11. Superbugs to kill ten million people…are antibiotics to blame? Dr. Debra Goff sounds off

Antibiotics can be life saving in certain situations. But when over-prescribed, they can be deadly.

 

Transcript

Dr Bill Ferro:  Okay. Welcome to the Quacks and Hypochondriacs podcast. I’m your host, Dr. Bill Ferro. I’m the founder of the BETR Health movement. And with me is my cohost Erin O’Hearn. I am considered a self considered quack and she’s the self considered hypochondriac. And often times her and I have lengthy conversations about how she’s going to die because she stubbed her toe and now she has a headache.

So we thought we’d make a podcast about all these conversations that we’ve had over the years. And there has been many. And so Erin, welcome to the podcast. 

Erin O’Hearn:  Well, I’d say thank you, but I don’t know if those are the appropriate words after that introduction. 

Dr Bill Ferro:  Okay. Well, the hypochondriac part could be very well contributed to the fact that you work in the news and all you do is, you know, they don’t report on a lot of good news.

So you hear  all the things that are going to kill you 

Erin O’Hearn:  Probably, and just the general feeling right now in the world, I’ve been a hypochondriac for a long time. So I don’t want to, I don’t want to point the blame at the pandemic or anything like that. I was the pioneer in the hypochondriac world 

Dr Bill Ferro:  Yeah, no news anchor was just because you wanted to get a leg up on all the things you could be hypochondriac about and you want to be the first to it. 

Erin O’Hearn:  Or I just would have more access to doctors and people who could help me every time I thought I was dying.

Dr Bill Ferro:  Yes. Well, the conversation always, I pick up the phone. Well, you don’t call you text. So text is usually good things. And then if the call comes, I know the opening lines going to be. Can I just tell you something? Can I just say something and, and can you be serious for one moment while I tell you this?

And then it’s like, here it goes. And then of course I’m never serious for that moment, but no, 

Erin O’Hearn:  we get through it and I’m still here. So 43 years and still chugging along. 

Dr Bill Ferro:  Exactly. Exactly. Well, I am incredibly excited about having our guest, Dr. Goff on.  She’s an infectious disease specialist.  She’s been named by the world health organization to be one of the  25 global advocate experts who are helping healthcare professionals and leaders and lower and middle income countries implement an anti-microbial stewardship.

She’s a Ted talk speaker, a mentor. She’s actually a photographer. And Erin, you guys are going to bond. Wait till I tell you the thing – triathlete.

So yeah. 

Erin O’Hearn:  Oh, I can’t wait. 

Dr Bill Ferro:   She doesn’t just talk the talk. She runs the walk and bikes the walk. So this is really important to us. And as you know, I’m a gut health nerd and antibiotics, and you know, I’ve been talking about this for many, many years. We had Dr. Wischmeyer on about COVID-19 and the use of probiotics to help people prevent going into ventilation mode, even mortality, just by using probiotics in the ICU with people like SARS.

That was an episode that people absolutely love. And we talk about this. We touch on this topic, right? We always say things like the overuse of antibiotics. That’s what are we, when we say that’s what’s led to this, but we’ve never had someone to really dial in on that. I had the fortunate, the ability to actually listen to her Ted talk.

 So without further ado, welcome Dr. Goff to the Quacks and Hypochondriacs podcast. 

Dr Debra Goff:  Thank you so much for having me. I really look forward to the discussion we’re going to have as I can see the two of you are quite lively.  Not the typical people I interact with every day in the hospital setting.

So I welcome this opportunity.. 

Erin O’Hearn:  I’m glad you, you considered me lively, which means alive, which means I’m not dying, which I usually think I am

Dr Bill Ferro:  the only judgment I might have the question for you doc is. Why you would agree to be on a podcast named Quacks and Hypochondriacs?

Dr Debra Goff:  Well, let me tell you, I did research you before I agreed to be on this. As the title had me a little concerned that our university has guidelines on what we can and cannot do in public media. So I did check that out before I agreed. 

Dr Bill Ferro:  Okay, well welcome. Welcome, welcome. And the frame of this is there is an epidemic of overuse of antibiotics and you have made it your life’s mission to educate and help people be a good steward.

And the definition of being a good steward would be an example of someone who knows that our ocean is important to us, and they have some responsibility in making sure that ocean, maybe it’s commercial fishermen, not throwing their nets in the line or people drinking, not using straws. Stewardship means we have something that can help people, but we also need to conserve it and use it in the right fashion. When you talk about being an anti

Dr Debra Goff:  you can say antibiotic steward because the public doesn’t know what anti-microbial even means, so we’re not using it anymore.

Dr Bill Ferro:  Yeah. So describe to us second what it means, but first why, how did you, what was the, what was the tipping point? What was like, Oh my God, this is an epiphany that changed, you know, changed your life and why you needed to make this, your mission.

Dr Debra Goff:  Sure. So when I started my career, my biggest challenge as an infectious diseases, clinical pharmacist was trying to keep up with the multitude of antibiotics being FDA approved every year.

That was the challenge. There were  you know, there’s many different classes of antibiotics. And one is considered cephalosporins and there was literally a cephalosporin a month, almost trying to keep up with them and how to differentiate them. You know, do we need to use these in our patients? That was the biggest challenge, but then over time, and really, I would say in the nineties, we started seeing escalating rates of antibiotic resistant infections and pharmaceutical companies stopped manufacturing and developing and creating clinical research in antibiotic drug discovery because it’s not profitable. They’re the dumbest drug to invest in because if you think of it, the more we use an antibiotic, the less effective it becomes. So if you’re a business, is that the product you want to be developing? And the answer is no, it’s not profitable. So they’re smart companies. They stopped developing in doing research in infectious diseases.

And so our pipeline for antibiotics got less and less as antibiotic resistance started going up and up. So when the two collide. You are in a crisis. And the crisis is I see patients where they have an infection that is untreatable. I have nothing in my toolkit to treat them with it’s fully antibiotic resistant and a lot of those patients die.

So I work in an academic medical center and we have a lot of oncology patients and there’s nothing more kind of the aha moment was when you have a patient who had a successful bone marrow transplant, there are one month recuperating. They beat cancer. The family is so happy. They’re so blessed. And then they acquire an antibiotic resistant infection during their recovery. When their immune system is really low and that patient dies, they did not die from their cancer. They died of an antibiotic resistant infection acquired while they were recovering. And that to me was when I said, this is a crisis because this is going to happen more and more.

And now it’s every day. So that is where really in the beginning of 2000, it was just clearly an identified healthcare global problem, and really became very passionate about what I call antibiotic stewardship. The word stewardship just means overseeing something worth protecting, and that something is an antibiotic.

Dr Bill Ferro:  And in that vein, when you started thinking about this.  Do you use the term did you have come up against resistance? 

Dr Debra Goff:  Absolutely. Because when you start looking at how are we using antibiotics in my own hospital? And, you know, you saw a lot of things that were just not appropriate. And the study that was, quoted in USA today which led to this invitation you know, that’s a brand new study done by our CDC and over 190 hospitals and it showed 50% of the antibiotics in 2015 are not prescribed appropriately.

They’re either not necessary. They’re the wrong dose or the wrong duration that is pathetic.. And so imagine back in 2000 when you were starting and you could identify all these opportunities of need for improvement, you know, why are you starting this patient on an antibiotic? And the answer I would routinely get?

Well, just in case they’re infected, which actually led to the title of my Ted talk. So I heard that over and over again, and I think the challenge and it remains the challenge today until you see the consequence of your prescribing, that there is a negative impact on the patient. You will never change what you’re doing because your perception is it’s helping the patient.

And that’s what antibiotics are. They’re a feel-good product. People think they make them feel better. So we have consumers that pressure doctors to give them antibiotics, because I don’t have time to be sick. I have to go to work and that’s one component of it. And then you have physicians that have been prescribing them and passing them out like candy bars.

That’s what I say,  for decades and not really realizing the consequence of that. And there’s a lot of consequences that we can talk about. So changing that behavior is not something that happens overnight.  Something that you’ve been doing for over a decade and you perceive it to be appropriate.

You’re not going to just turn that off in a day. So, you know, changing behavior takes time and there’s actually a science behind it and it’s difficult, but that’s what an antibiotic steward does. 

Erin O’Hearn:  Dr. Goff, the reason I loved your Ted talk so much, and, and obviously your approach to this whole topic is because as a society right now, and as a culture, we’re either anti or for like anti or pro.

So everything is one extreme or the other. And I’ve heard a lot of people, including some doctors, but mostly people in the healthcare industry or in the health industry say antibiotics are no good. You shouldn’t take antibiotics. And what was so fascinating about your approach is that you were not saying that antibiotics are bad.

In fact they can be lifesaving, but when they’re abused or used in the wrong way, that’s when there’s a problem. And again, like as a society, we’re all or nothing. Right. So I don’t think you’re not advocating not to use antibiotics. You’re just. Asking people and doctors and patients to use them in the appropriate way.

Dr Debra Goff:  Absolutely. I mean, they are absolutely lifesaving miracle drugs. I mean, we can go through  treatment of pneumonia and it was a fatal disease decades ago and it’s a hundred percent curable now in some countries that still have effective antibiotics. So I’ve worked on both sides of the story. And when you try to change or influence people’s behavior, the first step is you have to listen to why do you do what you do?

And so if you just preach at people, you should not use these antibiotics. This is not right. They tune you out immediately. And you know, we see that in society with political differences. You know, if you don’t agree with me, I don’t want to talk to you and you just yell at each other and nothing is accomplished that way.

So if you really want to create change, you have to first be able to listen to each other and have a conversation, or you, we will never succeed. And so I’ve worked a lot in my career with surgeons because they do prescribe about 50% of the antibiotics in a hospital. Rightfully so, you cannot do a surgery without an antibiotic given before the surgeon makes that first incision it’s called prophylaxis.

You know, you can be a young woman and if you need a C-section and do not have an antibiotic, there is a very high chance you’ll die post-operatively so antibiotics are part of a surgeon’s necessary toolkit to do surgery. You need an antibiotic, you need skilled surgical hands and you need tools to do the incision and the operation.

And without one of those, it’ll be a poor outcome for the patient. So surgeons need to use antibiotics, but the challenge comes in. Do they use the right antibiotic and do they use them for the right length of time? And are they using them postoperatively for actual infections or what I call just in case?

You know, when you have a patient that had a surgical procedure postoperatively, they can have a temperature. And it doesn’t always mean they’re infected, but when someone has a fever and the kind of knee jerk reaction is, well, I need to make that go away. So let me give him an antibiotic. Cause maybe it’s an infection.

And as a surgeon I’ve learned, you have, tell me why you’re prescribing these for 14 days. I don’t even know what it is you’re treating. Cause you didn’t obtain any cultures to identify if the patient’s infected, I don’t know what you’re doing. So you explained it to me, me, and that is where the dialogue starts.

And then when they explain it, you know, you’re right. I, I really didn’t get any cultures, but I’m concerned they might be infected. And so just in case, that’s why I prescribed it and I go, okay, but now let’s look at, could you actually be harming them the patient? And then I explain the harm that is done every day you keep a patient on unnecessary antibiotics. And the one that resonates most with surgeons is the development of a very potentially lethal form of diarrhea called C diff Clostridium difficile. And that when it escalates becomes a surgical medical emergency. So C diff when it develops into a foam and a case, it literally can have the patient’s colon explode.

So you can only imagine what harm occurs to your body. If that happens and you get what’s called a syndrome called sepsis and you can die. And surgeons are the only ones who can correct that problem. It’s a surgical emergency. So they very much understand that. So when I explained to them every day, you keep a patient on an antibiotic, whether it’s necessary or unnecessary, their risk of C diff escalates and you create a microbiome dysbiosis and you disrupt that.

And they understand that. So when I provide factual data, because working at a university hospital, we keep track of every adverse event from an antibiotic. So C diff is publicly reported by hospitals in the United States. And that’s a data, that’s a number I can obtain and actually show the surgeon. Well, your number of patients, this is how many have had this occur and, you know, facts don’t lie.

So when you can have a reasonable conversation, that’s, evidence-based to say, you know, there’s actually harm occurring from this. So let’s have a discussion. How can we change this? And so that is my approach, not just telling them what you’re doing is wrong and we’re going to change it. No one wants to hear that conversation.

Dr Bill Ferro:  So it’s interesting so Dr. Wischmeyer we had on from Duke has said that C diff cases just keep climbing. He has an interesting story cause he had gut health issues when he was 17. And so, you know, it really became part of who he is. And to that end I’m just curious. So why don’t they just have a videotape of you, of your Ted Talk at every you know, medical university right now to stop the bleeding.

Right. I know we have to get out to those that are not educated. Is that happening? Do you see in the universities, they’re now speaking about this and talking about it because in some of the folks that I have met, some of my medical doctor, friends that are younger, they do kind of know this already, right?

They know not to do this, but do you see that as this part of the new medical curriculum to teach people, to teach the new doctors coming out about this? 

Dr Debra Goff:  It is. So I find it very interesting when I talk to physicians. And I remember when we started our antibiotic stewardship program formally. In the early two thousands and you would say, Oh, I’m doing antibiotic stewardship.

They’re like, what is that? I’ve never heard of it. And that’s still true today. Now in 2017, all Us hospitals are required now to have antibiotic stewardship programs. But that doesn’t mean they’re all effective programs. You know, you can kind of gain the system. And if you have a committee that meets for an hour a month, you can say you have a stewardship program.

You know, to me, that’s a crime. You were only doing this to assure responsible use of antibiotics and that we don’t harm patients. And so you have to engage everybody in the discussion and there are necessary programs. And you know we have to teach this. At a early stage. So I actually teach it to children.

My daughter is a grade school teacher. So during antibiotic awareness week, I go to the sixth graders and teach them about responsible use of antibiotics.  I believe you have to start that young. And so in medical school, pharmacy school, nursing school, everybody has said, we need to do this, but I can absolutely guarantee you, it is not being taught in every Us medical school, pharmacy school or nursing school, which is wrong.

So it will eventually occur, but the younger ones do seem to have a little bit more appreciation for it. But, you know, we have a lot of healthcare providers that, that aren’t young and unfortunately they’re the most senior people in the hospital setting who kind of dictate what is done and not done. So I really since I am not 20, I am closer to the age of those more senior people.

And that is what I do. I sit and talk with them because I’ve been in the field for a long time. So I know what it used to be like. I know how they think, and that’s who I try to connect with. Cause it’s got to start at the top and move down. So I do a lot of that. Look, I know you’ve done it this way for 30 years, but give me a chance to explain to you why we need to change.

We’re doing this for our children’s children. So I asked them, are you a grandparent? And they’re like, yeah. And I go, so what happens if your child gets otitis media and it’s a bacterial infection  your grandchild, and there are no effective antibiotics orally to give your grandchild.

And they have to be hospitalized now for that infection. And they acquire a healthcare. So a hospital acquired infection and now have to be on IB therapy and heaven forbid there are no effective antibiotics and your child just has the consequence of now deafness. And you know what that resonates. You have to give stories that are real and people can relate to.

So if you don’t want to change your behavior, I tried to go, well, what would, and any grandparent as, I’m a brand new grandparent of a nine day old baby.  You, , see that change occur and I’ve watched it in a CEO of a pharma company. I’m not going to name which one, but, they fund a lot of our research in infectious diseases.

The few that are still out there that discover new antibiotics and you know, really didn’t fund a lot. And I would not say in my opinion was real committed to this area until his grandson ended up in a neonatal intensive care unit with a drug resistant infection and was close to dying.  And fortunately, he survived, but I watched that CEO turn on a dime.

And what is the biggest advocate of antibiotic stewardship? So it’s those personal stories, you know, it may not be you personally, but it’s your grandparents, your parents, your child that will be impacted by antibiotic resistance. And that’s when people realize this is a societal problem. It’s not just about controlling antibiotic prescribing, but it’s got to start somewhere.

So, you know, starting in the hospital setting changing that behavior of prescribing more responsibly is where I started. 

Dr Bill Ferro:  This is tough for the patients out there. And then people that listen to this, and that’s why we actually do this podcast is because if the stewardship is also for the patient to go in there and tell the doctor.

No, I don’t want to take that. You know, you said earlier that they pressured the doctor. Well, they’re pressured because they’ve been indoctrinated by the doctors. And to get antibiotics right now, we’re asking him no, no, no. Sorry. And  if they quit, if someone questions anything, now they’ll say, well, you’re a quack.

You just do you have a medical degree? Do you work at CDC? And that’s what does make people hypochondriacs. Because they say, how can I believe what’s coming out of these studies, especially if they are being funded by pharma, where are the stakeholders? So it does lead the person on the road, like, Oh, who do I listen to?

How do I know the information I’m getting? And in this scenario, we’re talking about critical use case of antibiotics to the other side of that is okay. You’re not sure  as a. You know, a person listening to this that I can go and convince my doctor that I shouldn’t have this, or shouldn’t have this.

And is it affecting me here because it’s not just the use of antibiotics, right? This isn’t our food chain system. This is what they gave to animals, right? Yeah. Animals can, can, and then it was for growing them. Like the point of saying is now that to bring it back to the kind of that the microbiome itself and the preventative measure making people aware that, Hey, you know, should doctors should not be prescribing this.

So in case I need it in a critical works for everybody, but secondly, what, what are the other consequences of not having good gut health? I do a live call and last night people, tons of anxiety, tons of depression. And I go back and say, well, can you think about when you were younger? Yeah, I was actually always ear infections.

I always had strep. I was a C-section baby right now, these things that used to be quackery are now like, Hey, actually, once your microbiome is off, if you don’t replenish it, you are more predisposed. Can you weigh in on, on what you think of the, kind of the conceptual process of keeping yourself gut healthy, keep it gut healthy so that you are, have less critical need for these things.

And if you do, maybe they’ll work better. Is, that even a thing you’ve you promote? 

Dr Debra Goff:  It is. Yeah. So you touched upon some really great points. I’m working now with a neonatologist who has done this  research on terms of the impact of giving a neonate and antibiotic. Oh my gosh. In the last five years, we’ve learned if you were exposed to antibiotics early on and many neonates, when they’re born if your child spikes a temperature, it forces the doctor to do this infectious disease workup for sepsis, which can be life-threatening in a neonate.

So they have to give them antibiotics until they can prove they don’t have a bacterial infection. But, but what happens is a lot of times they give the cultures that tell you if they’re infected with a bacterial organism or not, we’ll come back generally in two to three days, but the neonatologist will often extend the antibiotics unnecessarily, just for fear of maybe I would be missing something.

So the person I’m working with has done many studies to show. You can shorten that course once you have the definitive diagnosis and stop them, because what we’ve never known for years in the neonate, was there a consequence to the child for giving longer therapy? And the answer now is absolutely. Yes, you create a dysbiosis.

There’s been linkage to obesity in children, exposed to antibiotics early in life.  Development of asthma. There is so much, we are learning about the impact of giving antibiotics early on. And so again, you know, it’s a balance when you have a baby that spikes a temperature, they need antibiotics.

 And that’s a behavior change that currently is not standard of care. So that’s an area that I’m working on with my neonatology experts and trying to change the behavior and to just kind of circle back about. You know, pressuring the doctors to prescribe antibiotics in the hospital setting.

I’ve never had a patient pressure us for an antibiotic they’re in the hospital because they’re really sick and many of the antibiotics are justified and we need to give it to them. They’re life saving, where we have opportunities for improvement is in the duration of antibiotics we’ve learned shorter now does equal, better, less side effects, less dysbiosis.

So we know shorter courses and many infections are equally treated or equal successful outcomes. If we give five days instead of 10 days, which was old-school.  But I used to believe early on when I started doing antibiotic stewardship, if I could just get the antibiotic use right in my hospital, I’ve got the problem solved and you began to learn.

 Remember I work at a very large diverse university.  I get this email one day about joining the one health antibiotic stewardship program. And I’m like, what is that? So this was several years ago and it was from one of our veterinary professors. And it’s like, what is he asking me to be part of this support?

And that I started. So this was like 10 years ago. And I learned I go to this meeting with veterinary medicine, food and agriculture experts, environmental experts, myself representing human medicine. And we sit at this table and one health antibiotic stewardship is the intersection of human antibiotic use.

Animal antibiotic use and environmental antibiotic use. And my eyes were wide open. We spray our Apple orchards with an antibiotic that we use in humans. We give our animals a ton of antibiotics because it fattens them quick. So they go to slaughter faster. I mean, it was just like an explosion of new data and now I’m fully invested in that.

So you’re absolutely right that there is an animal to human transmission of antibiotic resistance. And there is a connection between all of this. So as a provider of healthcare  I know how to become an antibiotic steward, but what I teach everyone is we all need to be an antibiotic stewards. So you can support restaurants that serve antibiotic free chicken and antibiotic free meat.

And I tell them you have a plethora of choices. So when you go in, you ask, Hey, could you just ask the chef of certain antibiotic free meat? And the waiter might look at you like, Oh, I don’t know. And then I educate them in two seconds. I go, you know, it’s important to me and it really should be important to you.

Let me just tell you why. And you know, I have a lot of restaurants to pick from, so just let the chef know. I think it’s important. And now we have a plethora of restaurant chains like Panera  that serve antibiotic free chickens. So consumers do have power in this, and you have a voice because you can choose to spend your money where you want to spend it.

So that’s what I teach people is it’s not just, you know, shaming doctors in a hospital for prescribing too many antibiotics or shaming doctors in the outpatient setting that are pressured by patients to prescribing antibiotics and in defense of the physicians. When you’re in private practice and you have patients coming to you and you don’t give them what they want, guess what they do.

They go on social media and go, don’t waste your money going here. They rate you with one star on Yelp and you can’t ever erase those. So, you know, I understand that that’s a business so it’s a, it’s a balance and you have to figure out how to balance that.

But we know the CDC already told us 30% of antibiotics in the outpatient setting are unnecessary,  

Erin O’Hearn:  You’re just going to have to hold on a second because I’m on this podcast because I’m a hypochondriac. So I’m going to back need to back up for a little bit, because you actually touched on the story.

That was pretty personal to me. I am a mom of three, but my first born when she was five weeks old, Spiked a fever. So she went and got the workup done, and unfortunately they missed the spinal tap three times and she had hematoma and her you’re remember this doctor. She became a Toma and her in her back and they automatically put her on the antibiotics.

And then we, what should have been like a 48 hour or deal turned into a two week ordeal with going in and testing for all sorts of viruses and really not being able to identify what it was. And we had a whole infectious disease team come in. And while they said that the white blood cell count wasn’t as high up to indicate meningitis, it was, it was elevated.

And their conclusion was the reason it may have not been elevated to the point of indicating meningitis was because she had already started the antibiotics. So now you’re going to have to stay here because we can’t find a virus essentially that’s causing the fever. So she was on antibiotics for 14 days at five.

So from five to seven weeks.  And of course now you’re telling me all the repercussions and she’s almost 12 now. And I’m sick to my stomach, but  I mean, she’s a perfectly healthy child. She’s smart. And she’s you know, fortunately she’s not obese. I mean, we have a pretty healthy diet in our house, but my question is, so they thought that I was in, I was in a really precarious situation. Right. And I, I do think this is important to tell all your parents about, because especially with everything going around, babies do spike fevers, and it is important to get them to the hospital. What, in your opinion, should the parent be advocating for not to start the antibiotic until there is a clear diagnosis in this case, is the just in  case method the way you go.

I mean, it’s easy. It’s a little bit easier when you’re dealing with yourself, but when you’re dealing with a fragile newborn and you’re a new parent, and you know, your world’s turned upside down because they’re telling you she could have a life threatening illness. It’s a really hard situation. 

Dr Debra Goff:  So I very much relate to your story because my son at day five of life, I had this nice, healthy baby that I was home with spiked attempt.

And I went through the exact same thing you did. So I have my own personal experience with being on the other side of the stethoscope is what I say now. I’m the parent in the ICU unit, and I knew exactly what was going to happen. And because I have a lot of knowledge of the side effects of the antibiotics, my son was going to be on.

 I was in absolute panic mode and it was just a very frightening scenario.  But I’m glad your daughter and my son are both healthy. And, but that spinal tap and the antibiotics, let me address that. Nope, in a neonate, a newborn child, the first two months, if you spike attempt, your child is getting what we call a rule-out sepsis out, meningitis workup, it’s the spinal tap and antibiotics.

So the challenge. Why don’t we give antibiotics and wait, because we’re trying, and to make that definitive microbiology diagnosis of what bacteria is causing this, or what virus is causing this. So back when my son was in the ICU, the microbiology component to answer that question for a doctor is not real good.

And it takes, you know, there, there’s only a couple of viruses that can be identified, but we know there’s hundreds of viruses in the world. And actually there are next to zero antiviral medicines to give. But in terms of bacteria, you can definitively diagnose that. But the cultures,  the testing takes a microbiology lab.

Several days. You can’t make organisms grow fast, that you just can’t do that. But what has changed is we now have what’s called rapid diagnostic microbiology tests. Now, not all hospitals have these available, but they are allowing it is so that they’re expensive. It always comes back to money. Or every decision I think comes down to money.

So we have these rapid diagnostic tests and we can rapidly identify within hours. If it’s viral or bacterial and actually what the organism is, which then allows me to direct the appropriate antibiotic therapy. So that’s been a real breakthrough. And so, you know, what you described was exactly what my son went through.

And back then the duration of antibiotics was that 14 days, the neonatologist I’m working with he’s world renowned, published the definitive study that says you no longer need to give that many days. We thought you did.  But when you have what your son and my son or your daughter, and my son experienced is what we call culture negative sepsis.

They never grew anything. You don’t know why they spiked this temperature in those patients. He showed in a very well done study, published in the most prestigious international journal called the Lancet infectious diseases. You can treat for five. Oh my okay. Five days. Now let me assure you. Every neonatologist does not know about that study nor do they do that.

Yeah. So that is, is something we are actually doing a study right now. How do you change the behavior and get that new information into the hands of everyone? And so it takes time and, and you have to really hold their hand to go. I’ve done this. So he’s older neonatologist 30 plus years into his career.

And, you know, he is such an authority figure, but. Others still question, you know, are you sure you can do this? I’m so afraid. I’ve always given 14 days or 10 days. And you know, you don’t want to miss it in a baby, you know, but there’s now studies, his study is just a landmark study and you know, I’m, I work a lot globally.

So I work in South Africa and it’s actually a study we’re implementing right now, trying to take his expertise and that study and take it into South Africa with their network of neonatologist and change that down there. It’ll be unbelievable. So quite exciting. But yes, that’s a big change from what you experienced and myself

 Dr Bill Ferro:  so the crusade I’m on is I’m trying to teach people how, how important our gut is now and with their kids. And it just start teaching early and using fermented foods and make sure you have an Apple because the fiber, you know, I think it’s interesting to tell diabetes to person shouldn’t eat fruit. It’s like no healthy fiber going to my guts.

So the probiotics could live. I mean, you had to start them out while you’re at it, create more inflammation, more insulin resistance. And we try to let people off the hook like this is not your fault. Our world has been toxics toxified over your Santa’s box has put you in this position, it’s affecting everything from anxiety to your inability, to, to basically regulate your weight.

So the concept of the question for you is if I go in for, let’s say knee surgery, when I’m done, I have this rehab on my knee. If I go in for X, I have this rehab therapy. Do you think that anyone that’s prescribed an antibiotic in a snare should actually go on a gut healthy rehab, if you will, X prescribe six weeks to help them repopulate after, because when you give an antibiotic and I, right, it kills off just about everything.

You know, it tries to target, but ultimately, do you think there that you see in the future that we will be doing both, Hey, you’re coming in for surgery, let’s do four weeks of gut healthy prep. So you’re less likely. And your post let’s do four weeks of gut health, post therapy.  And you know, do you think that’s impactful and something they see feasible?

Dr Debra Goff:  I absolutely do. And we’re seeing, you know, the, really what I call cutting edge orthopedic surgeons that get it. You know, it’s a way to market yourself separate from everybody else. I mean, there’s tons of them out there. So why go to one versus the other? And it’s interesting. The infectious disease physician that I work with, she was a dietician.

And before she became a physician and she got tired of every physician just dismissing the value of nutrition in a hospitalized patient. And so she said, I, you know what I’m done? No one listening to me. So I’m going to become a physician, but at age 40, she went to medical school. And she’s amazing.

And we do everything together and yeah. So she’s one of the rare physicians. And once she went to medical school, she’s like, Oh my God, no wonder why physicians blow off nutrition. You get a one hour course and you’re supposed to be like the expert at it. They learned nothing and well, very little I should say.

And so it’s not their area of expertise, but the microbiome people are understanding that I find. So I worked with a surgeon. John Alberti he’s head of surgery at University of Chicago. That man is the total package. He’s an outstanding surgeon. He understands infectious disease and his passion is microbiome.

He has an entire microbiome lab. We connected over Twitter in just such a unique way. And so he invited me as a visiting professor and I spent the day in his microbiome lab watching, and he like yourself believes it’s the connection to cancer, every inflammation, disease, and you know, how many people have rheumatoid arthritis, all these issues that if you could get their gut microbiome in check they wouldn’t be so much healthier. So I do believe the microbiome is an  area that medical schools and pharmacy schools are going to start with teaching. But again, you know, you need champions to push this agenda and medicine. This is very traditional. I mean, it takes, you know, if you’re sort of an out of the box thinker, which I am, you don’t fit in.

And you know, people are always like, what are you doing now? Like, why are you on social media that is absurd?  Because you can reach a larger audience and it’s amazing what you can learn from each other. And so, you know, medicine is very, very traditional, very slow to change.

And sometimes that’s really good. I mean, you don’t want to quote, experiment on patients and give them new therapy that you don’t have a clue if it really works or not. And I think that’s what COVID taught us. Oh my God. It was terrifying at the beginning that nobody knew how to do anything. So, you know, we threw antibiotics at everybody.

And now we know that, I mean, we all knew at the beginning COVID is a virus. The antibiotics will never work for that, but we were so desperate in that fear of doing nothing just drove antibiotics for everybody. And, you know, I don’t, we don’t apologize for that. At the beginning of COVID, you know, you have a 30 year old dying in front of you, their chest x-ray had bilateral whiteout.

Maybe they had a bacterial infection. And I know I can treat that this other thing called COVID. We don’t know what we’re doing. So COVID really taught us so many valuable lessons in medicine, but it forced us to think outside the box, like we had to analyze things literally in real time, every day, and it taught us the value of working collaboratively together.

No one person could manage a COVID patient and you had to rely on other people to help provide the care. So as a pharmacist, we were reviewing the drug therapy for COVID 24 seven. I mean, he couldn’t keep up with it. You go to bed thinking hydroxy, chloroquine. That’s what we need to give them the next day.

Nope. Dial it back. We don’t give that now. And you know, it’s like it changed by the second and it still is.  So I think we’ve learned some really good things from that.  

Erin O’Hearn:  So, you know, being now that I’m in my forties and I’ve had, I did have a lot of antibiotics as a child.

I had strep throat a lot and every time we’d go on vacation and we’d get the sniffles, like the pediatrician would give my mother a thing of antibiotics, so I relate to the just in case  approach. And, but now that I’ve learned that my daughter had only had to be on antibiotics for five days as opposed to 14.

And I aged 20 years in the interim. What can I, what can people like myself do who had a history? And, you know, in addition to being a good steward, right? To ensure that I make better decisions for my kids and in myself, if I’m ever put in those situations, but what can we do to sort of repair what damaged and may have been done in specific, you know, specifically to gut health?

Because I feel like that’s within our control, because if you look at food as medicine, it’s right in front of us. So what are some things I can do for my daughter? What are some things that I can do for myself to sort of repair that damage? 

Dr Debra Goff:  So repairing it you know, that takes longer when you give someone an antibiotic, whether necessary or unnecessary your gut microbiome.

We’ve done studies to show it’s disrupted for up to a year. Now think about that one full year, but you know, many patients need antibiotics. So you just have to accept that. And I am one of the believers in probiotics to help repair that. But there’s, you know, because they’re unregulated in the United States, they’re considered a food, not a drug.

There’s a lot of garbage on the market and, you know, people, we, we actually did one study that showed how do people pick a probiotic. They picked the cheapest one on the shelf. And let me tell you, you get what you pay for.

 It’s a slippery slope, just like vitamins, you know there are studies to show lots of supplements.  They will do a chemical analysis. And what they say is in the product actually is not in the product. So it’s an UN regulated market. Unlike FDA approved drugs. And so you have to be very careful and sometimes people will go, I’m taking this product, you know, what do you think about it?

And I go, I can’t give you an opinion because there’s no data available on it. It might be really good and it might be totally worthless. I really can’t give you an opinion if it, if you feel like you’re, whatever you’re taking it for is getting better. Yeah, that’s probably a good thing. So, you know, there’s a lot of reluctance by healthcare providers to recommend things that you really don’t have a lot of factual data on.

So I’m always cautious in making sure patients understand that. So, you know, there’s not a fix for everything.  But I would say the most important thing is, you know, strep throat is a bacterial infection that needs an antibiotic. So the first step, when you start feeling your throat hurt and you’re getting quote your strep symptoms, there are rapid diagnostic tests that a doctor can do to say, yep, you’ve got strep or you don’t. Now, this is where the skill of a person comes in. There are some rapid diagnostic tests that just like we saw with COVID rapid diagnostic tests. They’re not that good. They’re the cheaper tests. And they’re cheaper because they’re not that good, meaning 40% of the time they will have a false outcome of report.

So it’ll say you’re negative, but you’re actually positive. So, you know, you gotta be careful. And a consumer is not going to know that, but the office or the doctor, or, you know, the pharmacy that’s providing the rapid test, they should know, are we providing the best test to make this diagnosis? Or are we providing the cheapest test that 40% of the time isn’t accurate?

So there are differences there, but you can ask for a rapid test and now you have a definitive. Nope, you do not have strep. And we use a really valid test. Therefore, I’m going to give you over the counter medicine, have you gargle with salt water and you’ll probably be fine, but if your symptoms escalate, then call me back.

So it’s kind of a watch and see approach. So there are ways to handle that, that, you know, the technology and microbiology has improved over time that we are getting better at that. 

Dr Bill Ferro:  So our approach is we’d tell people, if you could ask anyone in the street, you know, what’s your diet like, they go, I eat pretty well. There’s very few people that don’t tell me that. And then I say, okay, yeah, but for whom, right? Because their information is it’s calories in calories out. I know what to do. I just don’t do it. Well, they say things like I have a sweet tooth or it’s my genetics. And I say, well, that’s interesting because 99% of your gene expression comes to your microbiome.

So probably not.  And then what we tell them is like, you have to figure out what foods work best for your body, reduce the inflammation and the bad thing about bad bacteria is it grows fast. Right. And that can overtake you. But it grows fast for good bacteria too. And so repopulating the lining can actually happen much quicker, much faster.

You get such a great benefit from. So in our organization, what we do is we help people meal plan around foods that are high fiber, good count caloric density, water. We make them  weigh in every day, take pictures of their lunch, their dinner, sleep, energy moods. They have all these data points to actually see the outcomes of what’s happened because we can’t see what’s going on in the lining.

And then we give some foods that, you know, have good probiotic abilities like kimchi, sauerkraut, kombucha,  and then we watch. And what ends up happening is in our minds is that they start to reduce the inflammation. The body starts to feel in a state of bees.

It starts to target. Fat and turning into energy, their mood changes. Their anxiety comes down. Their cravings for bad food goes away cause they’re handling anxiety better. And then their cravings for good food increases because they’re now getting a more diverse microbiome and microbiome is responsible for craving better food.

We do sell a supplement that has a probiotic. The only reason why I added that in a few years ago is because what you said is people who are coming to me and say, which one should I choose? And they’d go, they’d go get, you know, taken at GNC, back with all these bottles. And so finally I just was like, I’m just going to find a good probiotic, good reparable and give it to them basically a cost.

So they stop this. But I always tell them, without this food, this probiotic, we’re going to have very little, it’s like throwing seeds on a desert. You really need the other things to go with it because otherwise there’s nothing to spend to eat on the inflammation will we’ll tear it up. And in this old getting back to the overuse of antibiotics system.

Oh, and lastly, it was through elimination reintroduction. We helped them figure out what works best for them, for broccoli. It’s one person for cauliflower. It could be the person who cooked, but how critical is it truly in terms of our life? Like all eyes are on COVID right now. Cause it’s, you know, killing and destroying lives.

What’s happening now, statistically. And what will happen in the future? Just statistically, if we don’t get a handle on it, because as you said, people need to relate to this story. How critical is this for us? And how many people, how many lives are being taken because of antibiotic resistance and how many will it continue to take?

But we don’t do something 

Dr Debra Goff:  yeah, so globally, it’s 700,000 people a year die it’s projected to be 10 million by 2050, if we just stay core first. So we are in a silent pandemic. I traveled the world, obviously not right now, but,  I work in a lot of low middle income countries.

I’ve been in hospitals across six continents to actually see there are hospitals in many countries. There are no antibiotics available to treat the patient with nothing works, nothing. There is nothing you come in with that diagnosis you die. And so their rates of resistance in these hospitals are far higher than ours.

 One hospital in South Africa that I was working in and their neonatal unit I watched multiple babies die during my few days there from antibiotic resistant infections that they acquired and there’s no effective antibiotics to treat them with you just watch them die. It was heartbreaking. So that will be the United States.

It will come. Everything’s a plane ride away. So we are in a silent pandemic. This has been going on, but it’s a slow pandemic where COVID like, hit us with like a fast moving train that we went from normal to shut down. And you know, but antibiotic resistance is like that slow dripping water. So you just kind of tune it out after a while.

Cause it’s been dripping for so long. You don’t want to listen to it anymore. It’s been occurring, but you know, it’s going to be a flood gate pretty soon.  It’s already there in countries.  And it’s in our country. You know, I, I try to tell people it’s higher in other countries for multiple reasons, but it is in our country.

It’s in your backyard. You might not know it yet, but I watch college students come to our clinic with their first urinary tract infection and have to tell them there’s no oral antibiotic that will treat your urinary tract infection. We’re going to have to put an IV PICC line in you. And you’re going to have to come here every day for an IV antibiotic.

And these young women look at me, you gotta be kidding me. Like, how did I get this? And that’s what happens. You know, you can be healthy, but you get exposed to an antibiotic resistant pathogen by eating meat. That’s contaminate. I mean, there’s many ways you can enter, you can have that enter your gut, and now you get a urinary tract infection.

And now you’re infected with this super bug that’s untreatable. So it’s happening everywhere. And we have a lot of work ahead of us to do it. So my goal is educating people, getting them informed to just always ask, is this antibiotic necessary? And the answer is often going to be yes, but then ask. And so you know, I call them the football scores, the seven, 10, 14 day durations.

Are those still necessary? And we know in many infectious diseases, the answer is no, we have proven studies, but everybody doesn’t know that yet. So as a consumer, as a patient, those are reasonable questions. You’re not trying to be Dr. Internet and tell your doctor, you know, I got on Google and learned, you know, this. These are responsible questions that you should ask your doctor and it’ll just make them pause to go. Is this antibiotic you’re prescribing for me necessary? And you know, hopefully the answer is going to be yes, and this is why. And then you listen and then go, okay. So you’re prescribing 10 days is 10 days necessary or would five be enough? And these are discussions. I think anyone could have it’s it’s not confrontational.

You’re not trying to tell a doctor how to be a doctor.  But we all need to listen to each other. And I think if we’re all in the discussion, it’s better. 

Erin O’Hearn:  There is one more thing I want to add in this is I think what you know, Dr. Bill has been advocating for it for so many years, is that one of the reasons that people are so quick to ask for an antibiotic and maybe I’m wrong, but what I’ve seen from friends and family members is that they don’t feel like you said, like they don’t have the time, or they just don’t feel like feeling sick.

Like they want to get out of that. They want to get out of them. They don’t want to have a sore throat. They don’t want to have a headache.  They don’t want to feel tired. So then they automatically think this is the quick fix. But if I think one of the ideas behind better is it’s when you’re on a regimen of constantly treating your body the right way.

When you do get sick, when you get a virus, you are going to handle it better because you’re just, your body is better equipped to fight whatever it is, that’s invading it. And so if you really, the whole just-in-case argument should be used towards diet and our lifestyle as opposed to antibiotics.

Dr Debra Goff:  Right. But our society doesn’t like that. I mean, right now, the number one risk factor for COVID bad outcomes in hospitalized patients is obesity. I mean, that’s what we’ve learned one year into this. If you’re obese, if you get COVID, your odds of a bad outcome are much higher.

So, you know, it goes back to being responsible for your own health. And so many people, you know, we’re a medicine driven society. I have diabetes, well, I’m not going to change my diet. My doctor just gives me sugar pills. I mean, that’s what they want. They don’t. I mean, we see these patients in the hospital.  

Dr Bill Ferro:  Let me challenge you on that because this is what I’ve been trying to tell our patients is that, potentially the harm that we’ve done to the people by the overuse of antibiotics in our food chain, we basically toxify them when you’re toxic and you have inflammation, you have insulin resistance, you gain weight.

It’s not a mind over matter thing anymore. Your cravings crave bad foods. So oftentimes I’m the champion of the patient saying, listen, this isn’t your fault. We keep telling them they just want a quick fix. No, the doctors want a quick fix. That’s why they gave us this stuff at the beginning with the patient would rather not have these medications.

I see them all the time, but they get so stuck. Now they’re down the vicious cycle road right now. They’re like, okay, just give me the pills. They want to change their diet. They want to live healthy. But every time they do, they’re told to count calories, flip tires and parking lots. Right. Stress themselves out, you know, mentally, emotionally make them feel terrible, which only creates more cravings and stress and their microbiome isn’t even there to support the proper function.

So no matter what they do, it’s going to get harder and harder over time. If they actually just focused on nourishing their microbiome, all of this stuff gets easier over time and they’d be less predisposed to these two COVID. I mean, we’ve set this up, we’d be right for this, this type of opportunity. So I think that it’s twofold approach here is that the doctors and all of us as a movement have to wake up and say we would design to thrive given the right environment.

If I plant a tomato plant and it doesn’t grow in two weeks, I don’t start yelling at the tomato plant to grow.   We don’t let ourselves off the hook. We keep yelling at each other. Well, the doctors don’t know what they do, and the patients won’t listen.

And the experts is a quarter of a million books written on diet and nutrition. It cannot be right and they cannot be wrong, but just not be right for you. So taking  matters into your own hand is really just about educating and empower you, power you to understand, like you just said, we can’t just take these antibiotics anymore.

 That is, unfortunately, the damage has been done. It’s been done in more ways than just having you know bacteria that don’t respond to antibiotics anymore. It’s also causing this pendant of anxiety, mental health issues. Our immune systems are so depressed. And as you just mentioned, then it causes weight gain.

That’s the outcome symptom. And that symptom is the one that predisposes you Doctor Wischmeyer with Duke was saying someone gets into his hospital within 24 hours. The bad bacteria literally takes over the microbiome. It signals all of its bad friends and takes over. And so if you go in there already, already depressed microbiome, your chances are lower than you had an inflammation in the weight gain.

We have to educate that this can be solved, but it doesn’t have to be solved in a hard way to be solved in a way which is changing. What’s going into our bodies, what type of putting on our skin. And when we do get sick, when we do need those antibiotics, they will actually do something, right. 

Dr Debra Goff:  I mean, that’s the problem we’re in now.

We are literally running out of effective antibiotics and it goes back to, you know, educating, why are we doing this? And creating that behavior change. I’m doing an initiative right now, dental antibiotic stewardship. So there’s this longstanding issue with orthopedic surgeons when they put a hip or knee in, they tell patients. Every time you go for a dental procedure, you need antibiotic prophylaxis. And then the dentist gets that patient in their office and they’re the American dental association said, no, that’s not evidence-based, it’s not correct. And there’s harm in giving people antibiotics. And so the ADA says, no, that’s not right.

And the two, the patient is the one stuck in the middle of getting different conflicting advice. So we actually brought them together in one room. This was before COVID and had a dialogue, a community, what I call a grassroots effort, let’s talk to each other and let me understand why you do what you do.

And let me understand why you do what you do. And I’m going to tell you as an infectious disease expert, what I think is the best approach. So it was all about risk versus benefits. So an orthopedic surgeon doesn’t want that hip or knee replaced because unlike a wound infection where you get source control.

You can’t just take out the implant and go put a new one. If it gets infected, it’s catastrophic to the patient. So even though the risk is less than 1%, they will give those patients antibiotics for life. And they still recommend that to this day. Right. And you know, we’re teaching them, there’s a consequence, ask a patient, who’s developed C diff from an, a single dose of an antibiotic.

And they will tell you how life altering that is to have their gut microbiome disrupted. You can’t work. When you have C diff you have explosive diarrhea multiple times a day. I mean, it might be like most people go, they get diarrhea. I’m sorry. If you work for a living. You can’t work when you have C diff, if you’re a healthcare provider, you can’t go into a hospital.

If you’re C diff positive. I mean, there’s so many things I could discuss about that, but there’s all a relationship, as you said, by what you put in your body, we need to be more responsible and we can’t just keep blaming each other. So that’s where one health, you know, the farmers were blaming the doctors.

Well, you’re the ones that prescribe all the antibiotics. Doctors blame the farmers. If you’d stopped giving them to animals. And now we’re at the same table. That’s what a one health committee does is let me understand. I’m not a farmer. Why do you give them? It doesn’t even make sense to me. They’re not infected.

And you know, I learned so much, you can’t isolate one cow. So if one cow gets an infection, you got to treat your whole herd. And now I start understanding, and of course there’s economic ramifications. So, you know, the, the rationale is different in each discipline. But until they hear from me, what you’re doing on farming is impacting patients.

And that could be you, or it could be your parents or your grandchildren. One day, that’s sitting in my hospital with an untreatable infection because we all want to try to blame each other. And that doesn’t, it has not worked and it will not work. So if we can listen and learn, we will see there’s value in all aspects of this.

Be careful what you put in your body. It definitely makes a difference and you have to be responsible for your own health. And I think our discussion today has given our audience some good ideas on how they can be more responsible for their own health and that’s a good thing.. 

Dr Bill Ferro:  Yeah, absolutely. And you know, you mentioned earlier, like it’s always about the money, right?

The decisions are made about, Oh yeah. You’ll be happy to know, like the way we’re covered by health plans is value-based care. So we actually only get paid for hitting milestones, like five, seven, 10% drop in A1C, because I knew that I would not have a fanfare enough to get all the studies. It would take us years to prove that how about just give them to us at our expense.

We’ll take them through this food, this medicine approach and watch what happens. And then we started charting it. And the reason why I bring up the point is Blue Shield of California now is starting to give us not only pay us to work with the clients, but they’re giving the clients dollars towards healthy food service.

So we have a meal delivery service they’re actually piloting this. And what we found is astonishing because people don’t think they can afford to eat healthy and gut health. And so we get them started on this pathway. None of that, actually, I can do this and Oh wow. My cholesterol dropped I’ve come off this medication, that medication, my pain, my fibromyalgia is going away. So I do think in medicine and the time is perfect for us in the healthcare. We realize our costs are out of control. We’re losing lives because we don’t have the medicines being overused. This wills that, that new dollar, which may have been only in the farmer, like the prescription pharma was the dollar.

The new dollar is how can you prevent these things and how you save lives and save costs at the same time. So I think we’re in a beautiful era of this healthcare system. That’s going to this value-based consumerization of healthcare driven, more community. And the work you’re doing is outstanding.

We are committed here at BETR Health to promote and keep talking about this on our Tuesday night calls, we’re going to put education into our pathway around this will make your TEDx talk. Actually, one of the great pieces of education that we send to them. And we are just so appreciative. I know you’re very busy and I’m going to let Erin stay with the last word, but before she does. Just thank you so much. Continue the work and we’ll do our part here to make this part of the BETR Health movement and part of the Quacks and Hypochondriacs family. 

Erin O’Hearn:  Yeah. Thank you. And congratulations on your grandchild. 

Dr Debra Goff:  Thank you. Fun. Great talking with you guys.

Dr Bill Ferro:  Well, thank you for listening to that the Quacks and Hypochondriacs podcast, as you know, we’re sponsored by, I think it’s the number one health and lifestyle brand in the world.  Said it will be the number one lifestyle brand on Mars. It’s called BETR Health,. You spelled it betr health.com.

Thanks for joining us. My lovely cohost Erin O’Hearn, and thank you so much. And that was a very powerful episode. And thanks again for Dr. Goff for joining us. And until next time maybe you rate like us. Write a little note to us.  All right. Thank you to Earfluence for making this podcast happen and we’ll see you next week.

Full Episode Transcript

Dr. Debra Goff is an Infectious Disease clinical pharmacist and founding member of the Antibiotic Stewardship Program (ASP) at The Ohio State University (OSU) Wexner Medical Center and Professor of Pharmacy Practice in the College of Pharmacy in Columbus Ohio USA.

Dr. Goff is a TEDx speaker on antibiotics “just in case” there’s infection. She is the Program Director for the South Africa Train-the-Trainer Antibiotic Stewardship Mentoring Program founded in 2012. She received the 2019 Ohio State University Distinguished International Outreach and Engagement Award for her work in South Africa. Dr. Goff is one of twenty-five global experts selected by the World Health Organization (WHO) to implement antibiotic stewardship programs in low-middle income countries. She works globally in hospitals across 6 continents. She lectures nationally and internationally and has over 150 publications. She uses Twitter (@idpharmd) to increase global engagement, educate and increase awareness of antibiotic resistance.

Visit our sponsor, BetrHealth.com, a gut healthy, effortless, food-as-medicine approach to whole person health . Try BetrHealth risk free at https://betrhealth.com/risk-free-trial/.

Quacks and Hypochondriacs is hosted by Dr Bill Ferro and Erin O’Hearn, and is produced by Earfluence.

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