Dr David Scales and Dara Parker
Off the Charts Podcast
Hosted by Dr. Bobby Parmar
[Dr. Bobby Parmar] (0:00 - 0:06)
Welcome to Off the Charts, Dr. David Scales, and welcome back, Dara Parker.
[Dara Parker] (0:07 - 0:09)
A returning guest, very happy to be here.
[Dr. Bobby Parmar] (0:10 - 0:20)
Yeah, you were so well-received by both Paige and myself, as usual, that I was like, I'll have her on literally daily. So any reason to have Dara back.
[Dara Parker] (0:20 - 0:24)
I'm here for it. I've never met a microphone I didn't like.
[Dr. Bobby Parmar] (0:25 - 1:30)
And Dara introduced me to Dr. David Scales and thought it would be an interesting conversation just around all kinds of health topics. But then we honed in on one specific thing that very much is near and dear to me in the fact that I'm a private care provider. I'm a naturopathic physician in British Columbia.
And so I get to see all kinds of people who are sort of like not fitting necessarily into the system. And Dr. Scales has experience in this world, as I was like, oh, this is great. I get to ask somebody in that world some of the questions I kind of love to ask to no one on the other side of the fence, I guess I can say, like what your thoughts are.
So we're talking about contested illnesses. And Dara, of course, like you're not in medicine, but like, please give your two cents about everything, chime in. I think it's so fascinating as well to have a non-medical set of eyes and ears on these kinds of conversations, because that's who we're talking to in the first place.
[Dara Parker] (1:32 - 1:37)
I'm here to throw popcorn and I love a good contest. So I'll jump in when I have nothing to add.
[Dr. Bobby Parmar] (1:38 - 1:46)
Okay. So we're talking about contested illnesses. Dr. Scales, can you help define what that means for us?
[Dr. David Scales] (1:47 - 2:28)
Sure. And first, Dr. Bobby, thank you so much for having me on. And Dara, thank you for kind of suggesting it.
I think it was a great kind of, when Dara and I first met, I think one of the first things, she didn't know I was a doctor, but one of the first things she said was basically like, I hate doctors. I go to a naturopath. And then later when she found out that I was a doctor, she was like, I'm so sorry.
I'm like, no need to apologize. This is the world we live in. And I think a lot of us have had experiences that alienate us from the kind of traditional medical system.
So, Dr. Bobby, the definition of contested illnesses that I love is one that an anthropologist gave, which says illnesses you have to fight to get.
[Dr. Bobby Parmar] (2:31 - 2:36)
Oh, that's a good one. That's a good one. Okay.
[Dara Parker] (2:37 - 2:46)
I love that it's an anthropologic definition. We have bypassed Western medicine and gone to a more sociological perspective.
[Dr. David Scales] (2:47 - 4:43)
Yeah. Because what I think is, I mean, I think practically speaking, I don't love the term contested illness. Some people can find it delegitimizing, but I think it kind of just describes a little bit of a phenomenon, which is like this idea, the way I conceptualize contested illnesses is essentially this idea that the mainstream medical community has some idea of what an illness is, its symptoms, its pathophysiology, its manifestations, its treatments. And patient groups also have kind of an idea of what that illness is, often an illness with the same name, kind of pathophysiology, symptoms, treatments. And where I find contested illnesses is when those, the Venn diagrams of those two conceptions really start to spread out.
For, say, this doesn't happen in every illness. So sickle cell anemia, for example, pretty well aligned. ALS, for the most part, pretty well aligned.
But then there's certain illnesses that with just the Venn diagrams overlap, but very much not completely. And these are kind of the famous ones that have been studied as contested illnesses, things like multiple chemical sensitivity, chronic fatigue syndrome, also known as myalgic encephalomyelitis. I think long COVID fits a little bit of this chronic Lyme disease.
So, I'm also starting to see this kind of contested illness dynamic of this kind of splitting between kind of what you're going to find in medical textbooks versus what you're going to find online. Even in illnesses that didn't used to be contested, things like cancer, irritable bowel syndrome. I've seen a number of patients that have a very different conception of their illness than my conception based on, kind of like, you know, the medical literature.
[Dr. Bobby Parmar] (4:45 - 5:35)
That's so interesting that you're like describing this world I see every day. Because like I said, people approach me because they haven't necessarily fit into any conventional model that they feel like they belong in or they haven't met a provider that really is understanding what's going on. And they've gone through a lot of poking and prodding, but they don't land anywhere.
And then sometimes even with IBS or irritable bowel syndrome, people feel like, is this even a real condition? Because I feel like I had to be proven to not have every other real condition. And then I landed on this IBS blanket.
Does that mean for me, psychologically, I should assume that this isn't actually happening in my body?
[Dr. David Scales] (5:36 - 5:41)
Yeah, Dr. Bobby, the funny thing about IBS and funny, not funny, haha.
[Dara Parker] (5:42 - 5:46)
Are there funny things about IBS? And this IBS blanket sounds disgusting, but go on.
[Dr. David Scales] (5:46 - 7:40)
Yeah, well, what I would say is almost funny as in like, shame on the medical world. Because when you look a little bit at the history of IBS, it was considered to be a women's illness. People were often marginalized.
It wasn't necessarily something that was taken seriously. Then what's interesting, and I apologize for kind of going this direction, but this tells you a little bit of something. Then some people did some really interesting studies.
They did something called rectal manometry, which sounds kinky, but essentially it's this idea of testing the pressure inside the rectum. So literally what they would do is they would go where the sun doesn't shine and inflate a balloon where they could test the pressure of this balloon. And what they actually found is that people with IBS actually had kind of pretty severe pain at much lower levels of pressure than people who did not have IBS.
And once they could find some sort of quantitative, objective measurement, it became a “real” illness. And the medical establishment actually started to accept it as a real illness. So to me, I see this as a little bit of a lesson in modesty in the sense of like we as physicians, like when patients come to us and say, I'm really suffering from something, like a lot of times our knee-jerk reaction is dismissal or kind of telling people to just like suck it up.
But it's like, if you actually listen to people, like you can, there's often a there there, right? And it might be really hard to put your finger on it or to quantify it, but you know, maybe in a couple of decades, we'll have some sort of, you know, the next generation's version of rectal manometry, as exciting as that sounds. And we might actually be able to figure out what some of these illnesses are in ways that the medical community is actually willing to, to kind of see and understand.
[Dr. Bobby Parmar] (7:41 - 9:44)
I'm so like, I don't believe in coincidences anymore. Because anytime stuff like what I'm about to describe to you happens, I'm always like, oh, there's, I'm going to take something from it. So this morning, because I record a lot of content for Instagram, I recorded a reel on rectal manometry.
And my content creator, Marlon was like, what? This is what we're talking about today? And I was like, yes, because I really like talking about things like you just described, like it was, I mean, you'll see this, you'll see the reel soon, probably tomorrow.
But the idea, this is so interesting, where they essentially inflate people's butts. And they can only inflate people's butts with this catheter that produces air. And that pressure by people who have Irritable Bowel Syndrome is allowed to go to like 40 millimeters of mercury before that person goes, this is, I actually am in pain now.
But in a person who doesn't have Irritable Bowel Syndrome, they can go to 45, 50 or higher before that person goes, oh, I'm perceiving that now. It's like a discomfort scale. And it's a 96% sensitivity, meaning it catches IBS 96% of the time.
And it's huge. And when we get these kinds of like data points that are just like, oh, maybe this is more than just not Crohn's and not colitis and not an allergy and not celiac, it's its own deserving condition that maybe doesn't have to do with like digestion, maybe it's a pain syndrome. Like maybe this is part of the picture, but we never categorized it that way.
And so we didn't send these people to the right clinicians, because we kept sending them to digestive doctors. Meanwhile, it's like a pain condition, you know what I mean? Like it's a – we didn't…
And so women were just said to have this question.
[Dara Parker] (9:44 - 10:07)
Is it the same threshold for men and women? Have they ever performed this test in a gendered lens? Because I heard Dave, you say that at the outset, it was considered a woman's disease.
And we know that we underrate women's pain, especially Black women’s pain. So I'm curious about that data disaggregation if there is any.
[Dr. David Scales] (10:08 - 10:11)
I don't know. I don't know about you, Dr. Bobby.
[Dr. Bobby Parmar] (10:12 - 11:26)
So in the study itself, they didn't. Like everybody's the same in terms of their like, what's called a positive predictive value and the negative predictive value. There's no difference between males and females that way, except more women.
And I was talking to Marlon, she was like, “I don't…” She felt so… She was like, “Is that what's wrong with me?” And I was like, women are more likely to say they have an issue with their digestion, they're more likely to bring up that I'm bloated, and this makes me uncomfortable, they're more likely to express this kind of thing, whereas men I can tell you, like a man can. I'll give you a perfect example.
There's a man who had been bleeding out of his butt for two straight years and didn't tell anybody. And when he came to me and I did his blood work, I was like, why are you anemic? And and then I had to like poke and prod and be like, I have to figure out where this is.
Do you have a serious illness? Because it's so unusual for a non-vegetarian man to be anemic. And he didn't even complain of fatigue.
He didn't complain. He was just like here for like, check me over. I'm 40 years old.
And then he admits to me, he's like, actually, I don't. I don't know if this is the reason, but like, could it be that I bleed every day and have for two years?
[Dara Parker] (11:28 - 11:38)
I totally get it. I would also not tell a health care practitioner that if I didn't have a trusted relationship, I'd be like, I don't think it's this. So I'll probably just keep it to myself.
[Dr. Bobby Parmar] (11:40 - 12:07)
There's this definite, like, the way we behave is different with our medical providers as well. Oops. The way we behave is different.
And so I think that's factored in a little bit to the way that we see this play out in the world. But in studies, yes, there are gender differences, but not with this kind of thing necessarily. Just more women experience this than men.
And I think there's different reasons for that. But it's not like it's not a female condition that way.
[Dara Parker] (12:07 - 12:30)
It might be reporting as opposed to. No, I wondered if there was just like, you know, what I'm sensitive to is that, you know, white men are the standard that we test on. And then we extrapolate from that data and apply solutions to everyone.
So I just wondered, you know, who participated in this study and are there potential differences? And not, not, I mean, my starting assumption is it's not a women's disease, but.
[Dr. David Scales] (12:30 - 12:31)
No.
[Dara Parker] (12:31 - 12:32)
Sounds like maybe we're not there.
[Dr. David Scales] (12:32 - 12:52)
I mean, I think some of these studies, and Dr. Bobby, it sounds like you've looked at them more recently than I have, but I think they were done in like maybe the late 80s or early 90s. So long before they were really, I think, thinking about some of the fact that like white men aren't the gold standard. So it wouldn't surprise me if they didn't give too much thought to that.
And I don't know how much they've been repeated. I do remember though...
[Dara Parker] (12:52 - 12:53)
Yeah, interesting.
[Dr. David Scales] (12:55 - 13:59)
Like one thing is the – Like, I've been surprised it was – Well, about the – In medical school, one of the things that we learned, and I remember there was a good colleague of mine who kind of had a similar background to me of kind of a survivor of abuse. And we learned that the chances of, if someone is diagnosed with IBS, 50% of people, and this was, I mean, this was a medical school statistic. So this is around the year 2000.
50% of people who've been diagnosed with IBS have a history of abuse or trauma. So that's one thing that also comes to mind. But when I think about potential gender differences, there's, Bobby, as you're talking about, like there's different ways that people deal with different types of pain.
I wonder if there are kind of gendered ways in which people might be internalizing some of that potential trauma? I mean, because definitely, kind of when you think about what is the male appropriate way of dealing with things like trauma, like, I'm not sure, but it'd be interesting to kind of know the data and whether or not that's different from how it might manifest in other populations.
[Dr. Bobby Parmar] (14:00 - 15:22)
I was reading a review on endometriosis last week on one of the risk factors for endometriosis, a condition that doesn't really have a very specific home in medicine. It's not only gynecological, it's not sort of just the nervous system. It's like, it's a systemic illness that has been sort of categorized as a gynecological issue, even though it goes beyond that.
And one of the risk factors for this chronic pain condition, again, another pain condition, that's how we look for it. We look for women with IBS that also have heavy menstrual periods with really bad pain. And it's hard to quantify and qualify those kinds of things, but there's this constellation that we look for, and like pain with sex and just pain, you're looking for pain.
And it's hard to diagnose. But one of the risk factors that I was, I've already knew about this, but I didn't know like how concrete it was, was a history of abuse and a history of sexual abuse. And I said, that is, it's this wonderful review that explores like, what happens to the human body when it's traumatized?
Like, how crazy that it may result in this cascade of things that turns into like a pain syndrome. And he's like, of course that makes sense. This person has experienced maybe acute and chronic and severe pain.
Where is that supposed to go?
[Dara Parker] (15:26 - 15:27)
I think the body knows.
[Dr. Bobby Parmar] (15:27 - 15:29)
Yeah, the body keeps the score every time.
[Dr. David Scales] (15:29 - 15:30)
Can I just ask something?
[Dr. Bobby Parmar] (15:31 - 15:35)
Dr. Scales, why, why is this of interest to you? Like, why are you in this world?
[Dr. David Scales] (15:36 - 17:01)
So I, you know, my background is, you know, I was very academic. I've spent way too long in school, but some of that academic is kind of a lot of social science. And so I'm very interested in the intersection of medicine and social science.
And it's one of those things where I think, you know, medicine is, you know, very “scientific,”, in the sense of like, we learn a lot of things through the scientific method and lab and kind of reductionist kind of methods. But there's so much that that perspective kind of leaves out. And everybody in medicine knows this.
But I think that the thing that really gets under my skin is that it's often kind of relegated to the art of medicine. And, you know, kind of knowing how to communicate with patients, kind of knowing how to work with patients who are kind of suffering or traumatized or in pain or patients who don't easily fit in boxes that like, it's so like people talk about it in the medical world as if that's an art and nothing gets under my skin faster because we actually have a lot of kind of evidence and data and social science research that talks about kind of like, you know, even just kind of the illness experience of a lot of folks that go through this, right? The experiences of marginalization, the just the so many aspects where there's a lot of literature and it just gets under my skin so much when I see kind of just like a, if I can't find it in a medical journal, then like, I guess it doesn't exist.
Must be the art.
[Dr. Bobby Parmar] (17:03 - 17:46)
How is that and what you're doing changing now? And I think from my perspective, things seem to start, they started to change with long COVID. I don't know if this is true, but long COVID seemed to happen in real time, like right before our eyes, and that it kind of presented this like a mysterious illness, this mysterious set of symptoms that were happening as a result of this virus that never happened before to humanity.
It was like, oh, look, these people are real and it's happening right here. Is long COVID playing a role in helping with what you just said and helping to like, move things forward in this way?
[Dr. David Scales] (17:46 - 18:17)
It is. I think it's aligning with a little bit of a groundswell that existed before long COVID. So I think long COVID was something that everyone could visibly see.
There was a lot of reporting about it. And I think a lot of people even know other people who have or continue to have long COVID. And I think it gave a spotlight on what at least the National Institutes of Health in the United States are calling infection-associated chronic conditions.
Sorry for the bubbles.
[Dara Parker] (18:18 - 18:19)
Ooh, exciting.
[Dr. David Scales] (18:20 - 19:47)
Party. I think there are some really interesting things that have like, maybe all of these things fall under an umbrella of infection associated with chronic conditions. And those are the things people do believe in, that kind of chronic fatigue syndrome and myalgic encephalomyelitis.
Some people are talking about chronic Lyme as these infection associated chronic conditions that may have been triggered by an infection and leave either some degree of some kind of an immune kind of dysfunction or pathology or something else. We don't really fully understand what's going on. But I think kind of putting those all in a bucket and saying like, hey, we need to kind of care about these and study these.
It's helped align a couple of different, I would argue, social movements, kind of these patient-driven social movements around a number of these illnesses. And especially kind of in Lyme and in myalgic encephalomyelitis, some pretty activated patient groups. Myalgic encephalomyelitis, there's a very strong patient group in the UK.
That's also in the United States. When you think about Lyme, there's very activated communities that have lobbied at least 13 states that require insurance to cover long-term antibiotics, something that's not recommended by the Infectious Diseases Society of America.
[Dara Parker] (19:48 - 19:48)
Really?
[Dr. David Scales] (19:48 - 20:17)
So we have these active, very active kind of advocacy groups for these conditions that I think also got aligned with long COVID and kind of, you know, I don't want to say show them the ropes, but I would say there's definitely kind of a cross-pollination of people learning from each other. And hey, like, we've suffered just like you guys are suffering. Let's work together.
And I think there's a lot that we could do. So that at least my, I'm not part of those communities, but that's my external view of what I see, kind of those communities kind of coming together to do.
[Dr. Bobby Parmar] (20:19 - 21:40)
There's this recent review in immunology that showed that people with lupus have higher levels of Epstein-Barr virus in their B cells than people who don't have lupus. And there's this residual effect potentially in the, I forget the number, it's like four times higher or 40 times higher, something just way higher, substantially higher. And that then allergists and immunologists online were like commenting on this, like, have we found, and it's different when it's like headlines from CNN versus when it's doctors online who are like, what an interesting study.
We are finding that there's this infectious component to an autoimmune condition that is not contested. It is, we know lupus, we understand lupus, but like, could it have been this virus that most of us have at some point, but that in their body for some reason related to maybe their genetics or some other factors, that it turned into this self-attack in the very specific way that lupus shows up. And I think so much more research is being promoted to finding this out, maybe in the same realm of understanding how infections play a role.
Do you think infections play a big role with a lot of these conditions and we just haven't found their sort of Epstein-Barr lupus connection yet?
[Dr. David Scales] (21:41 - 23:59)
I think it's likely in the sense that like, so even something I often say, we are really good in medicine at kind of understanding the stuff that kills you. So like heart attacks, like we're all over that. We study that a lot.
Cancer, we study that a lot. Other things like lactose intolerance, like we don't know much about it, but the little literature that's out there kind of shows that some people just lose it as they grow older, but there's some people who kind of after they've gone through some sort of serious GI illness end up with lactose intolerance for reasons we don't fully understand. So how much these infections kind of might leave internal scars either on the immune system or other things, we don't know.
But I also think it's like there's this problem with illnesses that have ancient names, like lupus literally means wolf, right? Lupus, we're starting to learn it's not one thing, right? So there's probably, who knows, just like cancer used to be a thing.
And now we actually not only, we used to describe cancer by the organ that it came from, like brain cancer, like GI cancer, liver cancer. Now we actually differentiate it. And sometimes there's actually more similarities in treating certain types of cancer that come from entirely different organs because you can use the same kind of checkpoint inhibitors or kind of immune pathways to treat those cancers that come from different organs than how we used to do it, which was basically kind of like, which tissue did it come from?
Let's treat that cancer. So I think we're starting to learn that we need to reorganize the way we're thinking about a lot of these illnesses. And there's probably this whole column of, you know, I don't want to say all lupus, but probably some subsets of lupus, lactose intolerance, a bunch of other illnesses as well that are probably infection associated.
And we just kind of haven't figured that out yet in part because there's like God knows millions of viruses out there and we're getting them all the time. And, you know, doing some sort of study to really conclusively show kind of cause and effect to someone's kind of later symptoms, that's a, that's, those are really hard studies to do. And then do that at a population scale.
So you can really say that like, you know, rhinovirus caused some, you know, later subsequent problems is, is a really tough thing. So I'm excited about the fact that we're moving in this direction, but I think there's just still so much we have to learn.
[Dr. Bobby Parmar] (24:01 - 24:19)
Dara, did you know that like Giardia, beaver fever, that causes lactose intolerance in people? Like you can get Giardia. That's what the, that's the, one of the main infections.
So a person can literally get Giardia when traveling somewhere. And then for two years afterwards, they can't have dairy.
[Dara Parker] (24:21 - 24:40)
I did not know that, Dr. Bobby. I mean, what I don’t know could fill a few medical textbooks. Listening to the two of you, I'm going to bring the superficial pop cultural reference into the conversation. Cause it feels like it's time.
[Dr. Bobby Parmar] (24:41 - 24:41)
Bring it in.
[Dara Parker] (24:41 - 25:24)
It makes me think, it makes me think of House and both the absurdity of that show where, you know, there was always some medical mystery, but actually listening to the two of you, I'm like, right, because so many things are being misdiagnosed or the wrong frame is being applied or the ego of the medical community assumes one truth when there's another, although that show was also driven by ego. Maybe the absurdity of the show is not the premise at the beginning of each episode, but rather the fact that they solved it. Like they almost always figure it out.
Right. There's usually like a few false starts and then House is brilliant and is like, "Oh, but it's this, you idiots." Yeah.
Yeah.
[Dr. Bobby Parmar] (25:24 - 26:15)
David, can I just say, I have a question from that. So if our medical model is, in my opinion, sort of built in this sort of siloed--like, you're here, gastroenterologist, and you're here, rheumatologist, and you're here, endocrinologist--and yet these conditions are breaking down all of those walls, and not everybody has access to, nor are there a hundred thousand Houses, like Dr. House... Does this sort of, like, newer understanding of maybe infections and cancer... is not just this one thing in the brain, and then there's this other... Does that mean that we have to sort of, like, change our model of the way medicine and the medical system and the medical professionals have sort of, like, been trained to stick to their lanes?
[Dr. David Scales] (26:16 - 26:28)
You know, Dr. Bobby, I think to me this gets, you know, Dara, this gets exactly what you're talking about. Like what's great about House? I mean, first from a medical perspective, he's always right, but for all the wrong reasons.
[Dara Parker] (26:29 - 26:29)
Right.
[Dr. David Scales] (26:34 - 26:42)
As a physician, it's a little bit like if you've ever watched MacGyver as an engineer, like way back in the eighties, but engineers would be like, you cannot make a linear accelerator with coffee grounds.
[Dara Parker] (26:43 - 26:44)
Right. Yes. Yes.
[Dr. David Scales] (26:48 - 29:48)
But what Dr. House is--that's amazing--is he's kind of this jack of all trades, master of none. Well, kind of master of them all, in a way, but, like, he's this generalist. He kind of knows a lot about so many different things.
And, you know, in the history of medicine, we've had this kind of like ebb and flow back and forth between kind of like, you know, when you read the literature, there's occasionally calls that say, like, we don't need generalists anymore because specialists are going to solve all the problems. And then like, you know, a couple of decades later, they're like, my goodness, like there's too many specialists. Like, you know, everything's so fragmented.
Nobody knows what to do. We need more generalists. And it really is this kind of pendulum swinging back and forth when you look in the medical literature, because it's like, you know, in the late forties, early fifties, it was all about kind of generalists.
And then that went away and it was all specialists for a while. And then in the early seventies, nobody could get a doctor. And then we're like, so we've really gone through this.
You can almost follow the trends on Google when you kind of look up things like generalists. And it's one of those things where it's frustrating in the sense that why is this a trend? It feels like we should just learn these lessons.
Right. And I think it's where we're kind of starting to see that, like, absolutely, you need specialization, but you also really need to invest in people that kind of cross across these specializations. Right.
And that's not just your family doctor. Right. Because I think your family doctor has often been kind of trained in those silos and they're kind of a specialist generalist.
Right--in all kinds of the amazing category. Yes. But at the same time, you need someone who's probably a little bit beyond that.
The people who are the Houses of like, of like, you know, we can't figure out this case. And rather than sending them to yet another specialist, we're going to send them to these people who really try to dig deep and figure out what's going on here.
And I've seen some really excellent examples, for example, in Lyme disease clinics. Right. Because there's a couple of clinics, one at Hopkins.
There's one in Nancy, France that basically says that, like, you know, we recognize that this is a complex illness and you may or may not have Lyme disease. We don't know.
But come to this clinic and we're going to get to the bottom--and we're going to bring in... Like, we send you for tons of tests beforehand. Kind of, they go through your chart, see if there's anything else that needs to be done.
And once all the tests are back, you come in and they get all the specialists there on that day and you just see them all. They've got kind of multidisciplinary teams talking about it.
We have kind of these models of like, hey, why are we just doing this for these cases? Right. It feels like this is a model here that could really benefit a lot of folks who have these, you know, these conundrum cases that may have latched onto an illness like Lyme disease, but it may be something else.
Right. Or it may be kind of a really complex confluence of a bunch of different things. Endometriosis plus IBS or something like that.
And really kind of try to cut across all of these specialties in ways that it's hard for any individual physician to do on their own.
[Dara Parker] (29:50 - 30:39)
I kind of love this because it speaks to me as a systems practitioner--so, not a health care practitioner, but one who rejects the binary. They're not specialists. It's not generalists--it's both. And then, too, you've introduced this new category of specialists, generalists, generalists, specialists. So we're going to need to rebrand that.
But it really speaks to me that, right, our family physicians are often they're good at certain things, but maybe not at this like next level integration going deeper, but not because they're the, you know, ear, nose, throat person or because they're the lung specialist or the traditional categories of specialization. But actually, their specialization is integrated systems. Like, that's how I think.
[Dr. David Scales] (30:40 - 30:40)
Yes.
[Dr. Bobby Parmar] (30:42 - 30:59)
Absolutely. Like, let's call these people gen specs. Like--so, like, whoever these people are... Is that not internal medicine, or am I off in thinking that that's that label?
[Dr. David Scales] (30:59 - 31:21)
So, Dr. Bobby, excellent question, because internal medicine is slightly different in Canada versus in the United States. In the United States, internal medicine, kind of the identity is essentially kind of a GP, but for adults. Whereas I think I think the internal medicine kind of structure in Canada is a little bit more oriented towards exactly what you're talking about.
[Dr. Bobby Parmar] (31:21 - 31:22)
Right.
[Dr. David Scales] (31:22 - 31:49)
The challenge that I would say is, it's still--I don't necessarily think it crosses over into as many specialties as it might need to. Like, I--there's a little bit of kind of gynecology, gynecology in internal medicine, but it's not... I don't know enough about it, but my impression is that it's not necessarily kind of as deep as it might need to be to kind of be that…
[Dara Parker] (31:49 - 31:52)
just a hint of vagina, but not enough. Is that what I'm saying? A whiff, you might say. Yeah. Okay.
[Dr. Bobby Parmar] (31:53 - 32:28)
A whiff test. So, when--like, internal medicine here is, if not working in the system, right? Like, I'm not in the system, but my patients, if they see a specialist, and that specialist refers to another specialist, and refers to another specialist--and if those three... it's usually like this confluence of three, of like a rheumatologist, an endocrinologist, and probably a gastroenterologist--and then they're like, “We don't know what's going on with you.”
And they kind of disagree with each other on something. They'll be like, let's send you to internal med. That's sort of how it works.
[Dara Parker] (32:29 - 32:38)
And then, does it work properly? Like, why doesn't that work? Is it simply inefficient, or is it not even working when they get it? Because eventually they're coming to you outside the system. So something's not working.
[Dr. Bobby Parmar] (32:39 - 35:34)
And I'll admit the problems with coming to me. So when they're in the system working with these providers, there's a time problem. So a person is suffering.
Like these are debilitated in potentially extreme pain or extreme mental, emotional situations because of their life situation. They're on disability. They don't have 16 months to wait for their internal medicine appointment.
They don't have two years to wait for their punt--like, hunting back to another specialist who, because they haven't seen them in six months, they have to get re-referred. Like, the time it takes these people... So then the flaw is in that amount of time that goes by--eons for this person.
They come to see me and they say, “I've been referred to by this person. I haven't been called. I don't know when this is happening, but it might be in 2029. Not sure.” Honestly, we have two to three-year wait lists for our versions of this Hopkins program. It's a two to three-year wait list.
And that is feral, in my opinion, in terms of what we're doing to people in terms of wait times. But I get it because of funding and who's going to be the House in that position and blah, blah, blah. All of that.
I get it. I get it. I get it.
But then they come to see me and then they say, listen, can I pay you $3,000 to do private testing? Because rather than wait two years, can I do it with you now? And I'm like, yes, of course you can.
I'm not going to gatekeep access for you to get certain lab tests. But then when it comes to contested illnesses, we don't have labs that run those kinds of tests. We have to refer out to private labs that cost $1,200, $1,500 to know if they have an interpretation of Lyme disease, an interpretation of MCAS, an interpretation of blank, fill in the blank.
And then we don't know what to do with that because these are, yes, accredited labs, but they're being interpreted in ways that we aren't used to those interpretations. And then a patient latches onto that result. So then the problem is, do I even run that test?
Do I even run that test in the gap of time the person's waiting, to offer this person something to then work on? That's where I have my... there's a sense of, like, I feel lost in that world of, like... And I tell every patient, I'll be like, “This is how I feel about this.” You can totally go see another provider who will take your money and then you'll spend it no problem.
And then you'll be on antibiotics for two years. We don't know if that's going to do anything for you, but go ahead. But I know that there might be this, like, fault in this process--that even though you want something to show up for you, it may be the wrong thing that shows up for you.
And we're treating the wrong thing for a couple of years while you're waiting for somebody else to get their hands on you.
[Dr. David Scales] (35:36 - 38:24)
Yeah. Dr. Bobby, there's a long COVID practitioner who I really respect who describes what she calls as kind of the Kool-Aid spectrum. And so like, I think you're describing it right here, which is this idea that like, you know, there's the medical system, which has all of its flaws, right?
But even if you did have access to it, like the vast majority of doctors in the medical system, aren't even going to do what you did, which is kind of send people for kind of some of these, these tests, kind of even consider whether or not to send them to these private labs for tests. And you're kind of sitting in a space where you're like, like, you know, sure, that's great when you need it, but there's a lot of problems with that system. So you're sitting here and there's a spectrum in which I'm willing to practice, but then you're also saying there's an edge at which I'm not willing to go beyond.
And this is something that I struggle with in the sense that like, exactly as you're saying, I've got my own kind of vibe sense of like, nobody follows the guidelines a hundred percent of the time, right? Like we know what the guidelines are, but like, then reality sets in and you got to move away from that just because like, people are human and like, they go on vacations and sometimes you might have to kind of prescribe the antibiotic, even though they don't quite meet the criteria because they're going on vacation to Colombia and you're not going to be able to reach them, right? Like there's these real world scenarios where we're kind of breaking the rules, but like where you're, how far you're willing to go on that spectrum and where it essentially becomes quackery, I don't know, right?
I think that's a really kind of challenging thing for me because the thing I worry about is, like, I'm not like a gatekeeper of like, oh, there's only one way to practice medicine. I think, you know, we need to be able to kind of adapt to people's kind of risk tolerances, you know, tolerance of uncertainty, things like that. But then there is, there are kind of malicious actors that are just snake oil salesmen that, you know, you send them a blood test and everything is Lyme disease, that are just trying to make a buck, that think they're helping people, but, I mean, maybe that's how they justified it in their head, but like, but this is what I worry about of like, you know, where people are on that Kool-Aid spectrum. I think it's, whether or not I trust them is a little bit dependent on whether or not they're willing to say no to patients, because that's outside of my level of comfort. I often say things like, when you go to a surgeon, the best surgeons are the ones who don't want to operate on you, right?
Because you actually have more trust in them when they're like, no, this is like, I could operate on you, it's not going to help, right? And so like, Bobby, I don't know if you could talk a little bit more about kind of where, like, how do you find yourself, like, where's your line? Where you say, I'm not willing to, because you say it's, Lyme disease perhaps is one of them, but like, do you have kind of a principle where you kind of find yourself on one side of the line and other practitioners might be on the other side of it?
[Dr. Bobby Parmar] (38:25 - 39:39)
Yeah, so I have a lot to say about this. One thing is, I'm like a naturopathic physician in British Columbia. It's very different in different jurisdictions in my country, and then also in the world.
Like, we are in a different scope here than a lot of other places. Our access to things is quite broad, and so we can do a lot. And so, like, I can't speak to other places in terms of how that shows up, but it's, I know that it's vastly different.
That's one. Two, people. So they have the access to the same labs that they would get from their conventional provider with me. They have access to the same testing methods as they would through their GP or the specialist with me.
They have access to the same scope of prescribing as they would in the conventional system as with me. It's all roughly the same. The one difference is, I'm outside of the medical system here, which means I'm not paid by the province.
It means every time I go to Dr. Bobby, it's... “How do you think I got these lovely fake tulips? This was from your last appointment.”
[Dara Parker] (39:41 - 39:45)
Do I want a free Pap smear, or do I want to pay for my Pap smear?
[Dr. Bobby Parmar] (39:47 - 40:46)
So, there's that element there too, right? So, I can't refer into the system. I have to always figure out, do I want this person to wait for whatever I think they need to do, and then they're going to pay for it, essentially.
But that's one thing. The second--the third is: have I had, and are there, people in my world who absolutely are out for gold? They're gold-mining patients.
All they want to do is offer them 15 infusions in a month, and that's $15,000, or they want to give them fecal transplants done in their basements, and that's $12,000, and they... Yes. Am I deeply ashamed that those people are in my world?
Absolutely. My level of, like, just red-faced embarrassment is beaming when I think about those kinds of people. Do I share a profession with them?
Yes. Do I do this kind of thing to try to offset some of that shame? Yes.
Do I, Todd? Do I?
[Dara Parker] (40:46 - 40:49)
I feel like we've moved into a therapy session, Bobby.
[Dr. Bobby Parmar] (40:50 - 40:58)
Dr. Scales asked the question, so he's my psychiatrist.
[Dr. David Scales] (40-58 - 41:00)
That'll be $50, Bobby.
[Dara Parker] (41:00 - 41:01)
And a fecal transplant.
[Dr. Bobby Parmar] (41:02 - 43:40)
Make it expensive. So that emotionally informs a lot of what I do, and why, for the last many years, I've been doing this for 19 years now, and for the last many years, I'm trying to do stuff like this to, like, encourage more of, like, a bridging dialogue between these worlds, so that we, in my world, get to then learn the kinds of things that we don't actually usually get access to, because we're not part of your world.
So when somebody says, meet David Scales, I'm like, put me on those scales. Let me talk to those scales. So that is very important for me to, like, say yes to these kinds of things.
Four. My line is patient-based. So if, as a person who had an illness growing up--and who wasn't just supported by the system, but basically denied care by the system for decades. I empathize immensely with patient choice of whether or not they want to pursue a direction with you, if they know that direction has uncertainty.
If I'm like, I'm... because do people in my world say things like, you definitely have this condition, let's work on it? How are you saying that?
How are you possibly saying that? You have just gone one step too far, because nobody knows if this person has that actual contested illness, what it is, because we don't even know how to diagnose it properly. So that's a problem.
I've had patients come to see me and say things like, “I went to see another provider, and they said--I just walked into the room, and said, ‘You have Lyme disease,’ just looking at you.” What? What are you doing?
No. So then I have this conversation with the patient and say, we don't know. Do you want to go down this journey with me, knowing that it might end up with you getting a test that isn't actually totally reliable, because nobody’s validated it in the way that we need to, but it might show a positive.
If it's positive, that might mean you get treatment, because otherwise why did we do that test? The treatment might look like a bunch of antibiotics, or a bunch of whatever it is, for a year to two years. Do you want to go down that journey?
And then we have a full conversation of, are they willing to go in that direction? And I'll walk with them along the way. And then we can change at any point.
At any point we can change. Maybe lupus showed up along the way. We're like, oh, it was lupus the whole time.
Actually, look at that. So that's how I try to navigate this very non-binary world of complex issues, because they see me all the time.
[Dr. David Scales] (43:40 - 44:01)
And I can see why Dara goes to you, because I would say most mainstream doctors would love to have the luxury of being able to have that conversation, and the amount of time it takes to walk people through not just the uncertainty, but what that means in terms of the pathway that you might be walking down once you embark on it.
[Dr. Bobby Parmar] (44:04 - 44:53)
I'm in a privileged position to be not shackled to a system that tells me what I have to do, and there's a freedom there. But there's a cost in that it literally costs. That is a problem.
I recognize that as a problem. And I wish the whole system figured this out together, to be like, hey, we see these people, you guys. Like, we're seeing these people.
They're paying a lot of money. We'd like for them not to. So how do we have conversations with you guys to maybe make that happen, and maybe not have it be like Hopkins?
I wish it was just the clinic down the hallway for me, but it doesn't exist that way yet. And I don't know if there's a resistance and where the resistance is coming from.
[Dara Parker] (44:55 - 45:12)
I'm curious about that 19 years into your practice. Do you see shifts in terms of mainstream Western medicine becoming more accepting of naturopathy and its modalities? Or where are we at in the tension scale?
[Dr. Bobby Parmar] (45:13 - 45:16)
Here in this province? Absolutely.
[Dara Parker] (45:16 - 45:18)
Sure. That's our reference point. Yeah.
[Dr. Bobby Parmar] (45:18 - 45:34)
That is absolutely happening. It is a night and day difference from 19 years ago, me being sent letters, calling me a criminal to now, it's “Good catch on my patient. Do you want to go for coffee?”
[Dara Parker] (45:35 - 45:41)
Right. Is it always because you've made a good catch? Or is there something a little more proactive?
[Dr. Bobby Parmar] (45:42 - 46:36)
No, no. It's always because I was able to prove that I'm not out in whatever world they think I'm operating in. Actually, I was doing good medicine.
I just had the time to do it, and I had the capacity to do it. And then I was able to walk with the patient to be like, oh, that's what you have? Let me write a letter to your doctor.
They’re aware now that that’s what your diagnosis is. They should be involved, and they should know what now I've done therapeutically with your case, because they're your doctor. And that is where it gets to like, oh, wow, there's an understanding now.
They did medicine. They did medicine. They just did it in the system that they're in that allows them to do it, that maybe I couldn't, wouldn't, whatever the reasons are, whatever that is, because not everybody can see everything.
[Dara Parker] (46:38 - 46:55)
And it's not how our public health care system is designed. David, I'm curious from your perspective in different geographies, because you work across Canada and the US, but I think primarily in the US, and from the MD side, how would you assess the perception of naturopathy?
[Dr. David Scales] (46:56 - 48:54)
I would put naturopathy kind of broadly in the spectrum of kind of like, if Dr. Bobby, if it's okay, broadly in the spectrum of kind of like alternative providers, right? I'm not going to say they're all the same. I'm not trying to say that.
But I would generally say, when you look at it from that lens, I would say kind of the allopathic medical community in the United States, I think, has come to terms with that. And the evidence, I think, backs this up. That there's... that alternative providers have something to offer.
Even if a lot of allopathic medical practitioners would think things like, you know, Qi Gong or Tai Chi are essentially just a placebo effect.
But there's a lot more kind of acceptance. That's actually an important thing too because if patients feel better, who cares, right? And so I would say in the United States, I think, and I'm separating the United States and Canada, because I think there's one of the major differences I see is in the United States, some of this is consumer driven. Because especially in the places that I've worked, New York and Boston, where there's a glut of physicians, I think physicians feel a little bit of like, well, I need to provide what patients want, or kind of be open to what patients want, because if I'm not, they're just going to go to some other doctor.
So that kind of competition effect has an impact on shifting the culture in medicine slightly. I mean, I'm not saying that like, people are saying, you know, welcome, you know, let's have the, you know, acupuncture conference at, you know, Ivy League institution. That's not happening.
But I think people are kind of like, you know, when it comes to certain conditions, like back pain, and like, you go to your doctor with back pain, and you talk to your doctor about how like, you might be doing acupuncture, you might be doing Tai Chi, yoga, no doctor that I know of is going to scoff at that. Most of them will be like, “You shouldn't be doing that. Like, why weren't you doing that earlier?”
So I think that's been a welcome change. I think, in my experience, in the Canadian- Oh, sorry, Bobby, go ahead.
[Dr. Bobby Parmar] (48:57 - 49:11)
Sorry. It's always weird on virtual calls, you don't know where a person is, where do you get in there. I also ramble, so feel free.
You called it positive care effects in your email. Like, is that what you're talking about?
[Dr. David Scales] (49:12 - 50:46)
Yes. Yeah, because a placebo effect implies that you're not actually giving anything, right? Right? Because when you're giving a placebo pill, that's an inert pill, right?
There's nothing in that pill, it's sugar. Whereas a positive care effect, you're doing things. Like, you might be touching the patient, you might be reassuring them.
Your presence in a white coat is doing something, that you're showing care. And that positive care effect is different than a placebo effect. So I think this is an important… I make a distinction.
When someone's doing acupuncture, and that's why I think I probably even did air quotes when I said placebo effect, because acupuncture, even if you don't believe in the lines of energy or the mechanism of action by which acupuncturists believe that their acupuncture is working, but people feel better after acupuncture, it's not nothing. It's not a placebo. Things happen when you go to an acupuncturist.
You spent time there, you were touched, right? You laid down, you might have had to reveal parts of your body. All of these things in various different literature kind of show that this is a positive care effect.
And the additional thing is on the provider side, no matter what they're doing, when providers show competence, that is actually something that augments this positive care effect.
So it's one of those things where I think it's important for us to separate the kind of--the things that do nothing, like literally a pill with sugar in it, versus the kind of things that tons of literature shows kind of has a psychological, positive impact on people's care.
[Dara Parker] (50:46-50:47)
Interesting.
[Dr. Bobby Parmar] (50:47 - 51:30)
I'll give you an example that I keep in my brain. So a patient that I wrote a prescription for an antidepressant for, I followed up with her four-ish weeks later, and she came back and was like, oh, I'm feeling so much better. I was like, well, that's great.
It's working. So she's like, oh, that's great. Yay, SSRIs.
And she's like, oh, I never took it. I just carry your prescription in my pocket, like the paper. And she's like, something about having it on me in case I want to take it is really helping the way that I'm feeling.
And I was like, oh, oh.
[Dara Parker] (51:35 - 51:35)
Fascinating.
[Dr. Bobby Parmar] (51:36 - 52:06)
Oh, and I was like, well, that's so interesting, because one, you know, we spent an hour talking about using antidepressants and what it means and all of the questions she had. So we had this really great connection on that first visit. I said, you can see me regularly, and I'll see you in a month.
Start this now, and then we'll see how you feel.
And then she... I'm like, that's when you're saying positive care effects. She didn't take anything. She didn't take anything.
[Dr. David Scales] (52:07 - 52:08)
She didn't need to.
[Dr. Bobby Parmar] (52:09 - 52:09)
She didn't need to.
[Dr. David Scales] (52:09 - 53:23)
And this is the kind of thing I think we dismiss in allopathic medicine. Like, in the United States, if you ever go to a federally qualified health center, these are patients-- patients at federally qualified health centers. This is essentially a kind of safety-net clinic. Poor people with government insurance are often going to these places. They're... Fantastic people work there. They're totally strapped budgetarily, and they have really tough experiences. It's like going to a public hospital where, kind of like, you know, the physical plant infrastructure is really poor because nobody has any money to improve it. So it's not the kind of thing that you don't... walk out of a federally qualified health center being like, “That was a great experience.”
Like, you know, there weren't any tulips, Bobby, right? Like, and it's one of those things where I think we actually, I see this as actually a health equity issue, because in the United States, usually the people going to those clinics tend to be kind of poor, Black, Latino, right? And so what we're seeing is we're seeing kind of like, if you want access to this positive care effect, right, then you essentially need to be wealthy in the United States.
Otherwise, you're going to get medicine, but you're not going to feel better. Yeah.
[Dara Parker] (53:24 - 53:30)
Can I ask, is there an inverse effect? Can you have a negative care effect?
[Dr. David Scales] (53:31 - 53:32)
Yes, it's called the...
[Dara Parker] (53:32 - 53:33)
Like, and there's literature...
[Dr. David Scales] (53:33 - 53:49)
We call it placebos and nocebos. And there's studies that have been done that if you tell people that you're going to give them something that's going to cause pain, and then inject them with saline, they feel greater pain than if you tell them that you're just going to inject them with saline.
[Dara Parker] (53:51 - 53:52)
That's the nocebo?
[Dr. David Scales] (53:52 - 54:03)
That's the nocebo. So it's a negative, negative placebo. And kind of the extrapolation of that is the negative care effect.
Yeah, which is like...
[Dara Parker] (54:03 - 54:04)
I guess I was wondering, like...
[Dr. David Scales] (54:05 - 54:31)
Yeah, it comes out with like, if you have an incompetent provider, right, of someone who's just like bumbling through things like, oh, like, you know, it's someone who's like a Keystone Cop that doesn't know what they're doing, even if they really do, and they're actually an excellent doctor, but you just come away with like, who are you and what are you doing? Like, you're just, that's, that's going to kind of like, your, your, your mindset is not going to be, it's not going to be a healing mindset that you're going to come out of.
[Dara Parker] (54:34 - 54:52)
And I was reflecting on some of my negative experiences with mainstream providers, where the interaction is sort of the opposite of what Bobby's just described, where I leave the office feeling worse because of how, you know, assumptions they made, questions they asked me. That's where my question comes from.
[Dr. Bobby Parmar] (54:52 - 55:45)
I'll give you a perfect example of that. It literally happened. So I run an iron infusion clinic, like a few of them, actually. And at the very beginning, three years ago, when we started doing iron infusions, we were like overly, like, listen, you might die from this infusion.
We would, we would, we would say to the patients right before they're getting the infusions, the worst case scenarios, and overemphasize them for both liability purposes. And just so that they knew, like, this is the worst thing that's going to happen. Do you really want to do this?
And then we met with… because we then kept getting negative reactions. And we were like, why are these people having horrible chest pains? And why are they doubled over while getting the infusion?
Like, what is going on?
[Dara Parker] (55:45 - 55:48)
You're running your own clinical trial. You just didn't know it.
[Dr. Bobby Parmar] (55:49 - 57:17)
So I had lunch with the drug maker of the iron, because I was like, I don't think this is right. I think in your study, you are downplaying the number of side effects during the infusion, because I'm seeing way more. And then they're like, they're like, walk us through what you're doing.
So I do. Then they were like, holy shit, shut up. Stop talking.
I was like, oh, okay. What should I say? They said, stop saying they might have an episode of severe chest pain, but that it's transient, and it's not lethal, that they'll feel better afterwards.
And just say they might have a mild flushing reaction. So we start--we change the way our verbiage is. And we don't minimize it. We say it, and we're just like--we just don't emphasize it.
I'm kidding you not. The number of reactions immediately went down to what they saw in the studies and lower.
So instead of having 10, 20 percent of people having crazy reactions to the iron--they're like, “I'm in hives”--it went down to 2 percent, 1 percent. And it was--it blew my mind.
And it's been two and a half years now of having just infusions running all the time with nothing happening. It's so--our minds, our nervous systems, they're so... they're running the show all the time.
[Dara Parker] (57:18 - 58:23)
There's this Canadian author who's a former lawyer and fisher. And I believe Harold Johnson was Cree. He passed a few years ago.
And he talks about stories as medicine, but it's medicine that can harm and medicine that can heal. Right. And it's the nature of the story.
And you're talking about telling different kinds of stories. There's a story that you'll have a mild flushing reaction or there's a story that you'll have a major cardiac episode. We have good evidence of this, the power of story to influence.
I think those are very almost literal examples. But we're part of these broader narratives of what it means to be a queer person, what it means to be a woman, what it means to be Canadian, all these things that inform the stories of our lives, some of which are, I guess, constructed. I guess the stories are often constructed.
Right. We're part of greater narratives than our own. And I just it's an interesting intersection when thinking about the very material impact it has on our health.
[Dr. David Scales] (58:24 - 58:33)
I love that--stories as medicine. I'd love to... I'm going to email you separately to kind of find the name of that Cree person that you were talking about, because I think that's...
[Dara Parker] (58:33 - 58:34)
Well, he's brilliant.
[Dr. David Scales] (58:34 - 58:38)
Yeah. Yeah. I mean, one of the things that grabs me.
[Dr. Bobby Parmar] (58:38 - 59:23)
I don't want to keep you. I know we're at time, but like, I want to do this again because I have so many more questions and so many more questions. I want to do this again.
I have so much more to say, but I want us to end on that lovely note of how you started this whole conversation with things like sociology and the anthropology of medicine and the art of medicine is sort of missing. And then Dara ends on this like it's storytelling that also matters, too. They're both the same.
They're both two pieces of bread, with the sandwich of medicine in between. It's like--it's a lovely way for us to go full circle and that. Thank you so much for joining me.
I appreciate it more than, you know, like we've just met, Dr. Scales, but I appreciate it so much. Thank you for being on Off the Charts.
[Dr. David Scales] (59:23 - 59:35)
Yeah. Well, thank you for having me, Dr. Bobby. You know, I love conversations like this.
I appreciate you being open to kind of conversations like this. And thank you, Dara, for connecting us.
[Dara Parker] (59:36 - 59:45)
I can't wait for part two and our, you know, new podcast series Off the Charts Charts with Dara and David. Love it.
[Dr. Bobby Parmar] (59:46 - 59:48)
Off the Charts Unfiltered.
[Dara Parker] (59:49 - 59:51)
Yes, that's right. That's right.
[Dr. Bobby Parmar] (59:51 - 59:55)
Thank you, guys. Thank you. Take care.
Disclaimer: This transcript may contain errors, omissions, or inaccuracies. It should not be considered a verbatim record of the conversation. For context or clarification, please refer to the original audio or video recording.
