator in all of those being our health and wellness. And that's why we're seeing a lot of fallout, mental health fallout, physical health fallout coming from the pandemic. And it's funny because I wrote an article several months ago for Circulation talking about the different waves of the pandemic. And we're so focused on flattening the curve of the acute infections and the acute morbidity and mortality. But if you think about all the curves that are out there, Curve number 2 is the preventable health conditions that we didn't diagnose. Curve number 3 is the long-term consequences of all the, the MIs that we didn't reperfuse or the strokes that we didn't reperfuse or what have you. Curve number 4 is the mental health effects that are going to last for many, many, many years. And curve number 5 is the economic burden, which directly relates to our physical health as well.

So I'm curious, as we As we move into a post-COVID world, eventually when the dust settles, what are your thoughts on the future of healthcare? What do you think is the biggest bang for our buck in terms of reimagining, re-envisioning healthcare infrastructure?

You know, I have to say, I think we're never gonna be the same after this. We're not gonna be the same and medicine is not gonna be the same. And it's almost like once you've had your smartphone, you can never go back to a flip phone. And I think that's what's gonna happen with virtual visits. Now, I will temper my enthusiasm just slightly by the fact that many payers are starting to make announcements now that they may not support virtual visit technology in the same way once the pandemic is over. They may not financially reimburse it in the same way. But I really do hope that what this has taught us and has accelerated healthcare delivery to the point where we really start thinking outside the clinic exam room because that has been the only way that we deliver healthcare for the last 30 years is within that clinic exam room sitting next to our computer. And I think this has really been a proof of principle that we can very quickly adapt to different ways of delivering. So one of the things that I've done for some of my highest risk patients, and you're gonna laugh when you hear this, but it's home visits. And that's really coming full circle because the doctors in the '90s used to have their little doctor's bag.

Yeah.

go into the patient's house and do a home visit. And I have instituted that and I found it extremely rewarding and satisfying because again, it improves the access to the patient's care. It helps you because you get really good context about how the patient is living and what they're doing. And obviously during a pandemic when business is slow, it really does help augment being able to see patients into their homes. So again, like I said, I don't think healthcare delivery is ever gonna be the same.

And I do home visits as well, but not that frequently, but I have done them. Do you have a little doctor's—

a little black doctor's bag?

I don't, I don't. But I think there is definitely a reversion back to, uh, old times, and I, I've always kind of framed my practice that way too, just to be a country doctor in Los Angeles.

Yeah, well, and I think the devices that we talked about earlier I mean, why do we necessarily need to have a patient in the office? It's really for that physical exam and for those vitals. And if you can get all of that at home with remote stethoscope technologies, and of course remote monitoring devices, remote EKGs, you can actually see patients across the world. And I did a consult in India a few weeks ago, and it was incredible, 'cause that's not something I ever would've done 5 years ago.

To that point, I have gotten some patients on the Kardia to purchase some of the Kardia devices, the 1-lead, EKGs, and they're also transmitting. So I think in some respects we're kind of putting more burden on the patients, and for the most part they don't mind it, actually.

You know, I think that's a really good point, and it's not just a burden on the patients, but I also think it starts to raise the question of patient-generated data. How reliable is it? Can we count on it? Do we need to take health literacy into account when we ask our patients to do things like this or their age. But as you know, with the rise of the millennial population, people are becoming more and more tech savvy, and it's becoming much easier to put these types of expectations on our patients, even the middle-aged ones.

One thing that nobody really wants to talk about nationally is this patient responsibility. I think there is a need for more discussion about patient responsibility in terms of their own health and I've actually implemented more of that from different courses that I've taken on the idea of patients putting in the work into their own care.

I think that's an important point because there's only so much that we can do. There's so many barriers we can remove, but at the end of the day, it's the patient that has to really cross the finish line for us. And so I think again, with what we've been discussing with more and more, not just knowledge shifting to the patient, but also responsibility and empowerment. And, I think of it as a way to empower patients to tell them that if this is you who's doing this, it's not the doctor telling you to take the medicine, but it's you deciding to treat your blood pressure or treat your diabetes or what have you. So, I think that mentality shift has to occur. It has to not be top-down as it has been in medicine for so long where the doctor tells the patient what to do, but it has to be the doctor kind of leading the way for the patient or pointing them in that direction and the patient walking the path.

Well, Dr. Coley, I want to be respectful of your time. So in closing, do you have any final insights, tips, or recommendations for those interested in staying connected to the next wave of innovations within healthcare?

Yes, and I would say that start early. That's my biggest tip is try to get engaged in whether it's startups, whether it's media, whether it's writing, whatever your interests are, early. And again, my, my really big emphasis here would be that when you're within an academic institution and you're doing the grind of residency or fellowship training, it is very difficult to anticipate what your life is going to look like afterwards. And you always think that at the end of the rainbow there's a pot of gold, and as soon as you become an attending, that you'll be at that pot of gold. And it doesn't happen like that. So I have seen way too burnout even amongst my young friends who are just a few years out of training that I really think if you start early and you start to develop those connections very early, then you can start to cash those out when it's time for you to look for a job. So fellowship or residency is the time for you to start reaching out to startups if that's what you're interested in doing, or start to submit writing samples to different outlets, or start to reach out to your local television stations and see They need a guest to come on. That's the time to really start defining what your career is going to look like. Don't wait to become an attending, get established, and then look backwards because it's a lot harder.

Those are great points. Thank you, Dr. Coley. How can people connect with you if they want to learn more about your background, your story, or the media work you do?

Yeah, so I'm on Facebook and Twitter, and it's Payal Coley, MD on Twitter, P-A-Y-A-L. K-O-H-L-I-M-D. And of course, you can also find me on LinkedIn, or you can email me at payal.kohli@post.harvard.edu. And I'd love to hear from you guys and point you in the right direction or help you get connected with resources or anything that you might need.

Awesome. And we'll be sure to link to all of that in the, uh, in the show notes. Thank you so much for your time, Dr. Kohli. We really appreciate it. It's been an absolutely delightful conversation.

Thank you so much for having me. It was my pleasure. I really enjoyed our discussion today. Thanks for listening to this episode. TechLink Health is a healthcare advisory platform for consumers and organizations to stay informed with the latest insights while connecting with healthcare experts for telehealth, eConsults, and consulting services. For more details, visit www.techlink.health.