Editor's Note: In this segment of Medscape One-on-One, Editor-in-Chief Eric J. Topol, MD, interviews Zubin Damania, MD, a practicing internist who uses musical parody as a clinical teaching tool and to bring attention to the concerns facing practicing clinicians. Performing under the name ZDoggMD, Dr Damania has used music to broach many topics from conveying the need for a more humane approach to end-of-life care to the frustrations of using a less-than-intuitive electronic health record (EHR) system.
After spending 10 years in the "Hard Doc's Life" working as a hospitalist in the Silicon Valley, he was lured to Las Vegas by Zappos CEO Tony Hsieh, a former classmate of Dr Damania's wife. There, Dr Damania founded Turntable Health as part of Mr Hsieh's $350 million investment to revitalize downtown Las Vegas.
Turning Medicine Into Musical Parodies
Dr Topol: This is Eric Topol, editor-in-chief of Medscape. I am very excited today because I have the chance to visit with Zubin Damania, who is one of the most talented people in medicine—a rarified talent—and it will be fun to figure out how you got there.
As far as your medical training, at least part of it was at Stanford, is that right?
Dr Damania: My residency was at Stanford.
Dr Topol: What about your music background? Much of what you do today (when you are not practicing medicine) is musically anchored; where did that come from?
Dr Damania: I have always been a kind of histrionic—a drama queen. I always have to be the center of attention. When I was a kid, I played electric guitar in a vain attempt to improve my dating life. It didn't work at all, and I had very minimal talent. I went to Berkeley and knew that I wanted to study medicine, but I also loved music and I loved Weird Al Yankovic. He was my hero, strangely enough. It was also not good for my dating career to be a big fan of Weird Al and have his posters on my wall. So I ended up doing a music minor and a molecular biology major. With the music minor, I got to play drums on the quad and practice guitar and really learn music theory. With molecular biology, I got to hang out with the guy who brought his own folding chair to class so he could sit in front of the front row because that was how competitive pre-med was at Berkeley.
Dr Topol: You are up on all the (latest) pop music—everything from Katy Perry to Jay Z to Kanye. You are into all of this stuff, right?
There is no song that we will not parody. None.
Dr Damania: I love music, again, to my wife's chagrin, because in the car I will be playing everything from Garth Brooks to Ice Cube, and it gets a little ugly. There is no song that we will not parody. None.
Dr Topol: Including country western?
Dr Damania: I did a Garth Brooks song, "Friends in Low Places," called "Friends With Low Platelets." "Blame it all on my labs, these bruises and scabs; is it normal to bleed when I floss?" I expected it just to be a lot of fun, but mothers of kids with idiopathic thrombocytopenia purpura and other platelet disorders were emailing me, saying that for the first time their kid feels like they have an anthem, and they are playing it at school. I thought, "That is beautiful."
"Ain't the Way to Die"
Dr Topol: You have done some amazing parodies of music. One that was relatively recent was about the end of life. Tell us about that one.
As a hospitalist for 10 years in clinical practice, I would see, at the end of life, that we really torture people. We don't have the discussions in time.
Dr Damania: As a hospitalist for 10 years in clinical practice, I would see, at the end of life, that we really torture people. We don't have the discussions in time. Patients are undereducated, largely because of our failure to take the time to educate them and the failure of primary care, in general, to connect in our current model.
So I wanted to do something, and I thought that we should make it really funny and make fun of this very serious topic. As I started writing, I realized that it was not something that lends itself to being funny. I thought, let's take the Eminem/Rihanna song, ("Love the Way You Lie,") which is a very emotional song about domestic violence, and let's just translate it ("Ain't the Way to Die"). This is a kind of institutional violence that we inflict on patients and on our loved ones when we don't have these conversations about end of life, and so that is how that song came about. When I was rapping the lyrics, they came very quickly. My colleague, Dr Harry Duh of Kaiser Permanente (a pediatrician), and I both feel very strongly about having end-of-life conversations. He deals with sick kids, so it is very poignant for him, as well.
Dr Topol: In that example, it wasn't even just the music. It was actually the message of that music and what it would bring into medicine.
Dr Damania: That's right. If you watch Eminem's original video, it is very moving. Things are on fire, and it really signifies a very painful, abusive relationship. When we made our video, it was the same thing. It was an abusive relationship within a healthcare system that is paid to do things to people, not necessarily for them. I played the patient and the doctor, and the doctor is very conflicted. I took a Hippocratic Oath, and yet here I am causing harm. That was the message we were trying to convey.
Dr Topol: Was that the only serious song that you have done?
Dr Damania: It was, although the one that was just released—"EHR State of Mind"—has a lot that is funny in it but is also an anthemic cry for vengeance against crappy software, outdated technology, and how we need to be moving into the future with electronic records, not stuck in the kind of DOS-based prompt that we get. That is a mix of serious and funny.
Dr Topol: How many of these videos have you produced?
Dr Damania: One hundred and ten, not that I am counting.
Dr Topol: I have only seen a small fraction of those.
Dr Damania: And you are very lucky because most of them are absolutely horrible, especially the very early ones.
Doc With an Alter Ego
Dr Topol: You go by ZDogg. How did you get the name ZDogg?
We feel so disempowered in medicine, right? We talk so much about patients being disempowered and not having an individual say. I think doctors are in the same boat.
Dr Damania: ZDogg came about when I was trying to come up with a name. I was really burned out at the end of my career in hospital medicine because half of the patients that I saw didn't need to be there, and I didn't have a voice. We feel so disempowered in medicine, right? We talk so much about patients being disempowered and not having an individual say. I think doctors are in the same boat. We are treated like cooks practicing algorithmic medicine. We are disempowered, we are paid in the wrong way, etc.
I said I am going to do this thing on YouTube because of my love for music and Weird Al and teaching. I want to reconnect with my passion. I went to the chair of my department and said, "I would like to do this," and he said, "You would like to lose your job, then? Because that is the most horrible idea I have ever heard." And I said, "What if I create an alter ego? They may never know." And I reached back to the 1990s and my love of Snoop Dogg and decided I should just be ZDogg. It has got to have two Gs because one G is necessary but not sufficient to be a gangsta. Two Gs, and you are done.
So it was ZDoggMD. I put it on YouTube, and that is how it was started. It was a cry for help, and I did it against medical advice. In Canada, I am ZedDogg, which is actually 30% cooler.
Dr Topol: One of the songs I remember is a Katy Perry song, with snoring or sleep apnea. What was that?
Dr Damania: The original song was "Roar." ("You're gonna hear me roar.") And I thought, or Snore. We redid it, and I played guitar. We did an acoustic, unplugged version, basically. "At night I bite my tongue and hold my breath. The decibels I make can wake the dead." The idea was to raise awareness of this problem that a lot of people don't understand—"My partner snores so much it keeps me awake," but this can actually be a medical crisis and shorten your lifespan.
"This Stuff Writes Itself"
Dr Topol: You have this mixture of both comedy and music, but you can really sing.
Dr Damania: Let's put that in air quotes. I can sing okay, but Auto-Tune helps me dramatically. Certain things that are in my range I sing well, but if I am trying to sing a Taylor Swift song (we did a version of "Blank Space" called "Blank Script," about prescription drug abuse), there is a lot of Auto-Tune, and I don't do that song live because it just gets ugly.
Dr Topol: But the comedy is awesome. What is the funniest song that you have done?
Dr Damania: There are a couple that I love; these are my "director's choice." "The Confrontation," which was a parody of a Les Miserables song called "The Confrontation," between Javert and Valjean. We have respun it as a confrontation between a hospitalist and an emergency department (ED) doc. There is a scene where they are circling each other in the ED, and each of them is shouting at the other typical characteristics of their specialty. The ED guy is wearing spandex and climbing Machu Picchu, and the hospitalist is mentally obsessed with labs and trying to block admissions. It is epic.
The other one I love is "Readmission," which was a parody of R Kelly's "Ignition." That one is just such a perfect fit. "It's my tenth readmission, I am not the sharpest clinician cuz I thought a CHF patient ought to eat Kentucky Fried Chicken." It writes itself, Eric.
Dr Topol: That was my favorite. I lost it during that song. It was just amazing. Now, these are big productions. This is not just you doing it alone. A whole bunch of other people are involved. This is better than Hollywood. How do you do this stuff?
Dr Damania: I fooled you, then, because it was mostly me until the last three or four videos. Now we have a very small crew, and we get extras from around the country. People will actually fly in if I put it on Facebook. They will be like, "I'll be there." It is great because it is now kind of a thing. We now have a crew called Variables of Light out of Las Vegas. They get me. Their director is married to a nurse practitioner. It is a perfect synergy. Now I have a team to bounce ideas off of, whereas before it was me with a Handycam and a green screen and Final Cut editing.
Dr Topol: But you write the songs.
Dr Damania: Most of them are written with my partner, Harry Duh, who helps me with the lyrics. Sometimes I will crowdsource lyrics from Facebook. Nurses are amazing at writing lyrics, and they will come up with that perfect line, and I will just pop it right in with absolutely no credit to the nurse.
Dr Topol: Some of these are actually done in the medical setting, in the hospital or wherever. Do you actually go into the hospital and clear people out and say, "We are taking over?"
Dr Damania: We are very deep friends with our local county safety net hospital, and they have been absolutely lovely. They rally the troops. We can use their facilities. We shoot on the helipad. It is actually moving to see that level of support from people who are so busy.
Motivating the Elephant
Dr Topol: Traditionally, publishing articles in journals, the usual way that you effect change, is trumped by something like this. It is not only remarkably entertaining, but it actually gets to people. This has more power to change people's minds and behavior (particularly in medicine, which is not so easy) than many other things that we do.
Dr Damania: I am a firm believer in that philosophy. The Heath brothers have a book called Switch about how you change behavior. They use a metaphor of the elephant, which is our heart, mind, motivation, fears, and emotions, and then there is the rider who sits on top and guides the elephant. He is about [2 inches high], yet he is our intellect and strategy and planning. Guess who wins when there is a conflict? In medicine, we are very good at confusing the rider and yelling directions at him, but we don't motivate that elephant, and we certainly don't make the path easy for them.
So what ZDogg tries to do is motivate both. Let's talk to the intellect, but let's get that elephant dancing and moving and remembering and get a song stuck in your head. The next time someone drops in front of you, and you are thinking about CPR, the first thing you remember is the song. ZDogg did a parody of Usher's "Clear" because it was exactly 100 beats per minute. You think, "I don't have to do mouth to mouth, because it is gross, and so I will just push on the chest hard and fast and call 911."
We did a One Direction parody called "One Injection" about the importance of flu shots, and we played it for the company Zappos, at their all-hands meeting. They were all dancing. Year over year, they had a 30% increased uptake of flu shots, largely because part of the message was that you can make vulnerable people sick by not getting a flu shot, even if you are going to be okay. You can kill a baby or an elderly person, and so you should do this. That motivated their elephant. That is how we work.
Dr Topol: Do you see that more of the impact is with consumers rather than the medical community?
Dr Damania: The opposite is what I have seen, Eric, because I think I speak the voice of the tribe of medicine. If I could wave a magic wand, I would love to broaden it more because what I find is that activist patients—e-patients—who have a stake in healthcare are big fans. Physicians, nurses, and EMS providers are all big fans. What I would love to reach is the lay population, which means that we have to broaden our appeal.
Mixing a New Model for Primary Care
Dr Topol: Well, you are building up. You are ready for this, and the level of quality and the creativity keep soaring. It is an inevitable track that you are on, and that is what establishes you as being truly rarified. There is no one like you, Zubin.
Let's go to this other part of your change, which is in the medical sphere. This is more traditional for the Medscape audience. You are trying to change medicine, not just through these videos but also through Turntable Health in Las Vegas.
Can you tell me a little bit about that and also your relationship with the CEO of Zappos?
Dr Damania: Sure. When I started making the YouTube videos, it turns out that the CEO of Zappos, Tony Hsieh, went to school with my wife back in the day. So I had his email address, and I would send him my videos because I thought, "This guy understands how to get into people's heads and cultures and those kinds of things." He never responded, and I just assumed that it went into that billionaire stalker box that emails go into. I am sure you have one, Eric, being a superstar. I need to get one just to pretend I am a superstar.
Dr Topol: You will have one.
Dr Damania: One day I got an email, saying, "Hey, I have been watching your videos. You need a restraining order. Something is wrong with you. I would love to have dinner."
Dr Topol: He really wrote that? You need a restraining order?
Dr Damania: Something to that effect in a Tony voice. He came by and said, "Here is this thing we are doing in Vegas. I am investing $350 million of my own money curating the development of downtown Vegas. We are moving Zappos into the heart of it, and I want you to quit your job at Stanford and have your wife (an academic chest radiologist at Stanford) quit her job and move your two little girls from Palo Alto to the heart of downtown Las Vegas. I will give you a little startup money, but you have to figure out how to make healthcare better." Then he drops the mic and walks off.
And my jaw drops. I Google "healthcare innovation in Las Vegas," and the first hit is the Hangover Heaven bus, and I thought, not with $3 billion could you do this.
Dr Topol: The Commonwealth Fund ranked them, among places for quality of healthcare, at the bottom. Out of 50, they were 48 or something like that.
Dr Damania: You are being too kind, honestly. It is really a tough situation. There is not a big academic presence; it's very fragmented. Take everything that is wrong with our healthcare system in America and magnify it. There are good people there, trying to do their best, but it is absolutely hard to do. There are 2.5 million people, with no sense of cultural identity of their own, but downtown was starting to improve.
We only spend 4% of our healthcare dollars on primary care and prevention. In the hospital I am seeing the failure of primary care and prevention, so let's double down or triple down on that.
I ended up taking the bait. We moved to downtown Las Vegas, and we studied the problem and said, "We only spend 4% of our healthcare dollars on primary care and prevention. In the hospital I am seeing the failure of primary care and prevention, so let's double down or triple down on that. Let's make it a flat fee—a membership model, and let's partner with somebody who knows how to do it—Iora Health, Rushika Fernandopulle out of Cambridge, Massachusetts. They had built these pilot clinics, and they were using this great model.
Health coaches were drawn from the community, hired for empathy, and trained to do motivational interviewing and other things. They were driving the care, and the doctors went from room to room practicing at the top of their licenses. It was really brilliant. I said, "Let's make an iPhone that runs your app," so Turntable Health then allows anyone to sign up with a credit card, or an employer can pay for memberships for their employees, especially self-funded employers, because they have so much skin in the game. The third party is the insurance plan—Nevada Health Coop, a not-for-profit, member-owned company, started with Affordable Care Act funds. They said, "We will pay your membership fees and wrap catastrophic insurance around you and put it on the exchange so people with no money can get federal subsidies to use you." So it was egalitarian across the board. It wasn't concierge, no copays, unlimited access, yoga studio, teaching kitchen, health coaches teaching classes—yoga, meditation, and nutrition—and it has been amazing. We opened about 2 years ago in downtown.
Dr Topol: In just 2 years, it is amazing how much you have been able to accomplish and set up a whole new model.
Dr Damania: Well, you know what finances the whole thing, Eric, is a meth lab that we put in the back. People ask me what happened, and I say, "We broke bad in 2013, and it has been uphill ever since." I still have all my teeth, though, so that is a start.
The Jon Stewart of Medical Parody?
Dr Topol: You are doing something that is very unique. You are on an arc that is having progressively more impact, and I think it will have even exponential impact. I think that is in the cards. Where do you go from here, Zubin?
Dr Damania: Our next step is to work with Iora to spread this model throughout the country, and it is already happening—Medicare Advantage in Phoenix, in Washington State, and in multiple clinics across the country on exchange-based plans. It is going to be transformative for primary care.
On the ZDogg side, which is my super passion, I will make more videos with better production that address the bigger picture of healthcare in the United States. On top of that, we are talking about starting a little YouTube-based show called something like "Against Medical Advice" like a Daily Show or Colbert Report but for medicine. I would love it if you would commit to be my first guest.
Dr Topol: Sign me up.
Dr Damania: We will break the Internet, Eric.
Dr Topol: How much of your time are you putting into the video production side?
Dr Damania: Too much, according to my team at Turntable; not enough, according to my team on the video side, so a lot. Probably one third of my time is spent on videos. And I am traveling and doing addresses and keynote lectures. That is part of the evangelizing.
Dr Topol: Congratulations on what you have already accomplished. You set a whole new path in the medical world, and it has already had a pretty stunning effect. You are destined to stay on that path. You certainly fulfill my idea of one of the most interesting people in the world of medicine, and I look forward to watching your progress and your videos.
For those of you who have not seen ZDogg's videos, you have to tune in because they are quite amazing. Zubin, thanks so much for joining us and thanks, all of you, for being part of the Medscape series, One-on-One, with some of the most interesting people in our field.
Dr Damania: Medscape represent.
Check out all of ZDogg's song parodies and other videos on his YouTube channel.
