Episode Transcript

Daniel Lobell: (00:00)
This podcast or any written material derived from its transcripts represents the opinions of the medical professional being interviewed. The content here is for informational purposes only, and should not be taken as medical advice since every person is unique. Please consult your healthcare professional for any personal or specific needs. Welcome to the Doctorpedia podcast. I am Daniel Lobell and joining me on the line today is the wonderful Dr. Doug Walled. Dr. Walled – how are you?

Dr. Doug Walled: (00:28)
Hey, Daniel. I’m great. Thank you. Thanks for having me.

Daniel Lobell: (00:30)
I’ve gotten to do a little research on you. I have so many questions. I’m excited. I don’t know anything about what you do. I know that you work in radiology – as far as I know that has something to do with Spider Man.

Dr. Doug Walled: (00:42)
[Laughs]

Daniel Lobell: (00:42)
I’m excited to learn more. But let’s start with you. I’d like to know a little bit about your background. Where did you grow up and what made you get into medicine?

Dr. Doug Walled: (00:53)
Yeah, sure. I was actually born and raised in Ohio, in the Cleveland area. So I’m a Midwesterner.

Daniel Lobell: (01:00)
Where my hero is from – Cleveland. Harvey Pekar.

Dr. Doug Walled: (01:03)
Who is it?

Daniel Lobell: (01:07)
The late great Harvey Pekar. He was a comic book writer and a jazz reviewer, who they made a movie about him called American Splendor, which started Paul Giamatti in around 2005.

Dr. Doug Walled: (01:24)
Oh, awesome. Well, that’s cool. I actually haven’t heard of them. I’ll have to check that out.

Daniel Lobell: (01:30)
How old were you when you left Cleveland?

Dr. Doug Walled: (01:33)
Let’s see. I would have been 21.

Daniel Lobell: (01:39)
It’s in your blood. You’re a Clevelander.

Dr. Doug Walled: (01:39)
Yeah, man. True blue – midwest.

Daniel Lobell: (01:47)
You’d probably love – he did a graphic novel on Cleveland called Cleveland.

Dr. Doug Walled: (01:52)
Oh, cool! I should definitely check that

Daniel Lobell: (01:55)
The history of the city of Cleveland as it evolved from when it was Indian territory until – not present day – but at least 10 years ago or so.

Dr. Doug Walled: (02:05)
Yeah, well that would be an interesting history indeed. Cleveland had a really long, interesting history, especially going through the industrial revolution and all of the steel work out there and sort of being in that belt where all the car production – automobile production – Detroit and Cleveland were essentially national capitals back in those days. Unfortunately, in the late seventies and eighties, it all started to fall away with foreign cars and that’s actually when we started getting the less than pleasant nickname – The Rust Belt – Detroit and Cleveland.

Daniel Lobell: (02:47)
Did your folks work in that industry, or what made them settle in Cleveland?

Dr. Doug Walled: (02:52)
Yeah, actually that was it. The story is a little longer than that. I’m actually half Cuban. My family on my father’s side were refugees from Cuba. At the time, they made the initial hop over to Miami, but it was actually very cheap to live in Ohio. So the first wave of Walleds that came over moved up to Cleveland and open grocery stores. That was sort of how they generated money to get the rest of the family over as quick as possible before Castro and his goons caught on. You know what I mean?

Daniel Lobell: (03:33)
Right. Wow. So Walled, I would never have thought that to be a Cuban name but I guess it is.

Dr. Doug Walled: (03:39)
Yeah, well, actually the original family name was Valez and then the spelling was changed upon immigration in order to prevent name discrimination on paper.

Daniel Lobell: (03:54)
Makes sense.

Dr. Doug Walled: (03:54)
Yeah. So my family came over to Ohio and then, exactly, my dad worked for the auto industry, basically my whole life – mostly Ford.

Daniel Lobell: (04:07)
So he was tinkering with cars and you started tinkering with bodies?

Dr. Doug Walled: (04:13)
[Laughs] That’s right. Yeah. He was very much an engineering type of focused guy. So I think that sort of ran strong in my family – science and engineering – and it was always one of my passions in school. I went to school and as I came along, I became really interested in biology and physiology and with a strong desire to also help people and – if I could – make a mark on society or at least make the world a slightly better place to live. I sort of settled somewhere along the way upon being a doctor.

Daniel Lobell: (04:55)
Right. Sounds like a noble pursuit. Was there medical history in your family that inspired you towards it?

Dr. Doug Walled: (05:05)
No, not really. I’m the first doctor. My mom’s side, they’re from the West – mostly Western Pennsylvania and Ohio. Lots of coal miners and – like I said – the good old strength of America, the industry types.

Daniel Lobell: (05:25)
Yeah. That’s a really interesting background to have – Cuban and American and really the blue collar American, like the real backbone of America American.

Dr. Doug Walled: (05:35)
Absolutely.

Daniel Lobell: (05:35)
I wonder – how did that influence you as a doctor?

Dr. Doug Walled: (05:41)
Yeah. There were times where – actually, at one point, my dad had to switch jobs. He lost his job with general motors and then ended up at Ford, but there was a period there where we were struggling financially. We never of means by any sort and same thing for the rest of the family. I think that did have a lot to do with it – experiencing the actual – I don’t want to say the actual, that that could be insulting to many – but sort of experiencing what life can be like when you have not an easy life. I think that is certainly motivating to, to try and make things better for everyone, especially the everyman and everywoman and trying to increase health and increase access to healthcare. Those are always goals that have been in the back of my mind. You’re right about the work ethic. Like I mentioned, on my mom’s side, the coal miner types, those guys just worked mercilessly and in completely unacceptable conditions.

Daniel Lobell: (06:53)
Like an ER doctor, probably. [Laughs].

Dr. Doug Walled: (06:53)
Exactly. Yeah. I was going to say like 68 hours a week, kind of like I work. Except they were breathing in rocks, they’re breathing in coal dust and burning out their lungs since they were like 16. So that’s a little different. [Laughs]

Daniel Lobell: (07:09)
I don’t know. Nowadays with Corona going around, I’d be afraid to breathe in the hospital, too. I don’t know which is worse. [Laughs]

Dr. Doug Walled: (07:15)
[Laughs] That’s a good point. Yeah.

Daniel Lobell: (07:18)
Either way you should be wearing a mask, right? [Laughs]

Dr. Doug Walled: (07:21)
[Laughs] Absolutely.

Daniel Lobell: (07:23)
Do you think it affects you when you’re dealing with your patients, do you think it gives you more empathy for them?

Dr. Doug Walled: (07:31)
I think so. Yeah. I definitely think so. There’s a few things that have happened in my life that gave me a lot more empathy.

Daniel Lobell: (07:42)
One of the things that I saw is that you died once and were resurrected or resuscitated, I think. Either word, right? [Laughs]

Dr. Doug Walled: (07:49)
Yeah, right! [Laughs] Resurrection notwithstanding, I suppose it’s always a grey zone how much spirituality we’re actually focusing in part on the power of modern medicine.

Daniel Lobell: (08:05)
[Laughs] But yeah, the fact is that you were resuscitated in a trauma bay. Can you tell me that story?

Dr. Doug Walled: (08:10)
Yeah, sure. It was a long time ago. It was when I was 21. It was right before I made the move from the Midwest out to the East coast to start studying medicine. It was a couple of months before I was going to start med school and I got into this really bad car accident, I was a passenger. Basically, the car went out of control and at about 40 miles an hour impacted a utility pole and the point of impact was the passenger door. So it was not a very good – mechanically – not a very good accident for me. I was like the main point of damage.

Daniel Lobell: (08:58)
Wow.

Dr. Doug Walled: (08:58)
Basically, the side of the car completely folded in – the seat that I was in twisted. My arm was like dislocated and trapped behind me, like between my body and the twisted seat. Is there like an NC-17 rating you can put on? [Laughs] I don’t want this to get gruesome.

Daniel Lobell: (09:21)
[Laughs] No, but it’s certainly painting a picture that this was no little accident, right?

Dr. Doug Walled: (09:27)
No, it was bad and I think I’m about to reign it in a little bit, but needless to say, by some – well, it’s not really a miracle, probably more just adrenaline – I actually managed to get myself away from the vehicle because I could smell fuel. Back then, we always see in the movies, how the car explodes.

Daniel Lobell: (09:58)
Right, I was thinking this is right out of an action film.

Dr. Doug Walled: (10:00)
I know, right? It turns out the car never actually explodes and extremely only rarely catches on fire. But I didn’t know that. So I smelled fuel and I was out, I got out of there and I walked away from the vehicle, but then sort of slipped out of it and then ended up at a local hospital and woke up long enough to hear them basically talking about how I wasn’t going to make it and that they needed to call in the Lifelight, which is the helicopter service.

Daniel Lobell: (10:34)
Wow.

Dr. Doug Walled: (10:34)
Yeah. So the helicopter picked me up and took me to Metro, and thank goodness we were that close to downtown Cleveland. Metro Health in Cleveland has an amazing level one trauma service. The helicopter took me there and it was there that they worked on me a bit and I basically smashed the whole right side of my body and I had pieces of ribs sticking into the kidney. Yeah, it was really ugly. At some point I sort of dipped out, but they resuscitated me. It was quite an experience. In the wake of that, the recovery – I would say that the recovery was actually worse than the acute situation, because there’s fear and there’s that sense of not knowing. And actually I was very conscious of the fact that there was a good chance that I wasn’t going to live. I was actually pretty certain – I’d say like 90% sure – that I wasn’t gonna live. It was weird because the certainty with which we can calculate those odds in that situation, is almost surprising, to take a step back and look at it. But despite that, I ended up pulling through and then the recovery was really long. I ended up having tons of physical therapy and my shoulder was locked. I couldn’t use my right arm for a while. I’m just now starting up med school and then you’ve got the whole psychological trauma aspects and some nightmares and all that kind of stuff.

Daniel Lobell: (12:29)
I started this interview by making a joke that you were like Spider-Man, but it’s sounding a lot more like it’s true. [Laughs]

Dr. Doug Walled: (12:37)
[Laughs] Yeah, a small dose of gamma radiation could have really helped me out. I could have had a web swinger.

Daniel Lobell: (12:45)
Well, you certainly came back with powers, it sounds like.

Dr. Doug Walled: (12:50)
Well thank you. Yeah. To that point, you’re right. That experience was certainly a traumatic one and I kept it – I don’t want to say my back pocket, I guess it would be more appropriate to say I kept that one in my breast pocket – as I went through med school and dealt with people and I saw people. You can see the fear in their eyes, when they’re waiting to hear. It’s not like a movie most of the time, you do have to tell them, “Hey, look, you have cancer” or you’re talking to a family member about their loved ones to say, “I’m very sorry to tell you, but your husband’s not going to make it”, or whatever the case.

Daniel Lobell: (13:35)
Do you ever have in the back of your mind that you’re like, “well, they said that about me, so who knows?” Right?

Dr. Doug Walled: (13:40)
That’s right. Yeah. You do sort of have that. You recognize – you do see weird things, too. You recognize that when you’re in those situations and you do actually see miracles when you work in the hospital all the time, it’s kind of interesting. You see things that basically can’t be explained. It’s very interesting.

Daniel Lobell: (14:07)
Like what? Can you give me an example?

Dr. Doug Walled: (14:09)
People who do come against all odds and come in – I guess, would have been like my situation – someone that you say, “listen, this person has multi-organ failure. There’s no chance. They’re not going to come back from this.” And then the family adamantly opposes. Once in a while, they do and you don’t expect to see it, but it does happen. Still, as a physician you always have to give the evidence and the data. When you see that, you still make the call and you still make the recommendation because, like I said, when you do see a situation like that, it’s one in a hundred or less. So you want to make the recommendation based on what you know, not what apparently is possible.

Daniel Lobell: (15:08)
Right. So, I was perhaps playing a little ignorant when I said I don’t know anything about radiology. I did know at least that it has to do with cancer. And I knew that, sadly, because I had a girlfriend who passed away from cancer and I attended some radiation sessions that she was in. It was a very traumatic and sad thing and remains a very sad thing. So I know about it in that much, but I wouldn’t know how to do it or anything or anything about how it works. I just, in my mind – which is probably typical of most people who are not medical in any way or not educated in terms of medicine – would be that it’s sort of like a microwave. You’re putting someone in a microwave and you’re just sort of blasting the cancer away with some kind of a nuclear something or other? That’s as far as I understand it. So my question to you on this is twofold. It’s: what is it and why did you choose to go into this specific field in medicine?

Dr. Doug Walled: (16:30)
Yeah, sure. Sorry to hear about that. That’s terrible.

Daniel Lobell: (16:37)
Thank you.

Dr. Doug Walled: (16:37)
That really is difficult to go through. I know that it doesn’t ever really leave you.

Daniel Lobell: (16:48)
It doesn’t. I get choked up talking about it and I’m married and it’s many years later and I still can feel it like it’s present, it’s very sad.

Dr. Doug Walled: (17:01)
Yeah, sure. That sort of a situation is more like radiation oncology. The delivery of radiation for therapeutic reasons is not totally off with the microwave explanation. Actually, that’s not a bad way to think about it. The radiation that we use is much more powerful than the radiation that you find in a microwave.

Daniel Lobell: (17:31)
You haven’t seen my microwave, in fairness. [Laughs]

Dr. Doug Walled: (17:35)
[Laughs] It burns every bag of popcorn.

Daniel Lobell: (17:36)
I don’t cheap out. I go for top appliances. [Laughs]

Dr. Doug Walled: (17:43)
[Laughs] That is the name of the game with radiation oncology, is trying to find ways to do with radiation. There are different types of radiation that we can use. We can use particular radiation or energy radiation, in which case the microwave analogy is most apt. But the name of the game – exactly – is you deposit enough energy and you try to do it in a way that can deliver the energy in a spatially predictable way. What I mean is if you had a microwave that you could sort of focus the beam on, and you really only beam the microwaves into one little sphere of space, which is where the tumor is. You try to sort of zap it. For my part, I do primarily diagnostic radiology. Diagnostic radiology is the interpretation of the medical exams, like CAT Scans, MRIs, x-rays, ultrasounds.

Daniel Lobell: (18:45)
Do you do stand-up MRIs?

Dr. Doug Walled: (18:45)
We do not. In my current practice, we do not have a stand-up MRI. I’ve seen them, though.

Daniel Lobell: (18:52)
I don’t know much about them. I just know that when I drive around the country doing gigs, every now and then, I’m always on the lookout for comedy clubs and I’ll pass a sign that says “stand up” and I get excited. And then it says “MRI”. I imagine comedians in those things, just doing their sets. [Laughs]

Dr. Doug Walled: (19:16)
[Laughs] Unfortunately, I think the images that you get from the standup MRI are almost as much of a let down as you’re describing. Really, the point of a standup MRI is for people who get claustrophobic. So the thing about an MRI is that it uses magnetic fields. In order to get a really strong uniform magnetic field, you have to basically pass people into a giant electromagnet, which means you put them into the middle of a very small tube. In order to do stand up, you basically try and make a magnetic field between – I guess the most simple use is between two magnets, so the field lines can pass through the person. But really it’s nowhere in comparison to the strength and uniformity you can get in a standard MRI. And that translates through the end of the day to image quality and the image quality is everything for the radiologist who interprets the exam. So there’s a little gem that actually most lay people don’t know.

Daniel Lobell: (20:21)
It sounds like most people doing stand up MRI bomb. [Laughs]

Dr. Doug Walled: (20:27)
[Laughs] Bingo. There you go. Yeah. That would actually be a really good piece of information for people to have because people think about it like, “Oh, well, I can’t do this one. Let me just go do this one.” Well, there is no “just don’t do that one” and you actually take a big hit in compromising the quality of your exam. So that’s important to know. It might be better to – if you can – get your doctor to prescribe you some Xanax or some anxiolytics to calm you down and see if you can tolerate the regular MRI scanner, because your images will be much better

Daniel Lobell: (20:59)
One of the few times that people are less terrified of standup. [Laughs]

Dr. Doug Walled: (21:04)
[Laughs]

Daniel Lobell: (21:05)
But in seriousness, it’s kind of amazing to me that people – there seems to be some kind of cognitive dissonance there – that people are like, “I’m not afraid of having these incredibly strong radioactive beams shot through my body. What’s really scary to me is the small space in which it’s happening.” [ Laughs] It says a lot about what we’re afraid of.

Dr. Doug Walled: (21:35)
It does. It does. Maybe I should come back for your philosophy podcast, because I think we can really start talking about some interesting stuff there. [Laughs]

Daniel Lobell: (21:46)
Yeah. To me, if I was talking about it philosophically, I would almost think about it in terms of spiritually, because it’s basically what you can see versus what you can’t see. I think that sometimes what you can’t see is a lot more powerful than the stuff you see that you are afraid of.

Dr. Doug Walled: (22:04)
Absolutely. Yeah. In the MRI machines, like I said it’s all electromagnets. Everything you’re doing, you’re switching really high currents rapidly back and forth to create these oscillating magnetic fields. The thing about the engineering, the technology behind that is at the end of the day, it’s just a machine. And so there are these massive forces inside – we call them coils. As the current is passing through the coils to make these fields, they move a little bit but with extremely rapid acceleration and they’re constrained – they can’t spin or fly away. It makes these incredibly loud noises and that actually contributes to a lot, too.

Daniel Lobell: (22:52)
I’m getting images of Dr. Frankenstein pulling levers. [Laughs]

Dr. Doug Walled: (22:56)
[Laughs] That’s right. It’s actually not too far from the truth because you’ve got a technologist right outside the room and they are pushing buttons and changing all sorts of parameters to get it just right. And you can’t see, you’re tight and you feel like you can’t move your arms. And then it’s like a hundred and some decibels just of all of this loud knocking and whining.

Daniel Lobell: (23:17)
And some mad man behind the curtain yelling “it’s alive!” [Laughs]

Dr. Doug Walled: (23:23)
[Laughs] You’re right. And people would say, “no, thank you. I’ll go do my stand up.” And then you get these garbage images and then you don’t know what’s going on as a radiologist. [Laughs]

Daniel Lobell: (23:34)
What is radiology? How was it discovered and how do you harness it? How do you get it? Can you pick it up if you run out of some at the store? Where do you get it? Where does it come from? Could you make it yourself at this point? Do you know enough that you could make some radiology? What is it?

Dr. Doug Walled: (23:58)
I think that’s why most people are confused as to what a radiologist does. In fact, most often I think people confuse the radiologist for the radiology technologist. The radiology technologist is the guy or girl behind the curtain who’s pulling the levers and pushing the buttons and running the machine. The radiologist is the MD. It’s really interesting. It’s another thing people don’t understand when they get a test like that and they see how much it costs and they say, “what the heck?” It takes basically nearly an army of people in order to produce the effect. I liked the way that you said, “what is radiology and how can you get it?” It’s a great question, actually, because the answer to it is you need basically a troupe of people that entails everything from the engineers at the company that have created the machine and that service it and maintain it to the people who run it to the people who designed the hospital and the exam room, the infrastructure that it exists upon, the massive amounts of energy required to operate the machine, the training, education, and knowhow of the technologist who takes the exam, and then all sorts of computer software, IT, and everything in between to get the exam to the radiologist, who nowadays might be reading it in a different state, because of teleradiology, and then that physician has a whole lifetime of clinical training and expertise in order to look at the images and say, “this is what I see.” And then it feeds back into the modern healthcare system where that report goes to another type of physician and that physician has to interpret the radiologist’s interpretation in the context of the clinical case of what’s happening. So, it’s extremely complex and it’s no wonder people don’t really know what that means when I tell them I’m a radiologist. They think, you get this all the time when you’re a radiologist, they say, “my niece went to radiology school and she takes x-rays at the hospital down the road or whatever.” And you say, “oh, okay.” You can’t take the 20 minutes to explain it in a casual conversation.

Daniel Lobell: (26:15)
Yeah. It sounds like it’s a ton of people involved and there’s no one-stop shop kind of deal. No guy named Frank who just goes, “look, I’ll do it all myself. Come over tomorrow afternoon at 2 o’clock.”

Dr. Doug Walled: (26:30)
[Laughs] Well, let me tell you, my first job was in Staten Island, and I think I know the guy Frank you’re talking about.

Daniel Lobell: (26:35)
He’s got a generator in his garage. He goes, “you don’t need all those radiation guys. Come on, I got you.” [Laughs]

Dr. Doug Walled: (26:43)
It’s cool. I think it’s a testament to the complexity and integration of modern medicine and how far we’ve come, the fact that you can’t do it all by yourself. So that’s really what I do is on that side, I get the images and review the images and call upon my training and experience to say, “this person has cancer. This person doesn’t. This kid’s got appendicitis. He needs to go to surgery right now.” That’s what we do.

Daniel Lobell: (27:17)
I wonder if you’d also make a good art critic. You already have all of this experience reviewing images.

Dr. Doug Walled: (27:22)
[Laughs] Yeah, you’re right.

Daniel Lobell: (27:27)
The Mona Lisa’s got cancer. The other Michelangelo there, that one doesn’t. [Laughs]

Dr. Doug Walled: (27:33)
[Laughs] Yeah.

Daniel Lobell: (27:34)
An art critic who says which people in paintings have cancer. [Laughs]

Dr. Doug Walled: (27:40)
You’re not far off the mark. I’ve seen some research articles about that actually, about spending all that time basically developing your visual cortex as a radiologist and how radiologists do tend to succeed at visual tasks. Not too far off. [Laughs]

Daniel Lobell: (28:01)
You must have a more critical eye than most. You must have incredible attention to detail to be able to do that job with what you’re looking at.

Dr. Doug Walled: (28:11)
Yeah. With some people, I think it automatically translates in their life. My friend was building a lake house and he always says how he can approach a building and tell when something’s not online just by his eye, even if it’s like a fraction of a degree off and I believe him. So that’s pretty interesting.

Daniel Lobell: (28:32)
How does radiology actually help someone? How does it work? We kind of touched on it when I was talking about blasting with the microwave, but what is it doing to the person and how is it helpful?

Dr. Doug Walled: (28:50)
Sure. Yeah. So there is a risk – especially in the last 10 years and currently – people are very conscious in the public about radiology and having exposure to radiation and that potentially being a bad or a dangerous thing.

Daniel Lobell: (29:06)
Right. Like going through the airport security, people get freaked out. Right?

Dr. Doug Walled: (29:11)
Right. And if you understood the physics you’d know that that level of radiation is like spending a day at the beach, because the sun emits radiation. Everybody who goes outside is exposed to gamma radiation that’s flying through the universe, primarily produced by our star. We have man-made ways in order to produce it and just higher qualities. But we’re very focused on that. We understand that. And so we do everything we can – in the past 20 or 30 years that I’ve been involved – have just seen ways that all of the engineers, et cetera, like I was talking about before – have managed to work into the system ways of reducing that radiation that comes from the scanner. CT scanners and x-ray, specifically. One good thing to note for a lay person is there is no damaging radiation from an MRI or from an ultrasound. Those do not use ionizing radiation. They use non-ionizing radiative energies. In the case of ultrasound, it’s literally sound waves. It’s literally like a super dog whistle.

Daniel Lobell: (30:27)
Dog whistles, nowadays people get freaked out more by those more than anything else. [Laughs] But since you are talking to a lay person, can you define what ionized is, what’s the difference?

Dr. Doug Walled: (30:41)
Yeah, sure. Basically all radiation, in the sense that we’re talking about it, is electromagnetic radiation. If you remember, maybe from science class in school, you learned about the electromagnetic spectrum and it goes all the way from one side to the other, in terms of energies. And it passes through in the middle, like everyone remembers, through visible light and each color of light is a different energy. The reds are the lowest energy and the violets are the highest energy. And then once you get past violet, you have ultraviolet, which is in extreme abundance from the sun, which is where it first starts to become damaging because too much ultraviolet light can cause slight genetic disruptions in your skin cells and ultimately melanoma.

Daniel Lobell: (31:29)
That’s what the sunglasses industry is always fighting against, are those UV rays, right?

Dr. Doug Walled: (31:33)
Yeah, that’s right. Yeah. The blue blockers, man, you’ve got to protect your retina. What we do is we crank up the juice higher on that and we make slightly more powerful, more penetrating radiation. And then as it pertains to ionizing vs. non-ionizing: visible light is non-ionizing radiation. What that means is it has a certain ability to penetrate matter and as it penetrates matter (or doesn’t, as it gets absorbed into matter), it basically slows down, dissipates its energy, and is stopped. In ionizing radiation, when that energy gets stopped by a material, because the incident energy is so much higher for the ray, for the individual ray or photon that’s carrying that energy, it has to basically dissipate more rapidly. So instead of dissipating harmlessly, it’ll knock an electron loose from the medium of the matter. So all matter is made of atoms, and all atoms have electrons – at least in the state that we’re familiar with. As radiation gets stopped by that matter, when it’s higher energy radiation, it has to basically knock off electrons as it’s getting stopped. When you knock off electrons, then you make regular matter very dangerous because those ionized particles have other effects, like subsequent ionizations and especially in a biological system, what happens is the way those separated charges get dealt with is you end up making reactive chemical species called reactive oxygen species. There are different ways you can sort of get back from losing an electron. If you’re an oxygen atom – and oxygen is very abundant in biological tissue – then one of the ways is to have this intermediate stage of a free radical, and that free radical can literally move all around a cell and chemically damage all sorts of different sites – different organelles within the cell and, most importantly, DNA. When you have these free oxygen radicals damaging DNA, the DNA may not be able to reconstitute itself in its initial form. Then when that happens, you have altered DNA and then we’re back into comic book land.

Daniel Lobell: (34:04)
[Laughs] Right, that’s what I was thinking.

Dr. Doug Walled: (34:04)
[Laughs] You know where I’m going. Unfortunately in the real world, when people mutate their cells, they don’t turn into X-men. They get cancer. [Laughs]

Daniel Lobell: (34:15)
Right, unfortunately. It’s not quite as cool as being the Wolverine.

Dr. Doug Walled: (34:19)
Unfortunately, no. You don’t get super healing, you get the opposite. But we do everything we can to mitigate that. So that being said – and I know we have limited time and I get excited because I teach this stuff – but we’ve done a lot of studies on what those effects are and I can tell you: at the rate at which people receive doses of radiation for the purposes of diagnosis in a medical context, the amount that increases their risk of getting cancer is very, very small. We’re always trying to debate as much as possible and physicians when they order these studies sort of always have it in their head when they think about it. So they carefully weigh the options and in the cases where we use it, we only use it because the benefits greatly outweigh the risks. I can give you the perfect example that’s pretty easy to understand. One really common way a lay person might encounter radiation or radiology is they’re going on about the business and they get extreme abdominal pain. So they go to the urgent care, ER, and they say, “I don’t know. He might have appendicitis. Go to the hospital and get evaluated.” So you’re in the hospital, you come through radiology, we do a CAT scan of your abdomen and pelvis. I look at the pictures. When I’m looking at the pictures, I’m literally looking at the inside of your abdomen and pelvis. Now that I’ve opened you and I can find your appendix inside your abdomen because I’ve done this 10,000, 20,000 – it’s actually a good question, I’m actually not sure how many times I’ve looked at that in CT – but 10 or 20,000 times and I know what an appendix is supposed to look like. When it looks different, I’ve probably seen it enough times to say why it looks different in that specific way. I’ll look at it and I’ll say, “nope, that’s a normal appendix, but there’s this other thing – this person has diverticulitis.”

Daniel Lobell: (36:16)
I don’t know what that is but I know I don’t want to have it.

Dr. Doug Walled: (36:16)
Right. That’s collateral information to what we’re explaining… But it’s important to say “you have belly pain, you have a couple of lab findings, it’s nothing specific. They don’t know exactly what’s going on with you.” You get the cat scan and I look at it and I say, “no, it’s not this, you’re fine.” Or “no, it’s not this it’s that and now you’ve got to get antibiotics for two weeks” or I say “yes, it is an acute appendicitis and you need to go to surgery right now.” Just that alone – being able to appropriately triage the treatment of the patient based on an accurate diagnosis – is like 90% of the huge benefit. I think in the case of appendicitis, you can look at a really nice counter example. A question to make that comparison is to ask, “what did we do before CAT scans?” Right? Because really, CAT scans weren’t around until the eighties.

Daniel Lobell: (37:22)
I didn’t know that.

Dr. Doug Walled: (37:22)
The answer is if clinically they suspected you might have an appendicitis, you just went to surgery and that was the general surgeon’s thing. A general surgeon was an expert in physical diagnosis, which is where we do physical exams and look at all the data, and they were really good about knowing if it was appendicitis or if it was not.

Daniel Lobell: (37:46)
It was just that they would cut you open to know?

Dr. Doug Walled: (37:50)
That’s the thing. You could never get past a certain point. So yes, there was a point at which you said, “we can’t be certain that you do not have an appendicitis. We literally have to cut your abdomen open and look at your appendix.”

Daniel Lobell: (38:04)
What’s the barrier nowadays? I’m sorry to interrupt, but what is the barrier these days where you’re like, “man, if only we could do that”?

Dr. Doug Walled: (38:12)
Right. There’s still tons of tons of places in medicine, as you go out along the webs where you find clinical questions where we don’t have a good answer, we don’t have a good test, and we’re still charting out that territory. But in the case of surgeons opening people up for an acute appendicitis, there was what you call an acceptable negative rate. What this meant was if you’re a general surgeon working in a hospital, you keep tabs and the hospital keeps tabs on all your cases. They look at what you did last year and they say, “alright, Daniel, you cut open 2000 people and 1700 of them had appendicitis. So good job. You only cut open 300 people unnecessarily.”

Daniel Lobell: (39:04)
Right.

Dr. Doug Walled: (39:04)
Abdominal surgery is not a benign thing. It comes with a lot of risks. It comes with a lot of complications. But back in the day, that was about the tolerable negative rate was 25%. Literally one out of four people with belly pain – I mean, I’m oversimplifying this for purposes of making a point – but say 25% of people with belly pain were getting cut open and didn’t need to. With the CAT scan, it doesn’t happen anymore.

Daniel Lobell: (39:34)
Wow. That seems like a huge advance. That’s incredible. That must’ve been… when they’d open up a person and they didn’t need it, they didn’t have the appendicitis. It would be so disappointing, I guess, for the doctor and so great for the patient. Right?

Dr. Doug Walled: (39:55)
Yeah, well–

Daniel Lobell: (39:57)
–Or not great because they’re opened up.

Dr. Doug Walled: (40:00)
Yeah. It goes one step farther than that because if you make a local – a relatively localized – incision and you look for the appendicitis and it’s not there. Let’s say they were bad enough and as a surgeon, you were like, “I’m sure there’s something bad going on here.” You’re going to widen that search to a full exploratory laparotomy, which is what they call the surgery where they just explore the abdominal cavity because you’ve got to look and see what the heck is going on. On the other side of the highway, look at the other side of the colon and all of the other organs in there.

Daniel Lobell: (40:42)
It’s like a kid digging around a Cracker Jack box. “Where is it? Come on!” [Laughs].

Dr. Doug Walled: (40:42)
[Laughs] “Hey ma, look, I found a diseased gallbladder.” “Congratulations, Jimmy.”

Daniel Lobell: (40:50)
I want to pick up on something from earlier that I had asked you, which is why radiation? Why did you choose this field? With so many possible fields in medicine to go into, what was appealing about it?

Dr. Doug Walled: (41:01)
For me, I’ve always been really into science, like basic science and technology. It doubles back on it because radiology is at the cutting edge, technologically, of most medicine. I’ve always really liked the process. In medicine, there are a lot of facets that you can get into and I think diagnosis was always one of my favorites and that’s what diagnostic radiology is. It’s basically the harnessing of radiation in order to make diagnoses. For me, it really drew me because it had that component of science and technology and what I’m doing all day long is basically like solving the puzzle: here’s a person with abdominal pain and increased white blood cell count. Let’s look at the images and figure out why that is. Or here’s a person with a headache and here’s some head CT images, let’s figure this out. And it’s kind of rapid fire. When you’re a physician, in most medical specialties, you’re going to have visits with patients and they can take 15, 20, 30 minutes an hour if it’s a long, complex consultation. But in radiology, you’re sort of “boom, boom, boom” getting through cases and you’re basically touching the medical care of way more people every day than you could, if you were just – I shouldn’t say, I don’t mean to say “just” – if you were diving deep, say like an oncologist would and sitting with a patient for 45 minutes at a time.

Daniel Lobell: (42:39)
Interesting.

Dr. Doug Walled: (42:39)
Maybe you’re not the face of it. Like the patient doesn’t necessarily even know you or know you exist, but you know that you’ve touched their medical care and that you may have made a difference in utilizing your expertise to say, “hey, it’s this not that” or “everybody thinks it’s this, but why don’t we think about this? Try getting these tests.” Then maybe that starts a new avenue to go down to figure out a clinical quandary.

Daniel Lobell: (43:11)
And you have to look at it and find it that quickly, because why? I wasn’t clear on that.

Dr. Doug Walled: (43:18)
Yeah. You go through it as you can. In some cases, you take a lot longer. A full body oncology exam does actually take a very long time to read through, but people coming through the ER, if you get an ankle x-ray foot x-ray, hand x-ray – you just sort of look at it quick and it answers the question, because if you were to look at that person’s hand, it might be blown up to four times the size and purple and they can’t move it for all the world, clinically you’re sure that it’s broken, but we can instantly see in 30 seconds, that’s not broken. And that really changes what they do, because if it’s not broken, then you wrap it up and you take your ibuprofen and Tylenol. Whereas if it’s broken, like, okay, now we need to get ortho involved. It’s the hands and they’re right handed.

Daniel Lobell: (44:09)
Got it.

Dr. Doug Walled: (44:09)
We need to be all over this and maybe we need to explore surgery depending on how it sets with the casting, et cetera.

Daniel Lobell: (44:16)
You must be a master at Where’s Waldo. Like you probably could find him right away. He’s right there. There he is. That’s him.

Dr. Doug Walled: (44:24)
[Laughs] I was. I had every single one of them growing up.

Daniel Lobell: (44:34)
[Laughs] I’m not surprised. So you’ve touched on this a bit. You’ve described yourself as an enthusiastic science nerd and you’re a senior member and an impact creator of I.E.E.E., which is the world’s largest STEM organization. How does your passion for technology help you as a radiologist and can you explain to me what I.E.E.E. and STEM organizations are and do?

Dr. Doug Walled: (45:00)
Yeah, sure. Science, Technology, Engineering, Medicine – I’m sorry, Mathematics. Some people in the medical field extend that to also mean medicine, or you could even spell STEM with two M’s if you wanted. The I triple E is originally – a long time ago, it was just an electrical engineering organization – but now it’s basically the go-to professional society for engineers. I have a really great friend Jacqueline Adams – she blogs and works very closely with the I triple E, she volunteers for them. I got exposure to it through her, and it’s a great platform to start integrating because one of the things that affects us negatively, I think, in modern medicine is the siloing that occurs naturally from the extreme subdivision, the more (as human society) we explore and get farther out on that web, the individual person never really contract any more than we’ve always been able to, so we have to start working in these larger and larger groups, but we’re always at more and more risk for siloing. So I really like working with the I triple E as a global engineering organization because we need to reinforce that and have more of those tie-ins between medical societies and engineering societies, especially since we’re so dependent upon them. Like I said, it takes a whole army. That’s how I got involved with them. And it’s great. You get opportunities once in a while to talk to some people, you do interviews, and they’re looking for opinions that have the medical depth. But it’s exactly that, it’s that the engineers that work on the machines that I eventually use to make diagnoses on patients that affect how their other doctors treat them, usually don’t have any exposure to medicine. Even small amounts, I think, of exposure would be huge on both sides, either way. That’s why I always promote bringing an actual conscious understanding of the underlying science and technology into the medicine, and so that’s what I do. I teach radiology residents that are MDs about the actual physics and engineering.

Daniel Lobell: (47:36)
Are you referring to the Doktor Doug Productions, LLC?

Dr. Doug Walled: (47:41)
Yes.

Daniel Lobell: (47:46)
I was going to ask you about that.

Dr. Doug Walled: (47:46)
Yeah, sure. That’s something that I just started doing on the side because I think as it goes, I happen to be uniquely passionate about that stuff. It just grew very organically that my first job was at a teaching hospital and in teaching residents about physics, they found it very useful and I found it very rewarding and it just sort of built and built. Then I switched practices. I came to upstate New York and I work in more of a private sort of environment, so I don’t have residents. They were asking me to keep teaching them. So I said, “well, how can I use science and technology in the form of modern media platforms?” So I continued teaching them, basically remotely, and that grew and a couple other programs came on board and I’m at a place where I’m looking to basically provide that education for any residents anywhere that want to learn from me about it.

Daniel Lobell: (48:47)
Right, I understand you’re secretly amassing an army of Dr. Doug clones to take over the world. [Laughs]

Dr. Doug Walled: (48:55)
[Laughs] Yeah. I could use you to do the artwork for the graphic novels.

Daniel Lobell: (49:02)
[Laughs] I’d be honored. I actually outsource my artists. I do paint but I’m not good at the technical kind of art that you need for that type of work. I just write them and then work collaboratively with artists. You’re referring to my comic books–

Dr. Doug Walled: (49:17)
Yeah, right.

Daniel Lobell: (49:17)
–which I don’t think people know I do, but I do these autobiographical comic books called Fair Enough.

Dr. Doug Walled: (49:23)
Yeah, that’s cool, man. It’s all about the story.

Daniel Lobell: (49:26)
I think it’d be very cool to do a medical graphic novel. I don’t know that I’ve seen anything like that, but to explain some of these tough concepts, I would be very interested in working with you on something like that. I think it’d be very interesting and a cool way to educate a new crop of doctors on things.

Dr. Doug Walled: (49:45)
Absolutely. Well, let’s talk about that offline. Cool.

Daniel Lobell: (49:49)
You’re – as we’ve seen today – an expert at explaining complex topics in ways that anybody can understand them. So it leads me to ask you, I’m working here with Doctorpedia, as you are as well. What do you think Doctorpedia can do to accomplish this with their website, to break down these complex topics as you are such an expert at doing?

Dr. Doug Walled: (50:12)
I think Doctorpedia is going to be the future of the way people get their medical information. It’s through the utilization of science and technology in terms of modern platforms on the internet, using video, using streaming, interconnectedness, maybe even finding ways to plug into telemedicine outfits. Doctorpedia will be positioned to have its own individual library of content that will span all of medicine and it will do so by – we’re in the process now of recruiting a lot of new doctors, we’re sort of in a linear growth phase where we’re finding people that are interested and, like me, that are passionate about actually teaching patients and taking the time to explain it and have it out there so that people can understand it if they want to. For Doctorpedia’s part, they’re amassing all of this, organizing it, figuring out how to deliver it, and making it financially viable. And at the same time, they keep it honest and keep everyone reined into a single style and platform. The major vehicle will be these video snippets that will be anywhere from one to two minutes long. I guess I should say that you have to look at it juxtaposed to what is the main way that people do that now. If you look something up on WebMD, let’s say, you get this sprawling text article that’s hard to navigate. There’s still a lot of jargon and it can be very difficult to understand.

Daniel Lobell: (52:06)
All you know is by the end of it, you know for sure you’re dying and you have two hours to live. [Laughs]

Dr. Doug Walled: (52:12)
[Laughs] I tell you what – in the beginning of my clinical training, that was a thing. When WebMD basically first started and it coincided with when I first started going into clinics. It actually became like a red flag. You’d be about to go into a room in clinic and the nurse would lean in and key in, “he’s been on WebMD.” And you’re like “oh G-d, here we go.” [Laughs]

Daniel Lobell: (52:40)
[Laughs] And I was one of those patients that you were probably worried about.

Dr. Doug Walled: (52:43)
That’s the thing, because it didn’t matter who it was. It’s scary. I think it’s been tempered a bit by time in the expectation of most people. But yeah, the first time medical information became available, people started reading and people that are in the medical field think they’re putting up a comprehensive answer? They’re really just putting up a lot of flack that’s going to raise a million questions and scare the heck out of people. I think that’ll be the key to Doctorpedia, will be the will be the top level organization and the way the information will be disseminated, divided, and then explained by physicians like me who are basically instructed to deliver the information in a way that will be like talking to a patient, so that can be understood and apprehended by people. One of the main features is going to be that basically each condition is going to have its own website. You go to the doctor if something’s wrong. You go back to our appendicitis example. You go to the ER, they say that you have appendicitis, you find this out. You don’t know what to do. Maybe you have your phone with you. You can actually pull up your browser on your phone while you’re waiting for the surgeon to come down and you’re sweating bullets, they tell you your surgeon’s going to come talk to you. You can go on to Doctorpedia and go to Appendicitispedia.com and you’ll get all of these little video snippets about “what does appendicitis mean? How is it caused? How do they treat it?” And they’re more conversational and flowing in a linear fashion.

Daniel Lobell: (54:31)
That’s what I learned about it. It just makes it so much easier and it breaks it down for people. Having you involved is a great gem for everybody.

Dr. Doug Walled: (54:40)
Thank you.

Daniel Lobell: (54:40)
Do you personally engage with any apps yourself to monitor your health?

Dr. Doug Walled: (54:44)
Personally, no. There’s an old saying that doctors make the worst patients and it’s a truism. [Laughs] So, no, I completely ignore my own health unfortunately. [Laughs]

Daniel Lobell: (54:57)
I’m sorry to hear that. Maybe I should become your doctor and I’ll encourage you, because I always ask the doctors at the end of the interview, “what do you do to stay healthy?” But you’re telling me nothing. Do you do anything?

Dr. Doug Walled: (55:12)
Well, yeah, it’s not nothing, I do. I try to eat healthy and try to work out. I have two kids, so the working out thing has gone to the wayside temporarily. [Laughs]

Daniel Lobell: (55:24)
I have one kid and it’s a workout just moving them around the house and doing all the things, catching up with her. It’s a bit of a workout just keeping up with the kid.

Dr. Doug Walled: (55:35)
Yeah. That sounds like maybe in the one to two year range?

Daniel Lobell: (55:39)
Yep. [Laughs].

Dr. Doug Walled: (55:43)
I have a two year old and a four month old. We don’t sleep much. [Laughs]

Daniel Lobell: (55:51)
Between that and the medical career, I imagine you probably don’t sleep at all.

Dr. Doug Walled: (55:56)
That’s right. And that’s why we make the worst patients, because we work a lot. We do institute the baseline stuff, we’re physicians so we know what we’re supposed to be doing. We monitor ourselves and if something starts going awry, we’re all connected at the hospital. I go in and literally can pick up the phone and call an infectious disease specialist or a pulmonologist, which is a lung doctor, or I know 20 cardiologists because I’m a cardiac imaging specialist. There’s no limit to the amount of free advice on demand that I have, so there’s that too. I don’t want to paint the wrong picture.

Daniel Lobell: (56:41)
That’s a pretty good perk. For comedians, all we can do is hopefully get a free drink. [Laughs]

Dr. Doug Walled: (56:46)
And a free laugh. [Laughs]

Daniel Lobell: (56:49)
Going to the club. But being able to access the top doctors in the world ain’t a bad perk.

Dr. Doug Walled: (56:56)
That’s right.

Daniel Lobell: (56:56)
But hopefully everybody will have that perk now with what we’re doing at Doctorpedia. Thank you so much, Dr. Doug. Should I call you Dr. Doug?

Dr. Doug Walled: (57:06)
Sure.

Daniel Lobell: (57:06)
Dr. Walled. Thank you for this very enjoyable conversation.

Dr. Doug Walled: (57:13)
Yeah. Thank you. It was great talking with you.

Daniel Lobell: (57:16)
Thank you. You as well, this podcast or any written material derived from its transcripts represents the opinions of the medical professional being interviewed. The content here is for informational purposes only, and should not be taken as medical advice since every person is unique. Please consult your healthcare professional for any personal or specific needs.

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