EPISODE 247: “You Can Prevent a Stroke” with Dr Joshua Yamamoto

Speaker 1 (00:04):

Welcome to the Bill Walton Show, featuring conversations with leaders, entrepreneurs, artists and thinkers. Fresh perspectives on money, culture, politics and human flourishing. Interesting people, interesting things.

Bill Walton (00:25):

Welcome to the Bill Walton Show. I’m Bill Walton. Well, today, we’re going backstage again with a friend of mine who also is one of the top cardiologists in the country, Dr. Josh Yamamoto. He is based here in the District of Columbia and really has one of the most interesting practices around. He is in the preventive business as opposed to just the disease business. And he’s written a book, You Can Prevent a Stroke, and we want to talk about that today.

(00:58):

But we also want to talk about the holistic view of what healthcare ought to be about, and particularly what you ought to be thinking about in terms of your relationship with your doctor. And we want to get into this notion that healthcare is something about a disease where we need to find a cure, but we really ought to recognize that we’re not immune from the aging process. And that would our best when we navigate the process.

(01:29):

And Josh is good at navigation. He was in the navy and he graduated from Princeton and has now also got his degree in medicine from Johns Hopkins. We were joking, he’s graduated from the 28th grade after many years of schooling. He served as an officer in the army, I believe.

Josh Yamamoto (01:52):

Navy.

Bill Walton (01:53):

Navy.

Josh Yamamoto (01:54):

The Army just borrowed me.

Bill Walton (01:55):

Army just borrowed you. Okay. And was in Iraq and Afghanistan. And my favorite, since I’m president of the local volunteer fire and rescue in Rappahannock County, Virginia, Josh did his first gig in the Alexandria City Fire Department as a medic.

Josh Yamamoto (02:14):

I was. I was even in the union.

Bill Walton (02:17):

So, Joshua, let’s talk.

Josh Yamamoto (02:18):

Sure.

Bill Walton (02:18):

You were in the union?

Josh Yamamoto (02:20):

Sure. Local 2141 International Association of Firefighters.

Bill Walton (02:23):

Are you still a member?

Josh Yamamoto (02:24):

No.

Bill Walton (02:25):

No. Okay. You’re gone. You’re gone. Well, let’s talk about you’ve got your practice and also the Foxhall Foundation. And we talked before, and I’ve learned a lot from you about how to think about my condition. I have this condition where I produce too many red blood cells and have a propensity to clot.

Josh Yamamoto (02:47):

You also have a condition called being over 65.

Bill Walton (02:50):

I have that condition as well. And you want to be [inaudible 00:02:55] a lot of red blood cells and you want to be a red-blooded American until you don’t.

Josh Yamamoto (03:02):

Well, you’re a nice example of somebody who has some genetic factors. Your issue, one of them is entirely genetic. So, it’s entirely beyond your control. You can’t change the hand you’re dealt, but you can certainly try to understand it and play it well.

(03:19):

And you mentioned that we try to approach medicine and look at aging not just as a bag of diseases, but as a process. We give a lecture at the Foxhall Foundation. Foxhall Foundation is a nonprofit we started about a decade ago with both an educational and a research purpose. And it’s dedicated to helping everyone age well.

(03:45):

And one of the things we noticed is our approach to medicine is still trapped in this notion that everything that happens to you is a disease. And as a disease, by golly, that means it’s your fault and we have to stamp it out and cure it. But there’s so many things that happened to all of us as a natural aging process.

(04:08):

And one of the lectures I give is that there’s almost, almost no such thing as heart disease. It’s just natural aging. And if you start to think of it as a process that we’re all going to participate in and say, “Look, there are things that I can do as a patient to help navigate that process, but there are things that I need my doctor to help me with to understand it and to help guide it.”

(04:36):

And the goal isn’t one or the other to say, “Oh, I don’t need medicine or I have to rely solely on pills to …” The goal is to age well. And I think it’s interesting, we often have the discussion that we don’t even all agree on what the definition of health is. I find a lot of patients will come to me on one of two extremes. One extreme is, “Oh, I don’t take any pills. I’m healthy.”

Bill Walton (05:06):

That was me.

Josh Yamamoto (05:08):

Yes.

Bill Walton (05:09):

That was me. I was really proud of the fact I didn’t take any pills, but now I have a whole shoebox.

Josh Yamamoto (05:15):

Now, you’ve got a bunch and I expect you to live to be 100 and come to my retirement party in 20 years.

Bill Walton (05:19):

I’m going to work on that.

Josh Yamamoto (05:21):

And I actually tell that to most of my patients. That is an understandable perspective. The converses, I have just as many people who come to me who say, “Yeah, I’m not going to put an effort into this. Give me a pill for that, doc.” And you know what? I can actually keep a heart quite healthy. And I have people who live in their 90s and 100s. I have folks I can’t even put on my treadmill because they exceed the 450-pound weight limit. But you know what? With the right pills and medicines, I can keep their heart working perfectly well. But just because the heart’s working well doesn’t mean you’re living well.

Bill Walton (06:00):

You have patients that exceed the 450-pound weight limit on your treadmill.

Josh Yamamoto (06:04):

Oh, sure. I’m a cardiologist. We see such things.

Bill Walton (06:06):

So, fortunately, not everybody watching or listening to the show is 65 or over. We’ve got a lot of younger people. When should you start thinking, at what age should you start thinking about health as something like this? I’m 35 years old. Let’s say, why do I care?

Josh Yamamoto (06:25):

The parents are on to something. When we have a child, we take our kids to the pediatricians. Why? They’re not sick. Because we’ve learned that there are things that happen as we grow up, as we age that we can navigate, we can make sure we’re reaching the right milestones. There are diseases that devastated humanity for years that we can prevent. And we always take our kids to the doctors.

(06:58):

Women, I have a daughter. She’s much brighter than I am by the way. Shout out to University of Michigan. But women habitually are brought to doctors their whole lives. And so, there’s somebody keeping an eye on things. Men, “I go to college, I’m good. I pass my physical. If it’s not falling off, I don’t need to fix it.”

(07:21):

And there’s a logic to that. You can do almost anything and make it to 50, but you should think about building a foundation of health your whole life. Because decisions we make now can have long echoes into the future. And so, that doesn’t mean you have to be … It doesn’t mean anything. We like to tell people, I never … Have I ever actually told you what to do or do I just try to explain this is what’s happening and here are our choices? And one of the things we’re not good at and the next generation isn’t good at is thinking ahead. I still take medical students and one of the first things they-

Bill Walton (08:01):

I’m still working on that.

Josh Yamamoto (08:02):

I know. But you have a much longer horizon than you might realize.

Bill Walton (08:06):

Okay. I’m counting on you.

Josh Yamamoto (08:08):

So, your watch, look at your watch. We have analog watches. We grew up in a generation of an analog watch where the young people today, I always make the medicine, “Show me your watch.” And they’re always fancy digital things that are beyond my understanding.

Bill Walton (08:24):

Or they just have an iPhone.

Josh Yamamoto (08:26):

Exactly. But a digital watch tells you where you are now. Whereas an analog watch, it’s half past. It implies something about, or it’s a quarter to, where have I been and where am I going? Not just where am I. So, you don’t just suddenly one day start, “Oh, I have chest pain. I wonder if I should think about my heart. I am staring blankly into space for seconds at a time, I wonder if I should ponder how reliable my heartbeat is.”

(08:55):

You start thinking about these things your whole life. And you know what? It’s not entirely your job. You didn’t go to medical school. Like you said, it’s 28 years of training to be a cardiologist if you start at first grade. So, there’s something to that. That’s my job. But we have to be a team. I have to recognize that you defined health as not taking pills, and I respect that. But then I have to say, “Look, I define health as living as long as you can, as well as you can.” And you know what?

Bill Walton (09:27):

Well, I was one of these guys who thought you could triathlete your way towards…

Josh Yamamoto (09:32):

Immortality.

Bill Walton (09:32):

… immortality or diet.

Josh Yamamoto (09:33):

Live forever or die trying.

Bill Walton (09:35):

And then of course then my diet changed every five years with each new fat.

Josh Yamamoto (09:38):

Yes, you can.

Bill Walton (09:39):

One point, I’m eating no protein. The other moment, I’m eating all protein and all points in between.

Josh Yamamoto (09:47):

Exactly.

Bill Walton (09:49):

But you said something before the show, I want to make sure because I do want to get people who are all ages thinking about this. You said if you don’t have a relationship, almost a firsthand relationship, first name relationship with your doctor, you really don’t have healthcare. And you got to think about developing relationships with somebody who can help you with the 28 years of-

Josh Yamamoto (10:13):

Right. We often, the other doctors in our practice and the Foxhall Foundation, most importantly Dr. Thomas, the co-author, who’s actually my wife and way smarter than I am. I’ll just digress, she and I trained at Hopkins.

Bill Walton (10:29):

Kristin Thomas.

Josh Yamamoto (10:30):

Kristin Thomas. And when we were finished with our training, they turned to her and said, “We would like you to be our chief resident and we’d like you to join the faculty.”

Bill Walton (10:36):

Really?

Josh Yamamoto (10:37):

And they looked at me and said, “Yeah, we know that thing you signed for the Navy, you can go to Guam. We’re okay with it.” And so, I honestly rarely need to see young people. Ninety-five percent of my daily work is with folks over 65. But if you come to me at 65 healthy, if you build a foundation of health, and again, like you said, medicine is the relationship between a doctor and a patient. Healthcare takes on a much broader view.

(11:11):

Obviously, there are public health issues and many things beyond that, but if you want to take care of yourself, you should have a doctor. But when I meet anybody, or if you make a request to see me as a patient, we’ll see just about anybody. But the first question is, who is your doctor? And in today’s world, that’s becoming a harder question to answer.

(11:35):

And this gets back to also that notion about thinking ahead in time. If you belong to a clinic and you can’t name your doctor, “Oh, I go to the such and such clinic.” Well, terrific, that’s great. It’s a great clinic, lots of people, lots of resources, but is there anyone there who’s your doctor? That means when you go to the clinic, you’re seeing somebody for that moment of digital time and they’re not thinking about where you’ve been or where you’re going. And that’s not how our generation was trained.

Bill Walton (12:04):

Well, how do you work the system to make sure you see the same person every time? Because most people don’t have that sort of practice.

Josh Yamamoto (12:12):

They don’t.

Bill Walton (12:14):

And that we talked before, doctors have become data entry clerks. You show up in the office and you’re sitting there looking at them and they’re sitting there looking at their computer screen.

Josh Yamamoto (12:23):

Right. And I’m one of those people who believes that-

Bill Walton (12:28):

By the way, you don’t do.

Josh Yamamoto (12:28):

Right, because I just can’t stand that. I cannot abide staring at a screen when I’m trying to have a conversation with someone.

Bill Walton (12:37):

But how does the ordinary person go into one of these practices and say, “Look, I’ve got to see this person,” and work that so that happens.

Josh Yamamoto (12:46):

So, there’s a lot of variety of practices today, and we’re in a very active state of change. As decade ago, most cardiologists, heart doctors, for example, were in private practice, meaning the physician owned the practice. So, the physicians controlled their work. And now, the vast majority are institutionally employed. And that’s a whole nother issue as to how and why that’s happening.

(13:16):

But the bottom line is doctors are federally mandated to submit data and it’s data we have to submit. There’s only so much of it we can farm out. So, you have to enter this data. And unless like you’re me and I take it home with me because I can. I’m my own boss. I’m not required by my employer to enter that data by the end of the day before I can go home.

(13:43):

So, I can have a conversation with my patient and I can listen. And I can think about where have they been, where are we now, and where are we going. And my job is to give them my best advice and their choices on how to take care of themselves because there are always choices. And again, some people want me to tell them what to do, I can do that. And some people need to see it for themselves.

(14:06):

How to do that? It depends upon where you are and what you’re doing. There are plenty of places in rural America, interestingly, doctors still actually try their best to take care of patients. And more urban environments are very commoditized and industrialized. So, you’re part of a clinic.

(14:22):

But you can always find out, well, I’m supposed to be assigned to some primary care doctor. Well, don’t just take that as an electronic designation. You can take the initiative. All right. “I’m seeing Dr. So-and-so, this is my doctor. Hey doctor, I’m now your patient.”

Bill Walton (14:41):

Well, this is the Bill Walton Show. I’m here with Dr. Josh Yamamoto, great guy, very smart man and has spent 28 years of education.

Josh Yamamoto (14:51):

And then I started to practice.

Bill Walton (14:53):

And then he started to practice. And I think he got a lot out of those 28 years. A very wise man. I think of him almost as a guru or a shaman when it comes to healthcare and the medical practice much more than the mechanical stuff you think of as medicine. And we’re talking now about how you really want to develop a one-on-one personal relationship with your healthcare provider.

Josh Yamamoto (15:18):

If you can.

Bill Walton (15:20):

Well, that’s the big question. Most people are intimidated when they go to the doctor. And most people don’t want to be there. They only show up typically when there’s something wrong with them. And then they’re defensive. And usually, the doctor will tell you, “Well, it’s all your …” You don’t do it. But people say, well, they say, “Well, you shouldn’t have been doing this. Tell us about your habits. Well, that’s a bad habit, so this is your fault.”

Josh Yamamoto (15:43):

So, one of the things I’ve also realized is that everybody has their perspective of their experience with their doctor or in the healthcare system, but it’s amazing how broad it is. Many people have exactly the perspective you required, but some people, doctors are somewhere between priests and bartenders or therapist. I’m your cardiologist. Why are you telling me? I joke with my patients all the time. “That thing you’re telling me about doesn’t pump blood. Why are you asking me?” So, there are different people who seek out different levels, but no matter what, to have somebody [inaudible 00:16:21].

Bill Walton (16:21):

Well, I go to you about everything.

Josh Yamamoto (16:22):

Well, hypothetically, all doctors go to medical school at some point.

Bill Walton (16:26):

My foot hurts. What’s going on?

Josh Yamamoto (16:28):

What is that? They still joke-

Bill Walton (16:31):

I’ve got a training injury.

Josh Yamamoto (16:32):

There’s a saying that I used to at Hopkins like to say, “If it’s not the heart, I’m not interested.” And that’s not exactly true, not exactly what I said. But you have to understand the whole person and the whole process, even if you are a specialist because I’m sorry, all these things interact. And you keep really bringing out the thing that you have your own perspective.

(16:56):

And you also mentioned something that I don’t want to tell the doctor because he is going to say it’s your habit and it’s your fault. And this goes back to the notion of how we were trained, and it’s a little old-fashioned. And again, I’ll digress to say I still have a teenager at home, who never misses an opportunity to make fun of me. And whenever I do something a little old-fashioned, he’ll say, “Hey dad, what was it like back in the 1900s?” And I really think about that because yes, I went to medical school in the 1900s, as did most of the doctors you’ll see.

Bill Walton (17:34):

The 20th century.

Josh Yamamoto (17:35):

The 20th century.

Bill Walton (17:35):

Okay. All right.

Josh Yamamoto (17:36):

But it was the 1900s.

Bill Walton (17:38):

That’s true.

Josh Yamamoto (17:38):

And once you phrase it that way, it starts to rock your mind like, “Oh, my gosh.”

Bill Walton (17:43):

By the way, this one you have at home is pretty smart, too.

Josh Yamamoto (17:47):

He is. He’s smart enough to want to be an aerospace engineer and not a doctor, I’ll tell you that. But the notion is that we have all of these ideas, and this is where we developed the disease model of medicine, which is wonderful, but we are moving past that. So, what do I mean? In the early 1900s, in the 1800s, medicine was based on symptoms. “Come to me when something hurts and I’ll see if I can help. Fine.”

(18:15):

But then came penicillin, marvelous. There are germs. They cause disease. And we can actually treat the cause, not just, “Oh, you have a cough and you can’t breathe here, let me beat on your chest and take you to altitude.” Or whatever we could do in the 1800s and early 1900s. We began to understand that human suffering was driven by diseases. And the late 1900s was an explosion of understanding.

(18:42):

And so, everything we tried to say is a disease. And there’s a lot of validity to that to understand what’s happening. But we have to be careful about the labeling. Go back and read the Old Testament. If you had a disease, that’s God’s wrath. You did something wrong. Leprosy is an infection. Okay. You’re not necessarily being punished.

Bill Walton (19:10):

But you talk about the disease model, and this is an oversimplification, but it seems to me that a lot of us have fallen into this trap or this pattern, where you have something wrong, you’ve got a symptom, and you go to the doctor and now there’s a pill. And it seems like there’s a pill for everything.

Josh Yamamoto (19:30):

Pretty much.

Bill Walton (19:30):

And the number of pills, when I was a kid a long time ago, and there weren’t that many pills.

Josh Yamamoto (19:35):

Back in the 1900s.

Bill Walton (19:36):

Back in the 1900s. Funny, I’ll think about that. I got to think about, really that brings you up short. There was a pill, not many pills. You’d had aspirin. You had a few other things. I’m sure if I were older, there were other pills to treat things. But now it seems like everything there is a pill and what’s happening here?

Josh Yamamoto (20:02):

So, there are a lot of marvelous things happening as we really are understanding human function, biology on a molecular level. But I always like to emphasize to my patients, and when I talk, “My degree is in physics. I actually know almost nothing about biology. And I know almost nothing about molecular biology or genetics, but it’s remarkable what we do know and what we’re learning.”

Bill Walton (20:26):

Well, when you say molecular, that brings the pill in because the pills are aimed at the molecular.

Josh Yamamoto (20:31):

And we are getting remarkably good at an amazing number of things. But as we get older and go through time, there are things that naturally happen. So, this is where we, at the foundation, are always emphasizing, it’s a process, particularly in our older, older meaning over 50, over 60, but aging starts when we’re born.

(20:58):

Pediatricians in some ways have it easy. If you do almost nothing, people grow up and get better. But if I meet somebody at 65 and do nothing, they will wear out and die prematurely. But we have the option of helping that. And so, if a process is going on. So, if I can give you one basic example.

(21:18):

The leading cause of death is supposedly heart disease. It is heart disease. And I always roll my eye at that notion because heart disease isn’t one thing. It’s like if you take your car to the mechanic, it says, “Oh, I know what’s wrong. You have engine trouble.” Really? How did that help? So, you have to understand what is the process of affecting the heart.

(21:40):

And so, in the late 1900s and still today, the number one cause of death is, let’s say a heart attack. Well, we now understand what’s happening. What it is is our arteries age over time. We have 100,000 heartbeats a day. Now, I’ll drive your sound guys nuts and do this. That’s 100,000 smacks on every single blood vessel every single day. If I do that on my palm, by the end of the day, I’m going to flay the skin off my hand. Yet this is a natural process that is supposed to happen.

(22:14):

Eventually over time, that wear and tear really beats up the arteries, and we have a healing process. This is where the molecular guys understand the biology of healing. We call it inflammation. Inflammation is our body’s natural healing system. We are supposed to heal. We need to heal. But the essence of life is intrinsically traumatic. We have wear and tear. So, all of our arteries will age.

(22:43):

And as we heal, we grow plaque. And so, we’ve been telling people, “Plaque is a disease. You have artery disease. It’s your fault because you had a cheeseburger.” You know what? You’re going to grow plaque. You’re supposed to. It is a natural aging process. It’s not a disease.

(22:59):

Okay. “Well, if that’s a process, shouldn’t we understand it?” “Well, actually we do. We’re very good at the molecular biology of this and the mechanics of this.” “Oh, well, why can’t you cure it?” “Well, you know what, how do you cure life? You don’t cure it, you manage it.” Ah. There’s no real good reason for anyone to have a heart attack anymore because we can prevent that. But it’s a two-person process, the doctor and the person, the patient.

Bill Walton (23:26):

Well, I want to dive into your book, which Maureen here on camera and Sarah have both read it and so am I, just extraordinarily taken with how clear this is. And Sarah said it reads almost like a mystery where you’re…

Sarah (23:50):

Thriller.

Josh Yamamoto (23:51):

Thriller. We try to demystify everything.

Bill Walton (23:54):

Thriller. Okay. Well anyway, it is a thriller and you got chapter one, prevent is an active verb. I highly recommend this. You can prevent a stroke because it’s also a clue as we’re going to talk a little bit about bone health and metabolism, other sort of systems that you can manage as well. But I’m not sure where we should dive back into this. But it just seems like once you think about a stroke or managing it, you never think about it the same way again.

Josh Yamamoto (24:30):

Right. And this book actually came in a very short story. A patient of mine that you may know, a guy named Bill Lilly.

Bill Walton (24:39):

Yeah. I know Bill.

Josh Yamamoto (24:40):

Died a little while ago of cancer-related things. He saw an article or news story a couple years back, all exciting, the latest treatment for a stroke, put a catheter up in your brain. And a stroke, just to understand, is a blood clot to the brain. And oh, we can do all these exciting things. We can stick catheters and tubes and suck out clots. And that sounded really great. Obviously, it’s not simple to do and not something you would wish on anybody. Let’s stick a tube up into your brain, but it can be done.

(25:15):

And so, he asked me, he said, “Josh, wow, this is exciting. What’s the best way to treat a stroke?” And I said, “Bill, that is the wrong question. The best way to treat it, treat a stroke is to prevent it.” And he was really taken aback because that thought hadn’t occurred to him. “You can prevent a stroke,” he said, “And yes, Bill, you can.” And that’s where the title of the book came from.

(25:36):

To be honest, the original title of the book was The Baby Boomer’s Guide to the Prevention of Vascular Dementia. And that is exactly what the publisher’s response was like, “You’ve got to be kidding me.” And this is where we-

Bill Walton (25:52):

Vascular dementia.

Josh Yamamoto (25:54):

Vascular dementia. This is actually where the foundation-

Bill Walton (25:56):

Is that a stroke or is that?

Josh Yamamoto (25:58):

Vascular dementia, which is more commonly thought of as senile dementia, senile to a doctor medically just means age related, age related, senile, things that happen over time. And so, if you interrupt blood flow to the brain, if you have inadequate blood flow to the brain or block it off or clot it up, you’ll damage the brain. Gee, that’s not exactly a hard concept. If I don’t pump blood to my brain, the brain suffers.

Bill Walton (26:28):

Now, what’s the specialty that gets involved after you’ve had a stroke?

Josh Yamamoto (26:32):

After you’ve had brain damage, then you need to see a neurologist.

Bill Walton (26:36):

But your goal is to never have to see a neurologist.

Josh Yamamoto (26:38):

Exactly.

Bill Walton (26:39):

Because they can’t prevent it. They can only tell you what’s not going to work.

Josh Yamamoto (26:43):

It’s not their job. You’re going to go to a brain doctor and say, “How do I …” No, you do. You can. But if you go to a brain doctor, and we work with neurologists all the time, and I always joke that if I do my job, if I do my job well, they’re not going to see any of my patients for at least not for strokes. Because the standard model is, oh, there are risk factors because it’s a disease. And so, the risk factors, of course, most of them are your fault. So, you treat your risk factors. Don’t smoke, treat diabetes, cholesterol, blood pressure, the standard risk factors.

(27:24):

But see, I just pointed out that vascular aging is chronic vascular blood vessel inflammation is an integral part of life itself. So, we don’t like the term “risk factor”. Why? Because that implies that there’s an element of chance. It’s not a question of chance. It’s simply a matter of time. Your heart’s not going to stop beating. Well, everyone heart stops once.

Bill Walton (27:53):

Eventually.

Josh Yamamoto (27:54):

As long as your heart’s beating, you have this relentless aging process. So, get away from this notion of, “Oh, if I treat my risk factors.” And this is what we’ve been teaching people. So, a young healthy guy, 35, 40, 50 runs well, quite fit. Again, the definition of health, mine is are you going to live long and live well. A lot of peoples are, “I’m fit.” Just because you’re fit does not make you exempt from genetics and time. And so, you say, “Oh, atherosclerosis or plaque.” And again, we taught people that you don’t want a blockage. But that’s not the issue.

Bill Walton (28:34):

Well, in my world of running and triathlons and that sort of thing, all sorts of everybody’s fit until they drop dead.

Josh Yamamoto (28:40):

Exactly. Fitness is wonderful. You had another thing you mentioned that when we grew up, there was a pill for everything. I love to tell my patients, “I do have a pill for almost everything, but not for fitness. You’ve got to do that. There is no pill for fitness.”

Bill Walton (28:56):

Most people don’t want to hear that.

Josh Yamamoto (28:57):

They don’t want to hear that. And fitness matters, but it’s not mutually exclusive from biology and medicine.

Bill Walton (29:04):

Yeah. This is Bill Walton. I’m here with Dr. Josh Yamamoto, I think one of the country’s best thinkers about all things related to cardiology. And he’s written a terrific book, You Can Prevent a Stroke, but we’re also talking about the links of cardiovascular health to dementia. And I’m going to recommend we send a couple thousand copies of these books over to Capitol Hill and also the White House. I’m not going to single anybody out. I’m sure depending on which side of the aisle you’re on, you have different candidates for this. But this is a must read even for those of us who may not be quite into that dementia column.

Josh Yamamoto (29:46):

Yes. And I am no longer the cardiologist to the Congress, so I have no input over.

Bill Walton (29:51):

Well, you had that job for a while.

Josh Yamamoto (29:51):

I did. I did.

Bill Walton (29:51):

How long were you there?

Josh Yamamoto (29:56):

Well, I was in the Navy for a little over eight years. And again, I got lent to the Army in 2005. And of course, after that, my wife informed me that I will be going into private practice when I come home from the war.

Bill Walton (30:06):

She missed you.

Josh Yamamoto (30:07):

She did. But the thing is really, the Congress itself is a great illustration in my mind. I just saw the cover of the New Yorker, which has everybody in their walkers trudging along and they call us a gerontocracy. And you know what? I have 85-year olds, 87-year olds running marathons. I have a 98-year-old woman, who complains that she outlasted all of her tennis partners. We are living longer. So, we want to live well.

(30:38):

And yes, the foundation was started in large part to try to help with dementia programs. So, how on earth did a cardiologist get involved? And it’s because as we age, circulation always changes. That’s a natural part of aging. And if your goal isn’t, “Oh, I’m going to do the latest procedure, I’m going to stamp out disease.” These are all…

Bill Walton (31:03):

How does your circulation change?

Josh Yamamoto (31:05):

Okay. There are three important things that are universal with aging. And it doesn’t mean we all do it the same way. The first and the easiest to address is chronic vascular inflammation, which I mentioned there’s a lot of ways to study it, but hey, wear and tear. My knees aren’t as good as they used to be. It’s a simple mechanical issue. That’s the number one cause of death because it leads to plaque.

(31:32):

And again, we told people you don’t want a blockage, but it’s not a question of blockage. Imagine drinking from a pipe. No, you don’t want the pipe kinked, so you can’t drink from it. But what you really don’t want is a pipe to be full of rust.

Bill Walton (31:48):

But my layman thought was plaque forms, piece of plaque breaks off that goes to the brain or the heart, then that’s what kills you.

Josh Yamamoto (31:58):

Not quite. That’s close. But the plaque makes the pipe rough. When I give the lecture out to people, I have a picture of a metal pipe and it’s full of rust. It’s the most disgusting thing you’ve ever seen. And I said, “Look, this has nothing to do with the human body. This is just rusty pipe.” And I say, “It’s not blocked. It has flow. But do you want to drink out of that pipe?”

(32:24):

The real problem is that rusty pipe, the plaque likes to crack and clot. The first part of healing is actually clot formation. We call it the thrombo-inflammatory response. So, clotting is part of healing. Clotting is actually part of plaque growth. So, in the heart, the clot can suddenly block an artery. You don’t have to have symptoms.

(32:49):

We’ve actually known for a long time that it’s not blocked arteries that kill people. It’s arteries with growing plaque, soft, young growing plaque that’s not blocking anything. It’s not giving you symptoms. But the plaque can crack and it can clot and completely block an artery. And that can cause sudden death. Sudden death is not the same thing as a heart attack.

Bill Walton (33:11):

Well, you’re not making me feel better about plaque though. Sounds to me like that’s-

Josh Yamamoto (33:15):

But plaque is easy, easy.

Bill Walton (33:19):

And what’s the pill for plaque? Is that that statin that you’re-

Josh Yamamoto (33:23):

Of course. But first, you don’t feed it. See, this is where we get into this notion of risk factors. They’re not risk factors. You’re going to grow plaque, give yourself time. You feed it, number one, with smoking. That’s easy. We all kind of know smoking is bad there. I said it, whatever. You smoke, that’s on you. But believe it or not, I really hate saying this, statins are more powerful than cigarettes. You can die of your lung disease, but I can still keep your arteries clear with enough medicine. That I probably shouldn’t quote because you don’t want to smoke.

Bill Walton (33:53):

Don’t want to do-

Josh Yamamoto (33:54):

But the biggest one is diabetes or the metabolic syndrome. And this is the hard one that confuses everybody. If we have a genetic metabolic mismatching, if we are eating something that we’re not genetically prepared to metabolize, you store that. And again, I’m not a molecular biologist, I’m a mechanical guy. But if you start storing that calories, you get resistance to insulin, insulin levels rise, sugar levels rise, and those things are very irritating to blood vessels, pro-inflammatory and you encourage plaque growth.

(34:30):

So, smoking and diabetes are the big two. Notice I didn’t say cholesterol. We actually don’t treat cholesterol. We treat people.

Bill Walton (34:41):

Well. I was very proud, I’ve got good cholesterol numbers. And then you reliably told me, “Well, that doesn’t really matter.”

Josh Yamamoto (34:49):

It’s not that it doesn’t matter. It’s helpful to not feed plaque. But the next step is to say, “This isn’t disease. This is a natural process which we can manage.” And the issue is inflammation, not cholesterol. Cholesterol feeds inflammation. It matters. Wouldn’t be great if I had a magic pill that shuts off inflammation and prevents plaque growth. Why? Yes, we do. It’s called LIPITOR. Any statin you want, they all work.

(35:15):

Now, there are people who don’t tolerate statins. Fine. We can work with that. We have other choices. How aggressive do you need to be? It’s not based on your numbers or, believe it or not, diet has very little to do with it other than that metabolic pathway. But you don’t want to feed plaque and you want to stop it. And it’s actually pretty darn easy to stop. Heart attacks are going to go the way of rheumatic fever.

(35:41):

Rheumatic fever. And if you had the sore throat as a kid in the 1930s, we didn’t have enough penicillin or we didn’t have penicillin at all. And that rheumatic fever could chew up your heart valves, and that could be terrible. Heart disease in the early 1900s was rheumatic heart disease. People don’t have heart attacks. I mean, maybe, but you died of infection and rheumatic fever. But we don’t hear about rheumatic fever now. Why? Because we have penicillin.

(36:08):

So, give it another generation and heart attacks will be a thing that people like, “Oh yeah, I remember those.” So, you stop plaque growth. And if you have enough plaque, you also have to prevent the clot, which is what the aspirin’s about. Aspirin’s marvelous. It’s a whole nother discussion about how pediatricians and obstetricians told us to stop taking aspirin. That’s a different story of the US Preventive Services Task Force.

(36:36):

But atherosclerotic disease, plaque formation, natural aging readily stoppable. But that’s not the only thing that happens. Really quickly, the other two things that happens is arteries do stiffen. Stiffer pipes mean higher blood pressure. Higher pressure means more work on the heart. So, I can beat up your heart just because I’ve made it overwork.

(36:56):

This is where the exercise comes in. If you say, “I don’t want to have stiff heart or stiff arteries, and I don’t want to beat up my heart and get so short of breath because my heart’s inefficient.” Exercise. So, we tell people, “High blood pressure, that’s a disease.” It’s a number. The question is what’s the health of your arteries and what’s the burden on your heart?

(37:19):

And yes, there’s a lot of things you can do for pressure, but at a certain point, you can run around in circles all day and be a triathlete and you can still have vascular stiffening that’s just genetically programmed. Yeah. We can help with that. Easy to treat pressure. Lots of pills for that if you need to. People are pretty keyed in on pressure.

(37:41):

The third issue that’s really important in our now 70-, 80-, and 90-year-old population is the fact that our electrical system wears out. What? We’ve known this for a long time. We just don’t realize how important it is for our older population. The baby boomers and whatnot.

Bill Walton (38:04):

What’s our electrical system?

Josh Yamamoto (38:05):

The heart’s just a muscle.

Bill Walton (38:07):

Okay. Which part of it is electrical?

Josh Yamamoto (38:10):

So, the muscle squeezes and beat when it’s told to. Now, my arm, sorry, my arm muscle contracts when my brain tells it to. The heart will tell itself to squeeze. There’s a little spot in the heart that sends out the electrical system signal. It’s literally a voltage. It says, “Time to beat.” And so, we have our natural pacemaker. It’s called the sinus node. It says, “Time to beat.”

Bill Walton (38:35):

And that wears out?

Josh Yamamoto (38:36):

It does. And the reason why everybody actually knows that but hasn’t been thinking about it is if you go to the gym, you can look at that big graph, and there’s a chart that says, what is your expected heart rate over age? And our joke is it’s the graph of everything with age, it always just goes downhill.

(38:54):

But guys look at that and we say, “Oh, yes, if I’m 70, I’m not going to run like a 17-year-old.” No, that’s actually not what the graph says. But the graph says is your heart rate, your ability for your heart to accelerate is going to be impaired as we get older. It’s aging. There’s nothing you can do about that, which is a drag. Actually, it’s annoying and it’s irritating for those of us who are a little bit of a control freak. “I want to be able to run and stay healthy.” Well, great, you can be healthy, but your electrical system is going to wear out.

(39:25):

Just last week, my car, I hadn’t driven in a while because we were on vacation, I turned it over, it would not start. And my mechanic is like, “You have a 10-year-old car, that’s an original battery.” And here I’m going, “Oh, but I changed the oil every 3,000, whatever.” There’s no maintenance I can do that’s going to extend the battery. I can make it worse, I’m sure by a lot of ways, but some things wear out.

(39:50):

Okay. So, what happens? As the electrical system wears out, the heart relentlessly likes to beat, and it starts to become irregular. And this is one of the most important parts of being 70.

Bill Walton (40:03):

But you have a solution.

Josh Yamamoto (40:09):

There’s no one solution.

Bill Walton (40:11):

Well, I think at this point you start talking about things like pacemakers.

Josh Yamamoto (40:15):

Well, it depends on the course.

Bill Walton (40:17):

And that used to be a sign of your heart is terrible. You got to pacemaker, terrible, terrible, terrible.

Josh Yamamoto (40:21):

So, yeah, pacemakers are…

Bill Walton (40:21):

Now, you’re saying if you age, you get to a certain point.

Josh Yamamoto (40:24):

You earn it. I love telling people, “You have earned that pacemaker because you’ve lived long enough that you’re perfectly healthy.”

Bill Walton (40:32):

You now qualify for a pacemaker.

Josh Yamamoto (40:35):

You deserve it. If we live long enough and you’ve done your job and you took your statin, you never had a heart attack, you stayed fit, your heart can run perfectly healthy, but it’s just too slow. The real issue, slowness is one thing, but it encourages the atrial fibrillation, which is the heart’s natural [inaudible 00:40:58].

Bill Walton (40:57):

So, you’ve now earned your pacemaker.

Josh Yamamoto (41:00):

Eventually. I haven’t earned mine yet. I’m still working on it.

Bill Walton (41:02):

All right. Well, I’m a little older than you.

Josh Yamamoto (41:04):

You’ll get there. All of my 100-year-old patients, and I have quite a few, have pacemakers, and they’re very active and they’re cognitively intact.

Bill Walton (41:13):

Well, I had to add this real quick. How do people find you on the internet?

Josh Yamamoto (41:18):

I imagine I could be Googled.

Bill Walton (41:20):

We’re going to put … Well, you don’t have much, but you’re very modest, man. You don’t have to put a lot out there, which is very interesting given your level of accomplishment. We’ll make sure we get your contact information as part of this.

Josh Yamamoto (41:33):

Our practice is, I have plenty to do. The foundation is what we’re trying to grow.

Bill Walton (41:42):

Well, let’s pivot towards that. I mean, I want to finish up on the heart now that we’ve gotten to the pacemaker part of it. I’m done.

Josh Yamamoto (41:51):

With that is the atrial fibrillation. Real quick. About one third of 70-year olds have a sustained irregular heartbeat. I like to tell people it’s a description, not a disease because we’re all going to have irregularity. A third of 70-year olds, particularly if they have a history of higher blood pressure, will have atrial fibrillation. Ninety percent of them do not feel it.

(42:13):

We really want to emphasize symptoms do not predict risk. I don’t care if you don’t feel it because as little as five minutes of atrial fibrillation is enough to double your stroke risk. Because with the irregularity, blood doesn’t move. It clots and it gets into the brain. But you can prevent that. But you have to know you have it.

(42:33):

And then of course if you have a stuttering heartbeat, sometimes people just blank out. But that’s the type of thing one must record to know what your heart’s doing.

Bill Walton (42:45):

Let’s turn to the foundation.

Josh Yamamoto (42:46):

Yes.

Bill Walton (42:47):

Because this is something that everybody can participate.

Josh Yamamoto (42:54):

Excuse me, a little more than a decade ago, I told you Dr. Thomas was tracked to be on the Johns Hopkins faculty. She really is an exceptional and brilliant physician. And of course, she made the tragic error of marrying a sailor and moving to Washington. But we notice in Washington, we have an aging community. People tend to be very health conscious and proactive. The Post did a story a couple years back that the average age in the ZIP code around our practice is 90. So, people are living longer.

Bill Walton (43:29):

What?

Josh Yamamoto (43:30):

Ninety, yeah. It’s not uncommon.

Bill Walton (43:32):

Average age in our ZIP code is right around 90 and near Foxhall.

Josh Yamamoto (43:36):

Yup, exactly. I’d love to take credit for that, but I’m not sure people appreciate it. The story in the Post was actually about the differences in different parts of town. But the thing is, everyone over 65 has the same insurance. It doesn’t matter who you are. When you have Medicare, your access to healthcare, just a question of where you can get. But be that as it may, Medicare is a whole another topic.

(44:01):

At Hopkins, the academic setting had devised a dementia program, whereas in the community, we weren’t seeing it in action. And there’s a huge gap between the academic world, my buddies, my fellow eggheads and former eggheads who come up with great ideas about how to treat a disease. And those of us who actually now are essentially full-time in practice taking care of people.

(44:31):

And that gap is growing and it’s quite astonishing. We’re like, “Okay, in a research project, you can manage this process and be very supportive and take these academic ideas and try to put into actual practice.” But again, one of the challenges with academic medicine is it’s more like a digital watch. If I’m going to see you as a patient, I kind of see you now.

(44:57):

I might think about the future, but my research study may only last for six months, 12 months, maybe five years. If you come to me as a patient, I view you as somebody that I’m responsible for for the rest of my career, period. Because I assume you’re biologically capable of living to be past 100. So, I have to do my job to take care of you over time.

(45:21):

But the gap between the academic world and the practical world of how we practice medicine is astonishingly wide and growing. And so, she tried to bridge that. And we tried to originally use things that were in place. And it was the number of roadblocks are vaguely mind boggling, which I don’t want to get into.

Bill Walton (45:45):

An example of a roadblock would be?

Josh Yamamoto (45:47):

Well, if you say we had a donor who wanted to support a program, they have to give the money to somebody. And we tried to do that through the existence systems, our local community hospital and whatnot, and they’re like, “No, no, we can’t do that, for all sorts of reasons. Well, they’re patients we can’t accept, or if we take this money, it has to go into for this purpose or that purpose, not for what you necessarily want to do.”

(46:17):

And we don’t want to create this program because it’s not monetizable or it runs in conflict with somebody else’s agenda. And we’re just trying to teach community doctors things that academic doctors have figured out that actually might be very helpful. And now this gap between physicians being able to learn things too-

Bill Walton (46:41):

So, Foxhall is bridging that gap? You’re between the academic and the day-to-day. And you’re a knowledge transmitter. You’re an agent of change to make sure that one side knows what the other’s doing, especially the academic side knows what the practical people are doing?

Josh Yamamoto (47:00):

That’s the next step. The first step is people who practice full time, they’re busy. And if you don’t think they’re busy, go ahead and try to call someplace and get a doctor. Just pick up the phone and call any cardiology group in town and say, “I need a new patient appointment. I have chest pain.” And currently, the average delay is way longer than you might think. It’s up to 60 days in a lot of places.

Bill Walton (47:26):

To be admitted to a practice?

Josh Yamamoto (47:27):

Yeah. Just to be seen as a new patient. Everybody is busy. So, the people in the community though, they don’t necessarily know what the academic world’s coming up with. So, the first step was the educational role of trying to bring academic knowledge and wisdom to the community. Now, we’re finding that the academic community is often losing touch with what people in daily practice are doing.

(47:56):

And again, the time factor is one of the biggest ones. I’ve taken care of people for 20 years and I’m going to take care of these people for 20 more. And there’s a lot of corporate knowledge. There’s a great quote. The founding doctor at Johns Hopkins is a fellow named Sir William Osler. And he said, “To practice medicine without academic study is to go to sea without a map. But to just do the study without seeing patients is to never go to sea at all.”

(48:30):

And now we have a new situation because never before in human history have we had so many 70, 80, and 90-year olds. It’s never happened. So, we have sailed off the edge of the map. And the academic institutions are the cartographers on the shore looking out to sea, plotting very fancy maps, they’re very good at it, they’re very bright, but we’ve sailed past where they can see, because I can spend all day and see nobody below 90-years old every day of the week. And they’re living well because we’ve spent 20 years managing that.

Bill Walton (49:05):

Well, I have so many places to go with this, but remember those ads for yogurt or where they’d have these 90-year old people in Finland or wherever they eat yogurt and everybody all decide they’ve got to go onto the Finnish diet.

Josh Yamamoto (49:24):

Yeah. If you’re a Fin, that’s probably a good idea.

Bill Walton (49:26):

It is. But I want to know what your ZIP code is because if the average age is 90, what are they doing in your ZIP code?

Josh Yamamoto (49:33):

Let see, what is it? The 20016.

Bill Walton (49:36):

That used to be our old ZIP code.

Josh Yamamoto (49:38):

Right. It’s in northwest.

Bill Walton (49:41):

It’s a high end.

Josh Yamamoto (49:42):

It’s a high-end part of town. And that, again, the Post story was just looking at census data and their rift on it was that the socioeconomic disparities are driving healthcare outcomes. But there’s more to it than that. There’s so many factors and it’s always perilous to try to pigeonhole everything into a single factor.

(50:10):

One of the things why I’ll never give up just actually being a real doctor, meaning seeing people, you get to practice medicine one person at a time. And I’m interested in how your life and your genetics are experiencing things, but I’ll never make presumptions. And I love to say that Ronald Reagan was the patron saint of cardiology when he said, “Trust but verify.”

(50:37):

So, you could say, “Hey, you’re fit and you run all this time. Great. Show me. And I’m going to look at your heart and I’m going to look at your arteries and I’m going to look at your rates and rhythms.” We call that the heart paradigm. D, heart D. You have to ask your doctor. You can’t look at your heart yourself. H, how is your heart? And how do we know? Are you just assuming that it’s healthy or did I actually check? It’s not hard. Just got to look at it with ultrasound. A, how are your arteries? “Well, I’m like a thin,” whatever.

Bill Walton (51:06):

How many cardiologists practice the way you practice-

Josh Yamamoto (51:08):

At least one.

Bill Walton (51:13):

Fortunately, I don’t have a lot of experiences of that. But it just strikes me that what you’re doing is just so axiomatic. And it ought to be everybody, every cardiologist in the country ought to be doing this. And part of the reasons we wanted to do this show is to get people more aware of the active steps you can take to protect your health. Including getting doctors to do all of the things that you do.

Josh Yamamoto (51:41):

You’ve asked a lot of questions in a very short question.

Bill Walton (51:46):

I do that.

Josh Yamamoto (51:48):

But cardiologists generally do not practice this way. For many reasons, some better than others. Most cardiologists do not think of themselves as a stroke prevention doctor. They view that as a primary care doctor’s role to treat risk factors. But we need to go beyond the risk factors. Most cardiologists are now corporately employed, which it is what it is. But then, that enforces a certain silo mentality. We do a lot of things. And most doctors, most cardiologists don’t do it like I do. I put in pacemakers. I put in pacemaker this morning.

Bill Walton (52:31):

Does it hurt?

Josh Yamamoto (52:32):

No. Are you kidding? People get all excited. Look, a little numbing medicine, a little incision, a couple of stitches. Usually folks are wide awake. Just let you know, it’s easier than going to the dentist for crying out loud.

Bill Walton (52:47):

Okay. I digress. Anyway.

Josh Yamamoto (52:48):

But I do my own imaging. In other words, I can use ultrasound to see any part of your heart and circulation of interest, and I’ll read my own pictures. And if I want to put you on a treadmill, “Just get on. Let’s go.” “I feel great.” “Good. Show me.” But I’ll do it myself and I see it all.

(53:04):

But that’s not the way industrial medicine works. You got a guy in the what we call the echo lab, meaning that’s the echo is the ultrasound of how we look at your heart. And it’s more efficient if one guy sits there and look at the pictures all day and generates a report.

(53:21):

Now, the doctor who saw you, “You come to me as a patient.” “Yeah.” “I want to know what your heart looks like.” “Well, of course you do. You’re seeing a cardiologist. Why wouldn’t I want to know what your heart looks like?” “Okay. Well, I got to send you down to have these pictures done. So, come back next week for that.” “Really?” But that’s the way it works.

(53:37):

And the guy who reads the picture is going to generate a report and it gets back to the guy who ordered it and he looks at the report. But a certain time, it’s pictures like the Mona Lisa. I can describe it to you. Brunette, smiling, kind of cute. But that doesn’t really tell you what the Mona Lisa looks like until you see it. So, I examine my own patients. You can, but on a corporate level, it’s less efficient.

(54:00):

And then you have different divisions. One of the biggest problems are people with weaker hearts often need pacemakers. They do lots of things. And the heart failure doctor, well, that’s a different division than the echo doctor and a different from the electrical doctor. And the heart failure doctor may say, “I need to adjust your pacemaker, but I can’t do that because that’s somebody else’s relative value unit. That’s their work unit.” And if they don’t meet their work units, they’re in breach of their contract.

(54:34):

And so, you are forced to divide out the labor, which also multiplies labor. So, you create more things to do. So, it’s difficult, which is why there’s a chapter in the book called Navigating Your Doctor, something like that. And currently, if you go to your doctor and say, “I want to know the health of my heart.” They’re not interested because the system’s not set up for that. You have to, “I’m short of breath.” “Well, you run hard enough.” But if you’re short of breath, that’s a symptom driven. What? Are we back in the 1800s? But that’ll work.

(55:10):

Guess what? If you run hard enough, you’ll be short of breath. Just tell them, I get short of breath when I run. And that will compel them to start asking, “Well, what’s the health of your heart?” You see what I’m saying? But the system is still in this fragmented, symptom-driven, siloed healthcare.

Bill Walton (55:26):

So, the line of action, because we’re drawing to our allotted time, which I hate, actually, every time we spend time together, I think he’s kicking me out of the office. I have more questions.

Josh Yamamoto (55:39):

I know.

Bill Walton (55:40):

But so, the line of action for everybody-

Josh Yamamoto (55:42):

Ask your doctor when they’re running late, just saying.

Bill Walton (55:45):

Is to read this book. And this is a handbook for taking control of your health.

Josh Yamamoto (55:52):

It’s a start anyway.

Bill Walton (55:53):

So, I interrupted you, I think about Foxhall. What’s the vision? What do you want to do to build that out?

Josh Yamamoto (56:00):

So, the Foxhall Foundation, again, began trying to bridge gaps between academia and the community, educational mission. I go around the country trying to talk mostly with doctors. We’re ramping up now into a research element. In other words, there is a gap in how we do research. We have databases. We’ve all been forced to enter in things in the community and electronic records, but the people looking at that in terms of actual practice.

(56:29):

It’s a whole different discussion of how research is currently being done. But it’s either being done by academia, which means it’s research under grant federal funding, which is wonderful, but it has a certain pipeline that it has to stay in. Or you have research funded by industry, which is marvelous, but it has a different objective.

(56:50):

So, what about the people just taking care of patients? We have the data, and it’s not just some, “Oh, we’re going to use AI to cure all disease.” That’s vaguely irrational. But we can use information to gain wisdom and to try to get inroads into the academic community to say, “Look, this is community data. It has validity.” Just because you didn’t design the study doesn’t mean you can’t learn from the wisdom of those of us who have sailed off the edge of the map where you haven’t been to tell you what’s out here in the new world.

Bill Walton (57:26):

That I think is a great summary. This has been fantastic. Dr. Joshua Yamamoto, author of a fabulous book, cardiologist, extraordinaire, wise man. And I think also, we’ve decided we want to live in the ZIP code where Josh practices in DC. So, Josh, thanks for joining and we’ll have you back to follow up. I have lots of lines of action that went unexplored because of time. But anyway, thanks.

Josh Yamamoto (57:57):

My pleasure.

Bill Walton (57:58):

So, this has been the Bill Walton Show, and hope you enjoyed this visit backstage to life as we really live it, as opposed to the policy world and its abstractions and strangeness here. We’re really concerned. This show in particular is the things vital to our day-to-day life. And we hope to do more shows like this and hope you enjoyed it.

(58:20):

And send us your comments to either on Substack or the billwaltonshow.com website. And of course, you can catch the show on all the major podcast platforms and YouTube and Rumble, and show’s also on Substack. You can see it there. So, anyway, thanks for joining and we’ll be back soon, I hope, with another interesting and entertaining episode.

(58:44):

I hope you enjoyed the conversation. Want more? Click the subscribe button or head over to the billwaltonshow.com to choose from over a hundred episodes. You can also learn more about our guest on our Interesting People page, and send us your comments. We read everyone and your thoughts help us guide the show. If it’s easier for you to listen, check out our podcast page and subscribe there. In return, we’ll keep you informed about what’s true, what’s right, and what’s next. Thanks for joining.