Alright, today we're going to be talking about evidence -based medicine, what the idea is there, where we stand today with it, and how it relates to what we do at Cascade Regenerative Medicine.

So the inspiration behind this episode and the corresponding article that I've written about it and just, you know, the idea that I've kind of turned over in my head a lot over the years is this double standard that I think has emerged, where in what I do, there's a constant push for getting better and better evidence, as there should be. We need more and more information on not only what, for example, PRP is good for, but what type of PRP is good for what, when it's not useful. All of the little nuances and intricate sort of details of clinical practice, right? Because we know for sure that we can't just say PRP is good for everything all the time, right? That's a silly thing to say, it's a silly thing to assume, and it's obviously not correct. Now, the other end of that, is really hearing from either patients or certainly from other health care professionals, from the media coverage of these types of things, of getting better, criticized from-- (you know I'm gonna struggle a little bit with language here) we'll just I'll just say conventional medicine as a way to describe sort of big hospital insurance based sort of mainstream medicine right so it doesn't I don't mean anything disparaging by it we just have to call it by something right we call it mainstream we call it conventional-- the criticism from that group right in what I do it's coming from primary care providers it's coming from orthopedic surgeons people like that where what I do will be criticized because there quote -unquote isn't enough evidence for that or there isn't any evidence for that. So within within my specialty right there's a push internally of needing more and more evidence which I I obviously agree with strongly and we need to continue to push for and it's why we do things the way we do at my clinic and then you also hear a lot like I said from patients and other health care professionals about how little evidence there is for the things that we do so you know I feel sometimes like I'm on the defensive often whether in patient visits or in speaking to other professionals about what I do because there is this sort of ambient sense of oh what you do is alternative and unproven and you know insinuating that whatever happens at you know the big hospital system with an orthopedist or a sports medicine doctor or primary care physician is evidence -based.

I think the most important thing for patients to understand is that most of medicine is not based on high -quality evidence it's just a simple fact: my primary thesis is that evidence -based medicine is an aspirational term it is not the actual state of how things are currently we in every medical field struggle with trying to fill our gaps in knowledge with better and better evidence it is not by any means unique to the regenerative medicine landscape or to PRP studies it is the it is this it is the normal state of things as they stand today in February of 2024 that most of evident most of medicine modern medicine is not based on high -quality evidence we work toward that goal we hope that it will be one day we all want it to be better but it is not that way right now. I think what happens with anything that's like what I do that's not you know covered by insurance so that isn't considered mainstream is is this dynamic this this double standard or asymmetry where I am criticized for doing things that are quote -unquote not evidence -based by people who are likewise doing things that we know are not evidence -based and there's an assumption that if it's done at a hospital and it's covered by insurance then it must be evidence -based and as I've written about and we'll kind of go through here it's simply not the case and so I think pointing out and as a patient especially being aware of this double standard helps you to kind of understand some things about you know how your health care works and how to choose hopefully a better provider.

So let's get into the specifics here. What do I mean by that? So what do I mean by, you know, evidence -based medicine is the goal, right? It is the aspiration. It is not the current state of things. In primary care practice, 18% of all recommendations are based on high quality evidence. 18%, right? That's less than one in five recommendations in the primary care setting are based on high quality evidence. This is based on a study in the British Medical Journal in 2022. So very recent in a very high quality journal. This isn't some reanalysis of data by someone with, you know, with a bad reputation. This is one of the top medical journals in the world looking at, like, where are we at with evidence -based medicine? Now, within different specialties, there's much better and much worse ones. Like, for example, oncology and pediatrics are the highest level of evidence -based for their clinical guidelines. Oncology, you know, you can see with oncology, it lends itself to randomized control trials very well because you can do single drug treatments for specific types of cancers with easily done placebos and, like, the whole process lends itself not to mention the enormous amount of funding, right, that cancer research receives, you know, for good reason. So on the other end of the spectrum, musculoskeletal recommendations and orthopedic medicine is one of the least evidence -based practices in all of medicine, okay? So within the primary care setting, if we break down that 18%, which is a number of total recommendations, Um, the within musculoskeletal recommendations, only 11% of recommendations are based on high quality evidence, 11%. Okay. So this, again, I'm going to keep repeating myself on this particular point, but this is where it's hard not to be a little defensive around people criticizing things like PRP that have strong evidence for certain conditions when done correctly. Right. There's all these caveats, but you know, dismissing it out of hand as there's no evidence for that while in the next sentence, we'll recommend something, um, that is, is either equally on based or actually has all the evidence in the world showing that it does not work and yet it is still recommended. So 11% of musculoskeletal recommendations in the primary care setting are based on high quality evidence, right? So that's what I mean when I say medicine today is not predominantly evidence -based, right? We try to be, but it is not.

Another way to look at it, orthopedically specific, six of the top 10 orthopedic surgeries, they're called elective, right? So you're kind of common non-emergency, non-trauma related surgeries, six of the top 10 most common orthopedic surgeries have no evidence of being superior to conservative care. Six out of 10 have no evidence of being superior. Two are inconclusive and two show benefit, right? So two out of 10 of the most common orthopedic surgeries actually have evidence showing that they work. 20%, right? 60, 60% of the most common orthopedic surgeries have not shown any benefit to conservative care, right? These include very common procedures that we've all heard of that as we'll get back to like make a lot of logical sense. Everyone knows someone that's had these surgeries, but again, they have not borne out to actually be beneficial. Things like ACL repair, meniscectomy, rotator cuff repair, subacromial decompression, lumbar decompression for stenosis, lumbar fusion for degenerative disc disease. None of these things I just listed have been shown to be superior to conservative care, right? Again, this was in 2021 in the British Medical Journal. This is not a fringe statistic or a alternative analysis, right? This was published in the journal, right? And if we take meniscectomies, which is where we cut out a piece of the meniscus when it's injured and take that as a case study, there are about 700 ,000 of these procedures performed annually in the United States, which totals to about $4 billion in healthcare expenditure, just in this country, just for that one procedure every year. The Cochrane Review for this procedure from 2022, the Cochrane Review being the preeminent evidence -based medicine sort of evaluator, the Cochrane Review about menisectomies concludes, quote, arthroscopic surgery provides little or no clinically important benefit in pain or function. Not to mention, now unquoting, not to mention we have a pretty good sense that these surgeries increase your risk of osteoarthritis, and there's also been large studies showing that they've been no better than a sham surgery. And yet again, 700,000 and $4 billion every single year for a non-evidence -based surgery.

Okay, so a couple other things as far as just kind of setting the table here, kind of learning about the kind of current landscape. An analysis of the top six orthopedic journals found that the average level of evidence in these journals is three with one being the best and five being the worst. So three's again, right in the middle. It's not bad. But again, I think when you talk to orthopedists or, you know, your primary care doctor about anything that's not steroids and surgery, you know, often my patients are sort of scoffed at. But it's not like we're talking about level one A, you know, solid recommended treatments as the mainstay, right? It's obvious at this point that the current state of orthopedics and sports medicine is is sorely lacking in effective treatments.

And then another one, you know, if anyone has heard me talk about foot health, you kind of know the general outline of this kind of thing. But you know, arch supports are one of the most common recommendations. Maybe for any musculoskeletal complaint, people give them for knee pain, for hip pain, for back pain. Certainly for foot pain they're one of the most commonly recommended things, even for things in which it makes no sense. And we see for arch supports, there has not been a single study that shows long term benefit or improved foot function from an arch support, right? There's tons of studies showing decrease in pain at three months or six months, right? But again, long term benefit showing improved foot health? There's never, never been a study showing that. And we have an entire, we have an entire profession and an entire business model is based on this sort of logically flawed, non-evidence based recommendation.

So, and then last thing, going back to kind of primary care, I'm switching between primary care and orthopedics and, and, you know, these things because a lot of people will end up seeing their primary care physician for musculoskeletal complaints, right? So it's not all just orthopedic surgery. Importantly, right, it's things within primary care, but that have to do with musculoskeletal orthopedic conditions. So the last thing is, you know, your average primary care visit is about 18 minutes. And that's actually bigger than I thought it was when I did this research, 18 minutes. But this 18 minutes average does not allow for evidence -based medicine to occur, even if it were possible in theory, right? So even if we had complete information, we had all of the right guidelines, 18 minutes is not long enough for the physician to actually make all of the necessary recommendations, right? So we have not only far from perfect knowledge, but we don't even have a system that would allow for the dissemination of it, even if it were complete. Paradoxically, longer visits are associated with more inappropriate prescriptions, so the longer the visit generally is gonna correlate with a more complicated patient case, and that correlates with inappropriate prescriptions. Benzodiazepines and opioids for pain, for example, is high on that list. Things that conflict with blood thinning or clotting medications, things like that. And then I found it interesting in this study that was published in JAMA last year, right? So top journal in the world, in the country, Journal of the American Medical Association, that's where this information is from, they estimated that a primary care provider needs a 27 -hour day in order to practice evidence -based medicine. So again, that sort of puts a very fine point on this overarching sort of subject, which is we don't have complete information as it stands now, medically, scientifically, and even if we did, we're not in a system that would allow for it to occur anyway. And thirdly, I think, as we'll get to, the implication of this is, I think people often assume that we are more advanced in our scientifically knowledge than we actually are. Um, and I think doctors and healthcare practitioners are a big part of why that misinterpretation or misunderstanding exists because I think a lot of people promote themselves as, you know, well, I practice evidence -based medicine, right? Um, and what that actually means again, in real world clinical practice is this is for everyone. Not again, I'm not singling anyone out. This is true for me as well. What that actually means is I try to use the highest quality evidence available at any given time and continually fall short because we have incomplete and imperfect knowledge, um, and being honest about that is step one. And I get the impression that. uh, we're simply not being honest about it.

And, uh, I get that impression again, from this idea using PRP as an example where PRP is dismissed as being not evidence -based, right? We're, we're, we're looking at these stats and going, well, 11% of recommendations in the primary care setting are evidence -based. So usually an 89% is not evidence -based. Um, so, you know, what, what are we really comparing it to? Right? Of course PRP has good evidence, but, and of course it could be much better. Uh, but we're not comparing it to some gold standard, right? The, the current state of medicine is not in a place to dismiss treatments out of hand because they don't fit into the, to sort of a drug and surgery model. So I think trying to explain how and why this is, this is happening, um, is important. Obviously in trying to explain why it's not ever going to be fully explanatory it's going to be more conjecture just by definition. But I think just alluding to maybe some possible partial explanations, right? This is a complex emergent property of a very complex system in a historical context. So it is, it's not as simple as, Oh, this thing causes, you know, cause this thing and that's the explanation, right? But I do think there are some threads that are, that are interesting to pull out as far as the, I think what a lot of people experience, and I know I, I, I see this in people a lot just with the foot and ankle care that I do because it becomes so poignant in that setting is just when you hear what I just said about all of the, you know, sort of evidence -based statistics and where we're actually at in terms of musculoskeletal and orthopedic evidence.

I think one common reaction is just cognitive dissonance and people not understand, not, not really. understanding like how could this possibly be the case? I thought that we were an advanced medical system and I thought that we had things more figured out than we do. And honestly, I mean, I'm in that boat as well. I feel the same way, or at least I did. And I think trying to understand why this is the case and how this came to be can be helpful in kind of easing that dissonance. So what they showed was that experts tend to be less inclined to change their preconceived notions when confronted with new data. Okay, so to say it a slightly different way, those who declare themselves expert in an area relevant to the intervention, Uh, so, you know, with what we're talking about, let's just, you know, again, I don't want to hammer too hard on any profession. We'll get to it that later. Um, you know, nothing is meant to be ad hominem or attacking, but those who declare this as expert in the area relevant to the intervention, right? So we can look at orthopedic surgeons in the area relevant to a menisectomy. Those people are particularly resistant to new information that the treatment is ineffective. Okay. So this is one phenomenon that we see. And the interesting thing about this study is that it was not a medical study, right? It was just looking at an expert, um, expert, um, phenomena, right? So studying how experts do or don't change their opinions was the study, right? They were, they were using opinions from all sorts of different fields of study. Um, it's, so it's a much more generalizable, um, much more generalizable pattern, it's not just, you know, it's not by any means specific to orthopedics or to, to doctors or to medicine or anything like that. But I think it's more valuable because it is broad. Um, and we can just see, and I think we just look at this from a human level, right? Orthopedic surgeons spend years training to do this particular procedure called the menisectomy, where they cut out some of the meniscus. People tend to be better in the short term for it. Like they feel better next month or three months later. Again, the data is conclusive and showing that these surgeries do not work. And they are not better than doing nothing. And they're not better than doing PT. They're not better than a sham surgery. And they increase your risk of arthritis, um, and, uh, need a knee replacement later, not to mention the cost to the U S health, the healthcare system, however, right. As a single person who trained and worked their butt off and got to this point where now they have an ability to do a procedure that, um, right. That is, you know, how they make a living. It's a sunk cost, right? You've spent all this time learning a thing and then you get this information, right? That's published in JAMA and says, hey, this thing that you do all the time, right? Cause this is a super common surgery. This thing that you do all the time, forget it. Throw it out the window, it's gone. Like it's, we can't be doing this anymore, right? From a human perspective you understand like the resistance to changing, right? Because what's harder than learning new information is unlearning old information, right? Unlearning outdated information. It's much harder, right? Because part of the psychology with that process is admitting that what you had been doing is wrong. You know, and it's not, quote unquote, your fault that you were wrong, right? You were, you know, everyone's, again, everyone's working with incomplete, imperfect information but it does take this level of humility, I would argue that, you know, in order to take on that new updated information, unlearn the old outdated information, there's a level of sort of reflection and humility and an admitting of, you know, if not stakes, we can call them, uh, you know, miscalculations. Um, and so that, the sort of experts in general being more resistant to change is the bottom line. And that's, that's a, that's a wide phenomena that's not specific to medicine, but it does help to explain how, for example, six out of 10 of the most common orthopedic surgeries have no evidence of being superior to conservative care. And yet they're done all the time and they're billed huge amounts of money and they're covered by your insurance, right? And this is what we call evidence -based medicine.

Next, I think one thing I'm confronted with a lot and that I, that I think is really important to identify because a lot of this subject matter for me is a matter of my own self -reflection and self -criticism and self -auditing about the space that I occupy, right? And really, um, not being intellectually lazy, right? So there is something called the naturalistic fallacy, right? It's very common in sort of alternative natural health for, for this to be either explicit or implicit in a lot of things. I find that, you know, if it's, um, well, let me start with defining it, right? So the naturalistic fallacy is the incorrect or misguided notion that because something is quote unquote natural, that means it's good for you, right? So this is no doubt a fallacy, right? It is not, it is not a hundred percent a correct assumption, right? There's plenty of natural things that will kill you, there's plenty of synthetic things that have made our lives happier and healthier. So it is no doubt a fallacy. It's an understandable fallacy, I think, because humans, you know, we are a part of the tree of life. We evolved in exclusively natural environments, right? Natural, meaning non-man-made environments. And so there is this, I think, and that's the trap, I think, for, you know, you can, there's so many examples, it's hard to even, I mean, like, so paleo diet comes to mind, right? So just, oh, just eat what a caveman eat, or eat what a caveman ate, is some version of like, you're sneaking in the naturalistic fallacy, right? Just because, you know, and there's lots of fallacies with a paleo diet, but it's something that I think people in the alternative or natural medicine world get criticized for a lot. And a lot of times as well, they should, right? Cause I criticize my own profession for it. I try not to fall into that trap myself, right? And specifically in what I do, right? It manifests itself in the choice between cortisone and PRP often, right? And as I've written about extensively, the choice between those two things is not simple, right? They're not like natural and synthetic corollaries of each other, right? They have very distinct benefits and risks. And I go over that with every patient and it has nothing to do with PRP is better because it's natural, right? That's not ever a part of the logic. Now, so that's kind of happening in the background, right? The sort of naturalistic fallacy of a lot of, you know, a lot of sort of criticism gets aimed at, oh, well, you know, plant medicine or natural foods or whatever.

Now, what I think is equally important, but I don't think is recognized nearly as enough. I don't even think it has a name. So I made up a name for it. And it's the flip side of this coin, which is what I would call the synthetic fallacy. And that is the belief that because something is uniform, homogenous, industrially manufactured, regulated, and created by the human mind, that means that it's safer and better for you. And that I think is an equally important fallacy because that too is obviously untrue, right? And we have this, and it's not everyone, right? Obviously you sort of, I think people split themselves along this line, but we have, I think this is, the synthetic fallacy is often the root of the bias towards drugs and surgeries as quote unquote, legitimate medicine and everything else being considered alternative, right? Anything else that has to do with health, right? That has to do with disease prevention or feeling better or anything, right? That's not drugs or surgery, right? Right, drugs and surgery are uniform, homogenous, manufactured, regulated, created by the human mind, that must mean that it's safer and better for you, right? So I'm not here to like sit around and divide which things fall into which fallacy category. The point, however, is that the naturalistic fallacy is very commonly discussed and I don't think the synthetic fallacy is recognized widely enough because I think this is just a version of a bias that a large swath of people sort of carry around with them implicitly because ultimately we do not yet and may never have a deep enough understanding of science in the human condition to understand and to synthesize all that we need. We do not have mastery over nature and being biased against things because they are natural is just as detrimental as the other way around. And so I think this synthetic fallacy idea is, you know, again a part of the complex series of causative factors that explain what we're talking about at the top with all the all of the statistics and misinterpretation of the idea of evidence -based medicine. Because we assume that, oh, drugs and surgery must be evidence -based. Nope, incorrect.

And then historically speaking, there's an important point, historically speaking, I don't think the role of the success of antibiotics can be understated. Antibiotics are the single most important medical discovery in human history, I would argue. You know, I would say plumbing and running water is probably the single most important invention for human health, but I don't know that people would consider plumbing a medical intervention, right? It's probably had the biggest impact on health. But as far as a medical intervention, I think antibiotics are the biggest success in human history, right? And it's relatively recent, right? Most of human life on this planet, we have not had antibiotics. And so because of the absolutely astounding success of antibiotics to, you know, decrease childhood mortality, increase life expectancy, improve quality of life, the unintended consequence of the success is that it gave rise to the approach to medicine as the, you know, a pill for every ill, meaning it really popularized and really deeply rooted the, you know, opposite medicine is what I would call it. So allopathic medicine is another term that we could use, you know, for MDs and DOs, we would consider allopathic. "Allo" means other, so it's this idea that we're using you know if you have a bacterial infection you use a the opposite of the bacteria and antibiotic and it antidotes it this and again it's that bias only exists because of how successful antibiotics were not because of you know not because of a considered effort by some company or some people or anything like that right it was because they worked so well that we thought oh my gosh maybe there's an anti fill -in -the -blank for every single disease and what it did is you know really root that sort of opposite disease pill for every ill approach into medicine and what we deal with today in modern life more than anything is complex chronic disease for which this anti -medicine approach or I should say an anti -medicine's confusing opposite medicine approach does not work right we can look at the commercial success of Ozempic as a great example of this I would bet my life on in five to ten years some study coming out showing oh yeah you know that FDA approved drug Ozempic that we were giving for people to help with their obesity and they're in their you know obviously a lot of people are taking who aren't obese they're just taking it to lose weight yeah that actually has this huge list of side effects you know if I had to guess again this is all conjecture but I'm saying if I had to guess you know ozempic's gonna cause you know early onset osteoporosis it's gonna cause sarcopenia it's gonna cause lower life expectancy because you're gonna you know maybe have an increased risk of hip fracture and falls as you age for people who have been on this potentially thyroid disorders I mean again you could it there it's a pharmaceutical way to starve yourself so and this is FDA approved right and this is what people would consider quote unquote evidence -based medicine even though there's no way of knowing the long -term effects because it hasn't existed long enough to study the long -term effects okay so and this is again an example of the misuse of a pill for every ill in the context of complex chronic disease right so and it's why I don't think it will work but it's an entrenching of the synthetic fallacy meaning because you know because it's you know approved and regulated manufactured it therefore must be safe.

Surgery as a profession kind of extending this metaphor a little bit more surgery as a profession began to be recognized sort of as a legitimate thing right so surgeons used to be more like barbers right barber shops that's you know they used to surgeons a very interesting history. They weren't quite considered doctors for a long time. And it was just, it was just a matter of, you know, scientific knowledge. And we would, you know, we had people just, you go to the barbershop and get a tooth cut out or your, your, your limb amputated. You know, no anesthetic or anything. So, it began to be recognized as a legitimate medical profession around the time of the Industrial Revolution. And surgical approaches reflect this, this time periods, thinking right through metaphor, meaning Industrial Revolution, we're talking about combustion engines and like machinery, right? And so a lot of them, a lot of the thinking around surgery is still rooted in this, the body is a machine type of metaphor, right? So we can just replace and fix, remove the broken part of the machine and the machine will run smoothly again. This metaphor is, you know, a metaphor that has some useful information. Um, some cases, but it is, it's, it's wildly incomplete and taken too far. We get, again, we get all these things that we see where, you know, these, these, these surgeries that are logically backed up, right? If you think of the body as a machine are not validated at all by the evidence because we are not machines. Uh, we see a similar thing happening now, um, with new technology, right? So the technology of the time, uh, right now, right. It's sort of computer or, you know, it has been right. It's been 20 to 30 years, but you know, we, we see, as opposed to metaphors with the combustion engine being around, you know, that, um, previous time period, we now see a lot of metaphors and medicine specifically around neurology and brain, brain function, brain health analogies to computers, right? Oh, the brain is a computer. The brain is the hardware, culture is the software. These types of metaphors, again, useful as metaphors, but very limited. Uh, if we, if we extend them too far and we need to be careful about how we use metaphors and how much meaning we take from them, because just like our bodies are not machines exactly, our brains are also not computers exactly.

The last factor as to explain why and kind of how did we get here is the fact that there's just deep flaws in the mechanics of scientific translation. So there are, uh, ways in which, right, even if we have perfect studies that it becomes very difficult for these studies to be implemented into clinical practice. Um, so the average time that it takes to integrate evidence into practice is 17 years. Okay. So if we had a, if we, everyone decided today that PRP really actually does work for knee arthritis, it'll be 17 years before it is covered by insurance and makes its way into clinical guidelines. This again, I think has to do with the difficulty of unlearning old information. It has to do with curriculum in medical schools and the churn of what I call institutional inertia, meaning it's hard to, it's hard to change things when the system is so large. It's like trying to steer the Titanic with an ore. It's a difficult ship to change course. And so even in the face of new and compelling, and if it were possible to know with 100% certainty that something was legitimate, it takes... decade plus almost two decades to get that translated into oh that's what you're gonna get when you go to your doctor routinely. There's a there's an issue with studies public it's called a publication bias right where studies that are conducted that don't result in the preconceived result don't get published right so if you run a study and the and the results don't come out how you thought that they would or you thought they should then the publish doesn't get studied right or I'm sorry so that or the study does not get published meaning there's a there's a huge swath of negative evidence that we don't know about because it never got study or never got published so that's that's it that's a big issue it's a well -known issue right this is not new information for anyone in the in this world and then you know the last thing I don't want to spend I don't want to emphasize this too much but I do think there is some minor role of research funding and interpretation bias in you know research is largely funded by drug companies and that research has been shown to be more biased toward favorable interpretations of the drug itself and I don't think this even comes close to explaining everything but it's just another piece of the puzzle as far as how the mechanics of science and what we use to for evidence -based medicine is is you know it's it's all flawed and we have to understand these flaws in order to practice better medicine or we can't just ignore the flaws and pretend that it's perfect pretend that it's okay right because not only are we studying humans right the the medical implications and health of humans but we are humans studying humans right and so that the studies themselves like institutions are just made of people scientific research is just made up of people so the publication bias is a great example of it's not just hard to study humans it's it's hard when humans are studying humans because there's human flaws and human folly that is embedded into these processes that as as as pure and as perfect as we want to make them are ultimately human at the core right you can have a super well accomplished and established scientist who has all of the has all the credentials has all of the the the awards has the the bona fides and they run a study and it doesn't turn out how they thought it would and they just don't publish it and we know that this happens and so it's that just comes down to the imperfections of humans and the fact that all of these mechanisms are are have the sort of human imperfections embedded into them so i think all of these things partially explain it. 

So the implications of, if we get out of the why, right? And we move back to, okay, so this is the state of evidence -based medicine. It's not even close, right? It's barely a coin flip. Even if you include, if you move the bar down from high quality evidence to like decent evidence, again, musculoskeletal recommendations go from 11%, level A evidence to 48% if it's A and B level evidence, right? So that's actually pretty good, but you're still looking at a coin flip, a 50 -50 shot of the recommendation you're getting being evidence -based or not, if we expand the scope of what we consider evidence -based to level A and level B, right? Which is a slightly lower level of evidence grading. So it's not where people think it is. I don't even think it's where a lot of doctors think it is. I think it seems to me, and I really hope in my tone here that I really don't want to engage in any ad hominem attacks here. I don't think that there are doctors doing a bad job. I really, I truly, truly believe that. And I don't just believe it. I think there's a thousand reasons to see that that is the case, that it's not a matter of bad doctors, certainly, and certainly not a matter of doctors trying to do bad things, right? I think that's a really silly takeaway from everything I'm saying. But I think people get conditioned by their training. I think people believe what they're told, even if they're very, very smart, because in medicine, you have to basically specialize. And if you are a primary care physician... you're probably not reading all the up -to -date information on PRP because it's such a small percentage of what your actual professional life entails, right? And you, like all humans and most doctors, right, unless it's in your specific field of specialty, are, you know, headline browsing and you read and you read a headline in JAMA from two years ago that says PRP is not effective for knee osteoarthritis and you read the headline and you go, okay, great, well, you know, that'll be, that'll be what I tell patients for the next five years. And instead of reading the study, and this is referred to in the article that I wrote about PRP quality and quantification, is that study, right, that that was like, that was made its way through into the highest journal, that study was a joke, right? They didn't even study PRP. They studied a diluted plasma injection that they did one time, right? It's so, the study was so poorly done. That it's, again, I don't believe it's done out of malice, right? But the amount of ignorance that is present in the publishing of that type of study is amazing, right? And the editors of JAMA for knowing so little about the thing that they're publishing on is astounding. And so that's the truth of it. I mean, you know, we are all operating on personal time constraints, right? You know, we only have so much time in a day. Like I said, you need 27 -hour long days to do all evidence -based medicine in primary care. So the point is, I think we, as a medical collective, we do not have the level of understanding that many assume that we do.

And if there's one takeaway from this, I think it's this. The loss of epistemic humility is dangerous. I think medical professionals who are dismissing out -of -hand, quote -unquote, alternative treatments because they assume that the mainstream treatments must be evidence -based because they're recommended and covered by insurance, right? Look at these studies. Look at the British Medical Journal. Look at JAMA. Look at the Cochrane Review. These things are not evidence -based. They're just what have been done in the past, right? And we all need to work toward better evidence -based practice. The epistemic humility is huge for me. I think it's, you know, being humble about how you know what is true and if you think you know what is true. And I think people project a level of evidence above where the actual state of things are often because they want to project confidence to their patients and all of those sorts of things, which is fine. But I think it's dangerous if you don't know yourself, you know, the landscape in which you find yourself. Because I think if we imagine the landscape of medical knowledge is like a sea or an ocean that's dotted with islands and archipelagos, the sea, the water in this metaphor is ignorance and the land, the little islands of land are scientific knowledge. And it seems to me that many think, many healthcare professionals, many patients think that we are on dry land most of the time and we're not. The illusion projected to patients, you know, again, either purposefully or not, I think mostly not on purpose, but the illusion projected to patients is that medicine is a science built on perfect knowledge because we call it evidence -based medicine and it is not. Medicine is an art and a science. The art of medicine lies in navigating the vast sea of ignorance we find ourselves in between the islands of knowledge. The winds and stars by which we navigate are changing, are as changing, and idiosyncratic as the individual patients we treat. And I think knowing that and practicing as though that is the truth is really the only the only way to to be in medicine today. We can't pretend like we know more than we do.

Now two wrongs don't make a right just because you know some some group of treatments doesn't have perfect evidence doesn't mean that it justifies that we should jettison it for some other you know equally unsupported treatment and that's it's it's the opposite point is what I'm making which is that the evidence for PRP is imperfect. It needs to be better but it is strong and it is growing for many conditions when it is properly made. Again we can go back to my you can go back to my other podcast the articles that I've written not all prp is created equally it really matters who you see who makes it if they know what they're doing right there's a lot of people who don't know what they're doing right and there's a gold rush mentality for some of this stuff and I think people who just shop around and look for the cheapest treatment possible are gonna get what they pay for pay for which is which is crap they're gonna get bad stuff but the evidence is there right and it is imperfect you know just like orthopedic surgery evidence and given where we're at in this landscape I think that the main point related to the beginning of you know someone telling you oh there's no evidence for prp the main point is that prp stands on much more equal footing with other standard treatments than most people realize and within a clinical decision making process PRP is superior to treatments like ineffectual surgeries because the downside is so much less, right? The risk of PRP is so much lower compared to a surgery when we're talking about rotator cuff, subacromial impingement, knee arthritis, meniscus, plantar fasciosis, big toe arthritis, labrum issues. I mean, I can go on, it's like everything that I treat every day, right? It's like it doesn't work for everything all the time, right? But the decision -making algorithm or the decision tree that you go through should include PRP because if you skip over that and you go, oh, well, let's just do this thing that's quote unquote evidence -based and then it's actually one of these six surgeries that not only lacks evidence but has evidence showing that it doesn't work, right? Then I think we're off base and we're not, we're just, we're believing authority more than we are looking at the evidence, right? And that's not necessarily a patient's job to do, right? The whole point is that doctors should be doing this for their patients. So within this, you know, I think how I try to position myself, right, obviously I have biases. I am not immune to any of these self deceptions, or, you know, flip sides of all these biases that I'm talking about. There's flaws in PRP research, there's flaws, you know, and it's, it's, it's, you know, none of this I'm claiming immunity to. What I do have, though, is I've set up a context for myself, both from a medical training perspective, and from a business perspective, and a patient experience perspective, that allows for me to think freely, allows for me to adapt and change quickly, to be nimble, to respond to your needs and to respond to the changing scientific landscape, without the institutional inertia, and the approval, that's going to take 17 years to make, you know, your to make the pivot and your treatment strategy work. You know, I can do, I can offer you the time that you need and the time that we need to practice evidence based medicine. I can do a detailed exam, you wouldn't be you would not believe the amount of people who I see for conditions. And I do a physical exam and they say, you know, I've been to three doctors, and you're the only person who's actually touched the area that hurts, right? Like they go to foot doctors, and they don't even take off their shoes. Right, so that's not evidence based medicine. I'm able to offer more nuanced explanations of your choices, I can do the full range of standard choices, right? I can do cortisone injections for you, I can do hyaluronic acid injections for your knee, but I'm also not constrained by things that insurance won't cover, and I can do PRP if it's needed, we can do MFAT, we can do perineural hydrodissection. right? We can be creative because creativity is not a cop -out. Creativity is necessary. We need to take who you are today, where you're at right now. There's never been a double blind placebo controlled trial on you with this condition at this point in time. So, um, evidence -based medicine is a goal. It is not where we are. So we move forward, right? Um, trying to do the best we can with all the information we have, um, and trying to understand that there's institutional and system -wide things that prevent medicine at this point from being as responsive as I think it needs to be, which is why seeing someone like myself, uh, is so advantageous, right? Because a huge problem with the medical system is not just the treatments provided or not provided. It's the The context in which we find ourselves does not allow for proper care to be delivered even if we knew what the proper care was. And I just have to say this out loud because a lot of this stuff, you know, because it's kind of anti establishment. I hope I hope again. I hope my tone has been has been adequately level headed. And again, I'm not, I'm not calling out any individual people. I don't think it's an issue of bad doctors. I think it's an issue of incentives of constraints of context. And we should never ascribe to malice that which can be adequately explained by neglect, bias, ignorance and incompetence, meaning there is no conspiracy here. There's no, you know, there's no cabal of people that that want to make Americans sick through through fill in the blank, whatever, whatever, whatever thing, you know, people talk about there is no conspiracy, right? It's just simple ignorance. And that's it. We can see this throughout because doctors are very competent and doctors want to do well. And you can see, you know, this conference that I was just at two weekends ago, we have a orthopedic surgeon from Stanford, speaking about PRP in the knee and you know, the proper dosing and all the ins and outs. And this so this person, again, all the bona fides, all of like anything you would want in a doctor, he's a he's a Stanford trained faculty at Stanford School of Medicine orthopedic surgeon. And he said, he said this thing that was really presented as like an epiphany and like this big deep idea, which is, you know, he was like, you know, and then I realized that the knee is connected to the person. Right. And it's, you know, and it's, you know, more power to him. I think it's great that he, you know, realizes that better late than never. But it's also it shows you how deeply trained he was to not think of the knee attached to the person for the first 30 years of his career, right. So really smart people can have blind spots and biases that are carried forward through force of habit and intellectual and institutional inertia. And that's what I think we see. Like I said, I'm susceptible to all these blind spots. I'm imperfect. I don't think I'm the I try to be as explicit as possible about my reasons for recommending what I do about my biases when I do perceive them, and just try to be as transparent as possible. And I think this whole subject matter hopefully shows you that I've thought really deeply about these problems that I'm very engaged in a form of sort of self analysis, and the constant sort of destruction of self deception, you know, again, however imperfectly I'm able to accomplish that.

So We need to be better, PRP research needs to be better. Cascade Regenerative Medicine is really set up to add to the science by collecting real world data. And we're also intentionally set up to be responsive to your needs, to change to the, and modify what we do based on the change in scientific landscape. We are as humble as possible, we are nimble, and we are focused on you, the patient. So I'm excited to hear your feedback on this one. Again, this is an audio, a little bit extended version of an article that I wrote that'll be up on the blog as well. So until next time, I hope you think about this podcast, think about the article, the next time you hear your friend or your doctor, whoever say, you know, there's no evidence for that. And just think, you know, it's interesting, I wonder what the actual details of that are, because again, most of what we do in medicine is not evidence -based, and we navigate this vast sea of ignorance as we hop from island of scientific knowledge to island, and we do the best we can in between, and you need a good doctor to be your navigator. So until next time, thanks everyone, take care.