EPISODE 10

Dr. Roger Seheult, Co-Founder of Medcram

05-05-2020

Why are young patients with COVID 19 having strokes? Why are ventilators not as effective as expected? Why do some patients have the symptoms of altitude sickness? One explanation for these mysteries is the disease keeps adapting and changing. But the other is that our understanding of it is catching up to what might be the truth: COVID 19 is not primarily a lung disease but rather a disease of the cells that line the inside of blood vessels and lymphatic vessels. Pulmonologist Roger Seheult, one of the drivers behind the popular Medcram video series, talks about the evolving understanding of COVID 19 and his approach to explaining complex medical subjects to a general audience.

Transcript

 

DR. RISHI DESAI: I'm Dr. Rishi Desai. Today on Raise the Line, I am happy to be joined by Dr. Roger Seheult, co-founder of MedCram, a popular, fast-growing source of online medical education, with over 50 million video views and a quarter of a million subscribers. In addition to running MedCram, Dr. Seheult is a professor at the University of California, Riverside and Loma Linda University. 

He is also a practicing pulmonologist and sleep physician. Thanks so much for being here today. One other thing I have got to plug is that we have a family friend and that we've done one of these pre-COVID. It's really nice to get caught up with you, Dr. Seheult. I am so glad you're here with us today.

DR. ROGER D. SEHEULT: Yes, and I'll say hi to Dr. Furutan for you. 

DR. RISHI DESAI: Awesome. That's my wife's auntie, so it always helps to have connections through the in-laws! Let's just jump right in. Why don't you start by telling us about your background and the path that led you to starting MedCram.

DR. ROGER D. SEHEULT: Yeah, so I am a pulmonary and critical care specialist, also in sleep. As part of my connection with Loma Linda, we used to have PA students that came out to our clinic. In doing that, I met the co-founder of MedCram.com, Kyle Allred. He was actually one of my students and was involved with medical education before because his dad was also involved with medical education. 

He told me, “Look, Dr. Seheult, students don't go to the library anymore. They don't check out journals. They don't photocopy them and don’t need a library card. They just go to YouTube. They go to Google and Google these things.” That fit well with me because every single month I was giving a lecture to the medical students and the PA students about topics in pulmonary, and I was doing the same lectures over and over.

That's when he introduced me to flipping the classroom, where we would have them watching the video and then coming to the clinic the next day to discuss it, so it really worked well for me. That's how it started, as a little channel on YouTube, almost there just for my students, then more and more people came to it. The rest is history.

DR. RISHI DESAI: What year was this? Just to give some context around it?

DR. ROGER D. SEHEULT: This was around 2012.

DR. RISHI DESAI: Got it, so around 2012 is when you started getting into this. What percentage of your time did it take up then, and then what percentage of your time does it take up now? 

DR. ROGER D. SEHEULT: It's grown proportionately. I would produce a video maybe once a week, and after I had done a cadre of them and we had a rotation, I really didn't have to do much, but as it started to grow, and people wanted more, and there were more questions, then we did more and more, and, of course, since January, when my wife one day said, "Hey, you should do a COVID update, you should do a COVID video.” It’s just exploded, and we've been pretty much doing them every weekday. 

We take the weekends off, but it's really taken up a large amount of my time. But it's also helped me because I would have to learn about this virus anyway, so if I know that I have to teach somebody something, I better know it well enough to be able to teach it. It's really helped me to be on the cutting edge of COVID-19

DR. RISHI DESAI: What do you see as MedCram's mission, and how does COVID-19 fit into that mission?

DR. ROGER D. SEHEULT: The motto that we have is explaining medical topics clearly, or demystifying. One of the great things that I get in life is looking at someone's face light up when I can explain to them something that's been perplexing or a mystery to them. That is really something that is in medicine....you know medicine has its own language. We kind of do this as doctors, as healthcare professionals; we try to keep it away from everybody by having these funny terms like hypothermia. What's that? That just means that your temperature is low, but we use these Latin terms, so we take these things and we demystify them because we can actually do this. 

We can take complicated topics, then boil them down to their essence and explain why things are happening. As I've noticed, this is not only helpful for medical students, PA students, or NP students, but for people who are not in the medical field, but may be very interested in a diagnosis because they have it or because they know somebody who does have it, and that goes into the next part of your question, which is about COVID-19

Everybody, of course, wants to know about COVID-19. I can remember back in late December, early January, where I would go to a news report or a newspaper, and maybe there were— maybe 20% of the news items there were on the coronavirus. Now you go there, and every single news story is about coronavirus. If it's in the sports section it's  because they can't play sports. It's in the business sections because the stock market is going up or down. Every single story right now is revolving around COVID-19, and so it is the hottest story on the planet, and everyone wants to know about every single newest thing. 

What's funny is that a lot of people are looking at this now and finally beginning to understand that medicine is not 100% science. It’s art. It's trying to figure things out. The body is extremely complicated, so when you try to describe what the virus is doing to the body, you've got to use terms like angiotensin II receptors, T cells, B cells. What are all those things? If you can boil it down to its essence, people really want to know, and they want to know what they can do to make sure that they're not the next victim of COVID-19.

DR. RISHI DESAI: One thing that I really admire about the videos you make is that you beautifully blend in things like you just said - angiotensin II receptors - with a cutaway to a screen of a blackboard, chalk-talk style. Would you mind just talking about the evolution of that and how your learners like it or whether they've given you feedback on that?

DR. ROGER D. SEHEULT: The term that Kyle likes to use is "learning at the speed of explanation." Sometimes, you can get way overloaded by so much information and words  put up on the screen. This is exactly what happens nowadays. We want more medical providers. We want more PAs, and so what we do is we make more schools, more classrooms, and people are not maybe educated enough to teach, so they put together a slide or a PowerPoint presentation. They go through; they whip through 60 slides in an hour. 

This is basically Niagara Falls into a styrofoam cup. What people want to know is, let's slow it down, let's figure out exactly what's happening. What a chalk talk does is, it innately has to allow you to describe something and draw it at the same time. For some people, that can be a little slow, so you may notice in some of our chalk talks, we speed it up sometimes because, let's face it, people are going to pick videos on YouTube based on which is the shortest way to explain something, but it's got to be described, it's got to be talked through.

If someone needs to go back, that's the beauty of YouTube, is you can stop it, go back and replay it again. If it's too slow for some people, well, that's the beauty as well. You can click on 1.5 or 2.0 speed and get the essence of it. I think chalk talks allow you to go through things linearly rather than everything popping up on the screen and just boom, boom, boom! It's just too fast. 

DR. RISHI DESAI: In your opinion, what would you say are the main learners that come to MedCram? Are they health professionals, students, the general public? I imagine it's changed quite a bit through COVID-19.

DR. ROGER D. SEHEULT: Yes, it has. Prior to COVID-19, I would say the majority of our viewers were healthcare providers. When I say healthcare providers, it could be anything from a physician to a nurse practitioner, PAs, PA students, respiratory therapists, even EMT workers are watching some of the videos to get more education, so in that sense, that's primarily what we had. That's primarily who we were playing to. 

Obviously, after COVID-19 came, there were a lot more lay people that were watching, and we had to realize that and maybe take some time to explain some of the terms that we're using.  In fact, what we're about to do now on the channel is we're going to go through a little bit more because I personally believe that this disease is starting to look more and more like an endothelial disease with all the ACE2 receptors on the endothelium. 

The reason why we're having problems there is oxidative stress, so how do you now talk about oxidative stress to people without using terms like superoxide dismutase and superoxide catalase? We're going to have to go back to medical school, and we're going to have to educate people on what these terms mean, so now we can have a rational discussion.

DR. RISHI DESAI: For our listeners who may not understand what you mean by endothelial disease, would you mind just spelling that out for us now?

DR. ROGER D. SEHEULT: Exactly. An endothelial disease is this tissue, the cells that line your blood vessels, and they are very rich in ACE2, which we all know now is the target for the SARS virus, so just in that sense right there, when you're talking about this virus, and you want to explain what's going on, people want to know....people don't want to be dumbed down. I don't want to rain on the nightly news because they have a different job.

They have to explain everything that's happened in the world in half an hour, and you don't have time to do that in those kinds of shows.   I used to be really upset at these medical correspondents for the evening news. It's like, “Wow, you could have gone into a lot more detail. Well, they only get 10 seconds to give a little bit of something?” No, they really don't have time to do that. 

Well, that's what we can do. We don't have a half-an-hour slot. You and I, Rishi, we can talk and explain things. What I’ve found is this, the bottom line to your question is this— What I found is if you can explain something well, then you should be able to explain it at just about any level given the vocabulary. 

If you can get through the vocabulary so that people can understand, because words have meanings and you've got to explain what those are. I think anybody could learn and understand every concept, and that's really what we're attempting to do now post- COVID. We realize that we've got a bigger audience that we have to satisfy, and we have got to satisfy a lot of people at the same time with that.

DR. RISHI DESAI: It is also a very empowering message, this idea that you can really teach something that's so complex to every level of learner and not have to dumb it down, but that just sometimes takes a little bit more time to work through the vocabulary because I think once you get the vocabulary... Everyone understands that learning a new language is a little tricky at first, but we all speak some language so we've all figured that out.

DR. ROGER D. SEHEULT: Yes. The nice thing about this is that people are motivated. There are a lot of people now that, whereas before they could care less, now people are motivated because they see the consequences of this in real life.

DR. RISHI DESAI: What is your sense of that motivation piece for learning online? Do you feel like it takes a certain type of motivated learner to do that, or are we maybe seeing motivated and non-motivated digital learners? Are the online platforms really just helping those that may not need the help as much?

DR. ROGER D. SEHEULT: I think that there's probably a little bit of truth there, maybe more than a little bit of truth. There are a lot of people that just will get their information from the evening news, and I think that's okay. There are those people who come into the hospital, into the clinic that are very involved in their healthcare, and they want to know why you're prescribing this medication and what are the side effects. 

And there are other people that are like "Just tell me what I need to do, and I'll just do it," and sometimes they won't even do it when you tell them. There are all sorts of people, and I think the people that come to the internet, that come to Osmosis or MedCram are people that want to know more. These are people that have an internal locus of control. They have control over their environment. 

They want to have more control of their environment because they see the consequences, and so long as we can give them good, rational, peer-reviewed information and not over- promise, but try to deliver, I think that's the goal  of an organization like yours and mine.

DR. RISHI DESAI: One thing I have also thought about— You've brought the news organizations a couple of times, so I'll go into this— Sometimes, it feels like a "bleeding edge" of information, and maybe MedCram is that bleeding edge, and this idea you just posed here about endothelial damage being the main reason behind why we've seen strokes in younger folks, that may not hit the news cycle for two or three more weeks.

I'm curious, do you sometimes have or have you had experience with news media reaching out to you to say, "Hey, what are the things that we should be focused on that we're not focused on at the moment?"

DR. ROGER D. SEHEULT: Yes, they have. Sometimes they don't want to hear all of those things because they have a different job that they have to do. They have a narrative that they want to have, but at the same time, they use the daily news cycle of what's topical, and they have to put that narrative with what is topical. We don't have to do that. We just can report on what medically we think is going on because that's hard enough. I mean, COVID is covert. 

There's a news bite for you there. COVID is covert. It seems to morph and change, but actually, it's our understanding that it's just maturing, and I think we're getting a better understanding of that. We have talked about all sorts of things on our channel. We have talked about hard science. We have talked about coronavirus and how it infects the receptors. 

One of the things that had bothered me from the very beginning, in terms of our management, generally speaking, and it's not anyone's fault, it's just that we have concentrated a lot of our resources at the end stage of the disease because that's the least amount of people in the whole epidemic. 

How are you going to get to millions and millions of people the treatment that they need before they get and before they need to go to the hospital? Well, that's different. We've talked about things that some people might think are a little bit soft or squishy in terms of scientific evidence, but when you really look at it, everything that we're doing right now for this virus is soft and squishy. We don't have a lot of evidence.

What are some of those things that we've talked about? We've talked about, "Is Tylenol good for people who have a fever? And therefore, is heating up the body good for the immune system, is this helping the innate immune system?" Everything that we've talked about is circumstantial, and we don't have any direct evidence that it works in COVID-19, but at this point, what else are we going to do? 

Wait for those studies to come out? The epidemic may be over at that point. I think the bottom line is when you start to bring up these topics, sometimes people's brains aren't ready to be wrapped around some of these ideas. That's how I would say it.

DR. RISHI DESAI: One other thing that I wanted to get your input on specifically is how you like to thread the needle with things where you might have a personal view, and then there's also the documenting of what's actually happening. For example, digital surveillance technology, we know it exists and that certain countries are deploying it in different ways. 

That's quite different than maybe your personal take on it - where that lands in terms of public health versus civil liberties? I'm just curious about how you thread that needle for yourself and for the channel in terms of injecting your opinion into the issue?

DR. ROGER D. SEHEULT: This has been something that people are just really, really looking for. I see it in the comments all the time. They say, “Thank you so much for not giving us your opinion.” We actually do give our opinion, but we make it very clear, "This is what the evidence shows, and here's maybe what my opinion would be." We'll say, "This is complete, evidence-based medicine, and we try to do both sides of it." We try to be the prosecutor and the defense attorney at the same time. 

“Here are the pros; here are the cons."  As an example, probably no other medication is as political as hydroxychloroquine, so what we did was we reviewed all of the data on hydroxychloroquine, and it was interesting; there was a comment that came up, and they said, "Okay, I'm going to comment here. It sounds as though Dr. Seheult is taking this side of it, but I'm going to watch it, and I'll come back, and I'll edit my comment," so he came back and edited, saying, “I was wrong. He actually presented both sides of this, and he's not actually taking the line that I thought."

What you need to do is to be able to do what we, you and I, Rishi, we were all taught in medical school and residency.  We've always had to look at stuff and say, “Yes, this looks good, but what could be all the fallbacks on this?” That's exactly what we did with those studies on hydroxychloroquine. I can't tell you right now whether hydroxychloroquine works or not.  I'd certainly like to be able to have a discussion with somebody in the medical field like you and me about it without being pinned down as the devil or God, you know what I am saying? 

That's really what we have to do, and that's one of the things that I really want to make sure, it’s that MedCram, Osmosis and all of these companies that educate, that we have the trust of the population, of humanity, that we are going to present the data as we see it, and then we'll tell you what our opinion is if we think what it is. We'll label that very clearly, but I think this is what it is, but I don't have any evidence of this or the other. 

I think Remdesivir may work in vitro, it’s something that may work, but I've got no evidence right now that it does. Another thing that I think is also helpful is educating the population on what these words mean, so when someone comes out and says, “I have no evidence that”—  Sometimes, people will mean and think to say, “Well, that means that there's no way that this is true.” That's not the case; something could be very true, we just don't have evidence because no one's done a study. I can tell you right now that I have no evidence that putting a roof on a hospital keeps people's heads dry. I have no evidence of that. No one has ever done a study to build a hospital without a roof and actually check to see if people's heads get wet. Do you know what I'm saying? 

When the WHO comes out and says, “We have no evidence that getting antibodies is going to confer immunity to this disease,” they’re right. We don't have any evidence, but there's a good chance that there's probably going to be some evidence at some point that shows that because this is a virus like any other virus and people have antibodies. So we have to be careful with what we do and what we say. That's a long answer to your question.

DR. RISHI DESAI: It's a great answer to my question. I like the analogy of a roof and keeping my head wet. It's very concrete, and I can wrap my head around that very easily. I'm curious— You've talked about online medical education a few times, and right now we're going through a very clear shortage of healthcare workers, and this was before COVID-19

I don't necessarily mean physicians. I mean across the spectrum, PAs, NPS, and nine of the top 15 fastest growing fields are in healthcare, and that's accelerated now. I'm curious about what your thoughts are in terms of what role online medical education will play in the coming years to help address that shortage of trainees?

DR. ROGER D. SEHEULT: I think that our demand for healthcare workers is outstripping our supply of good medical education professors. I think that's just the fact. I don't want to disparage our colleagues, but I've heard it from students saying, “Yeah, they came in here, gave us a PowerPoint presentation and then left, and we really didn't know what was going on.” 

Right now, it's hard to get people in there. First of all, it doesn't pay much to be a professor or a teacher. You do this as a part-time thing. Usually, you're busy in the clinic, and you’d be asked, "Hey, could you do a lecture on Friday, ok what is it on?" "Okay, I'll put some slides together." While, at the same time, we're trying to get a lot of people educated, we're not really investing in our education.

There are some bright spots, though. I think what you've done, Rishi over at Khan Academy and this flipping of the classroom really spearheaded a lot of us into getting into this field and doing online education. I think one area that is concrete in COVID-19 is that there was this thought, rightly so, that we were going to need a lot of ventilators. These are machines that people haven't seen in years, some of them. These are surgeons that haven't managed a ventilator, even ophthalmologists that haven't managed a ventilator, and they thought they might have to do it.

Well, we offered a basic ventilator course on our site, and whereas before we had charged for it, we made it free. We advertised for it, and people were taking this course in large numbers. I think that's one way of potentially educating a number of people in one field who have to be upgraded in another field. 

DR. RISHI DESAI: That's a great example. I think that we're increasingly going to see that not just in healthcare but in other fields where people have the added necessity to continue learning new things well after they've finished college or med school or whatever; that it's not just like you learn in the first half of your life and then you work in the second half of your life, but that learning has to continue through. 

I really appreciate these chances to talk to you and get caught up with you. Any final thoughts or advice you have for our audience of future health clinicians as well  as public health professionals?

DR. ROGER D. SEHEULT: Basically, two things, COVID-19 and just in general. In general, always remember in terms of your education to never look at how long something is going to take to go into something. If it takes five years to do something, guess what? Five years is just going to come and go. Get involved. Educate yourself. There’re many opportunities that you can do online.  

Then what I would say specifically about COVID-19 is that we are about to enter into a period, I believe, in the next few months here, where a number of the fruits that we have sown here in the last couple of months in terms of research are going to start to come out. 

We're going to get a lot of information, and we're going to start to understand a lot more about this disease in the next couple of months, so it's going to be exciting, and hopefully, MedCram, Osmosis and a number of other sites out there will be the vehicle for you to learn about what's going on with COVID-19 and the things that are going to happen in the future. 

DR. RISHI DESAI: Thank you so much for your parting advice. I really enjoyed talking to you today. 

DR. ROGER D. SEHEULT: Thank you, Rishi.

DR. RISHI DESAI: I'm Dr. Rishi Desai. Thanks for checking out today's show. Remember to do your part to Flatten the Curve and Raise the Line. We're all in this together.