Whose Evidence Counts? Trump, Peptides, and Selective Skepticism

David (00:00) Two experts can examine the same evidence and reach opposite conclusions. At that point, most of us tell ourselves we're following the science. usually following something else fear, identity, distrust, and whether we like the person delivering the answer. This week, from peptides and testosterone screening to Trump inserting himself into the World Cup spotlight, we ask a harder question than who's right. Why does the same evidence suddenly count differently when it comes from the other team? This is Shrink the Nation. Let's go. David (01:09) Alright, welcome back. I'm David. I am a board certified psychiatrist. I have served in the military over twenty years and this morning I'm drinking a big old cup of coffee because it is very early in the morning. So at some point halfway through this thing I'm gonna have way more energy than I currently have. But what the hell, Robbie, let's give this a go. Rob (01:30) Hey, good morning everyone. This is Rob. also board certified psychiatrist, also long, long time in the military. and this morning I am doing my standby black rifle coffee and I doubt I'm gonna ever end up with more energy than I need. I've crossed the Rubicon in my life in terms of ever having more energy than I need. David (01:53) I don't know what to do with that, Robbie. Rob (01:55) You know, I don't either. you hit a certain point in your life in which you realize that, excess energy is just not a thing you get anymore. You gotta meet it out. So let's do this. I've got just enough in the tank to get through this podcast, I believe. I have no promises in terms of whether I'm gonna make it to next week though. David (02:12) Well our tens of listeners appreciate your effort, I Rob (02:15) Uhhuh. I'll probably be winded by the end of this. let's get it done. David (02:19) right. This week we're gonna do something that we haven't in a while, I hope. but we're gonna try to stick to a topic that is apropos for the news of the week, but also not one hundred percent focused on Donald Jehosaphat Trump. And I think we're gonna do it. Rob (02:37) I don't think we will. there's like five things I've already want to talk about related to but David (02:42) Damn it. Rob (02:42) Let's try. No, David (02:43) Damn it. Rob (02:44) it's fascinating and I spent a good deal of the week actually thinking about this. on one hand, I am literally bored stiff with the man. I'm just bored. Every time I turn on the TV Every time I check the news, every time I read anything, somehow his face is there and he's in the middle of it and he's doing something else. And he's so ubiquitous that I truly am sick of it. But there's some dynamic in that being ubiquitous thing and getting numb. We're getting desensitized that I'm almost to the point where I'm not even listening to some of the stuff. that is relevant because there's so much irrelevant stuff coming at me with his face and name attached. and I am glad you broke the code that J stands for Jehosaphat. that has troubled me for quite a long time. now we know. David (03:34) Yep, I think that's what that means. I think so. But who knows? I don't think there's Rob (03:37) it's it it ha it has to be. David (03:40) a way to know. Rob (03:41) when he was born they looked at him and Mama Trump said This young man looks like a Donnie and his dad said and we're calling him Jehosaphat and there we go. David (03:51) actually one thing. I have to make a retraction to something that I had said before. Rob (03:55) wow. David (03:55) and this goes back. This one actually bothers me enough that I feel like Rob (03:59) we have journalistic integrity, folks. that's what's going on here. David (04:02) Well yes. I have to go back and retract it because I very confidently said something to you in a past episode. I don't know which one. This was don't know, a year ago. I had a strongly held belief that the integrity of the medical system was such that they would not falsify the documented height of our president. I did not feel like that was something that would ever be done. But this week During the World Cup Finals ceremony, there was a picture of Donald Trump standing right next the president of FIFA, Infantino, and he was standing across, like right next to one of the players on the winning team. Viva La Espania. And it is very clear that Donald Trump is not anywhere close to six foot three. The player in question is six foot three. and Infantino is six feet tall. so based upon the visual evidence of him standing next to. Both of these men, I would confidently say he is not six foot three. Whereas before I was very confident that he's one of the tallest presidents of all time because they have listed him as six foot three in all of his medical documentation. I just didn't think that was something that the medical community would bother fabricating to just appease him. And it turns out Fuck man, I was wrong. I was super wrong. And this goes back to his first presidency. Donald Trump I don't know what he is, but I know he's not six three. He looks to be maybe six feet tall. Why does that matter? I don't know. But I was like, fuck you, Robbie, he's six three. Rob (05:42) so thought number one, and this is just the reality of medicine, when is the last time after pediatrics in which your height was measured? Not in the military. Outside the military. yeah, yeah. Yeah, yeah. Yeah, that David (05:53) I was gonna say boot camp all the time in the military. I got my height measured, yeah. All the time. Rob (05:59) that That that's super unique. The military always does height weight, height weight, height weight. but think about in your medical career, et cetera, et cetera. When is the last time that your height was measured? David (06:10) feel like right now in this moment I am this many days old learning that it is not common for an adult man to know his exact height unless he has served in the military. I never considered that otherwise because my entire childhood went directly into the military at seventeen years old. spent my entire adult life in the military, it has never crossed my mind that your height is not regularly considered. Rob (06:39) Yeah. So that might be the simplest and least fun answer of why there's a disparity between the stated height and visual evidence for the height. is that, you know, patient comes into their adult internal medicine doc. Doc says, What's your height? Patient says, six foot ten. Doc looks at him, thinks Probably not. Puts it down anyway. because we don't care that much. it is not super relevant. and most people lie in the span of a couple of inches one way or the other, whatever. David (07:11) Are you talking about height or Penis length. Rob (07:13) both. David (07:13) it just depends on where you're measuring from, Robbie. Are you going from like base to tip or are Rob (07:17) Right. David (07:18) you starting around the gooch, you know? Rob (07:20) No, no, I I like to start from my vertebrae. My L four is is the appropriate David (07:24) Yeah. think the perennium is the right starting point to just be on the tip. Rob (07:28) Yeah, yeah. Exactly. Just just beyond. it's like when you do a waist measurement. you don't tighten it, it's gotta be loose. so that's the most innocent answer. The other thing that did occur to me though when you brought this up, is that one, apparently this was the best FIFA. of all time, whatever that means. David (07:47) It was incredible. There's never been anything like it. Rob (07:51) Uh-huh. Uh-huh. let me come back to that one because that one cracked me up. But I think it would be incredibly challenging to be the physician for Donald Joseph at Trump. the pressure that is placed on these relatively young physicians that end up being White House physicians who are taking care of the president. and the reality is, and you've know this, I mean he he's seen at Walter Reed. it's a military facility. this is active duty docks, and some of them are certainly senior docks, I'm sure, but they're still relatively young, career wise docs. And they're beholden to a lot of forces that would potentially affect how they write things, when you are Given an option of documenting, you can document conservatively or less so. And I have a feeling that they're very thoughtful that their documentation is going to make it into national news and be viewed by the patient. When you know your documentation is going to be viewed by the patient, you document a little differently. David (08:51) I don't I think that right there speaks to your age versus mine, growing up in the medical field with more EMRs versus paper charts and things and what patients will actually eventually see. But nowadays they document under the assumption that the patient could potentially see all of their paperwork and hopefully they're documenting what they would document regardless of what the person sees. But you're right. you are right. especially for the president. Rob (09:17) there's a little bit difference because their documentation actually does become national news. and some of it's supposed to be released. it's not that this White House has been terribly transparent about health issues at least as previous White Houses have kind of traditionally been. but you make a good point. modern physicians, physicians of your generation and upcoming are more accustomed to electronic medical records in which patients have a my chart and they can look at things. So it has changed a bit. Back in my day we were handwriting stuff and that chart, it might as well been like something from Raiders of the Lost Ark. It was gonna go into a warehouse. No one was gonna ever find it again. David (09:56) And even if they could, it was written in fucking hieroglyphics that only pharmacists and nurses could read, Rob (10:02) Yeah. David (10:02) Worst part of my day when I see paper charts still. Written by somebody who has an active seizure disorder. Rob (10:08) Right. So speaking of tell me what FIFA stands for. David (10:11) I have no idea. Something federal, Rob (10:13) Seriously? David (10:14) international, fucking I don't know, football association. I've no idea, man. am a true blooded American. You say football and I say hike. All right. not flop myself to the ground so that the other guy gets a red card for looking at me wrong. Rob (10:28) it's Federation Internacional de Football Association. So yeah, the federal David (10:34) Okay, I close. Rob (10:35) yeah, yeah, you were real close. So the International Federation of Football Associations so somehow in this FIFA championship in which Spain who do they even Viva La Spain, who who did they play? David (10:49) Dina. Rob (10:49) Yeah. So and Argentina was the reigning champions, weren't they? David (10:53) Yes, Messi was playing. Rob (10:54) Okay. Yeah. Yeah, yeah. So Spain won. my understanding was it was you know, as far as soccer goes, an exciting match. that means they scored a goal, as opposed to like zero goals. Yeah. And it's no wonder we all know that guy that screams go Because he only has to do it one time a match. I mean, it's the most boring sport in my mind. That's neither here nor there. I'm sorry to offend our few t Yeah. Yep, yep, yep. David (11:19) Wow. gonna yeah, you definitely offended people. I know very little about soccer, but nothing makes you more of a soccer expert than talking to somebody who knows less than you. Rob (11:29) at David (11:29) That's what I found. Rob (11:30) so my understanding was this was this was a fantastic event, that it was very successful, that the folks who came to the United States enjoyed themselves, the cities that opened their doors to these international teams did a great job. they were very welcoming. it actually was good. It was good and it was a successful event. why, pray tell, did I flip on the news and see a picture of DJT standing with the Spanish football team. how did he get involved? How did he get his way into that? David (12:00) I think the real answer is that as the host nation, it's actually really common for the president or prime minister or whomever of the host nation to be there for that ceremony. I have to be fair. It is hilarious to watch Donald Trump show up in that Rob (12:15) But standing with the wedding team? David (12:17) that's the part that's yeah, when he starts lingering around as the trophies going up and being celebrated, that's where it gets into the territory of well this is odd. it's yeah, of course he was there. He should have been there it's the host nation, But once the trophy's been handed off by, him and the president of FIFA and whoever the fuck else, once they've handed that off to the winning team, it's then their moment. And I think that's what you're getting at, why was he in the middle of their moment? Rob (12:46) Yes, yes. Why is he so ubiquitous? Why is he everywhere? And why is it lacking any cohesion? We're in the middle of a war that's not going well. the Red Sea The Houthis have shut down the other side of the oil routes. we're still attacking Iran. We have more service members who are killed. we've got now twelve and a half percent, whatever it is, worldwide tariffs. there's so many things going on, and he just is everywhere and there's no cohesion. I'm getting numb. I'm getting desensitized to his presence. And it has made me wonder whether that is a tactic. Or a function of his psychodynamics. David (13:27) No, that makes a good point. I'm trying to wrap my brain around how the very first thing we talked about was not talking about Trump to then immediately talk about Donald Trump. Rob (13:37) Well, and then at FIFA, let me hit on this one. This one killed me too because it reminded me of the Nobel Peace Prize. So it made a big deal about the trophy. And the quote was, they said, Could you hold this trophy for a little while? So we put it in the Oval Office. And then he said, When are you gonna pick it up? and he said, never gonna pick it up. You can have it forever in the overall office. So it's in the Overwatch. And they made a new one. Why would the Oprah office have a FIFA championship trophy? Just like why would there be a Nobel Peace Prize hanging from his wall? David (14:11) why would the Oval Office have Spain's FIFA trophy? It is odd. one could potentially argue that if the USA had won, they wanted to celebrate by having it in the Oval Office. I mean, that happens all the time, right? There's a trophy case in the Oval Office, isn't there? for all of the work that the president puts into. No, it is very okay, that's weird. Did that happen? Is that real? Is that fucking real, Robbie? No. No Rob (14:32) And and the that's that's real. And then here here's the other thing. The captain the Spanish football team, his name's Reese James, I believe, but they asked him about Trump being on stage with them and he he said, I wasn't expecting him to lift the troth be with us, but I guess it shows how big of a deal it is. David (14:54) So fucking weird. Why is that a thing? It's so weird, Robbie. It's so weird. Okay. Rob (15:01) as I'm watching this thinking just how awkward and weird it was, I think, my gosh, there he is again I can't have a moment of peace. He's gonna start showing up on some streaming show on Netflix. anything that I pick up, it's you know, whatever. he'll make a guest appearance. And I realize just How bored I am with it. And I imagine so are the American people. I don't think I'm that unique then I think about the psychological concept of desensitization how if you are presented with a stimuli over and over and over again, you do become numb to it. it ceases to be relevant that when you're bringing in information into your brain, that thing that's pushed into your face over and over again gets downgraded. in importance. it blends into the background. it occurred to me that is this psychodynamically driven or is this calculated? to numb everyone? maybe this is something he's done forever. and I can speak to that slightly but then I stepped back from it and thought, how much of all this four-dimensional chess that people want to apply to him is just pure psychodynamically driven, not thought-through behavior that then we are trying to make some kind of cohesive plan out of it. we're trying to see it as if it has a bigger connection. Certainly not. This is just not three-year-old who likes to be in the center of attention. Certainly not. That can't be. So we make it a big deal. We make it this plan. I walked away a little contemplative, we'll say, as to what is going on with all that. David (16:42) I think that's a really tough question to ask. it just doesn't seem like there's really a black and white answer. I do think it maybe leans more in one direction than the other. But it has that feeling as if there is some intention to it from a outside forces. But that it's primarily driven by internal forces on his part, so that psychodynamic need to be center of attention is definitely seems as though it's there. But it also serves a purpose for external objects. for instance, Project 2025 this was a strategy that had been planned out before his election even that They would just flood the zone with changes. and this isn't new to Donald Trump. It's not new to Project 2025. This was the whole shock and awe method of doing anything. Just slam so much information out there that it's difficult to track. he has survived off of this. his entire political career. It's flood the zone with him, his behaviors. but then there's that piece that you get with the media. it hasn't really changed our behavior yet. Maybe it should, but with our clips of our episodes If Trump's name appears in the clip title, it is going to get more views than if it doesn't. we go from like one to eighty or something like that. Rob (18:07) Tearing it up is what we are. David (18:09) yeah. Almost viral. Rob (18:10) Killing it. David (18:10) so the media definitely feeds off of the fact that he is everywhere because they want that piece. so there's some driving factor outside of it. But I think where it gets into the psychodynamics probably is more the fact that he is willing and able to be that. Whereas our past experience with presidents hasn't been I want to be the news story. they've tried very, very hard to not become newsworthy. yeah it's a little bit of both Rob (18:38) potentially. just for our tens of listeners, let's imagine an individual with a narcissistic personality structure. not making any diagnosis and not putting a name to it. so one of the interesting things about f folks with narcissism Is the way they end up stabilizing their internal sense of self is through external validation. And to a degree, we all do this. we all kind of use the world around us as a mirror to how we're doing. So when we're receiving lots of approving nods of the community or our significant other it gives us a little bit of a data point saying, okay, I'm doing all right. and that does help stabilize our ego. Now, for most people, hopefully, in an ideal circumstance, and certainly none of us are completely clean when it comes to psychopathology, but Most of us also have an internal sense of self, that's enduring, that you can make a misstep, you can disappoint someone, that doesn't send you into a spiral of who am I? am I good? am I worthy? Folks with narcissistic personality structure are much more dependent on external validation in order to stabilize their sense of self. so They project greatness, they project an aura of confidence so that they can get from the external world, the people around them, that kind of approval and that kind of support. Theoretically, someone that was structured like that would have this internal drive to perpetually be the center of attention, in the midst of something important, The golden child in the spotlight. And that would make them feel pretty good for a while. And then they would leave the spotlight and they would go into their own internal space, by themselves. And that would stabilize them for a while, days, weeks, hours, apparently, in this theoretical case. so they would just be driven to perpetually be the news story and have that opportunity to show themselves as competent, capable, important, grand. But it could never be enough. if there's no ability to internally stabilize the ego, it's never gonna be enough. So that's a possibility here. That it's just this drive to go. There's another possibility that it's all calculated, that they are shooting to desensitize us to the point where we just stop listening. We stop thinking, we stop paying attention, and then other stuff gets done. because we're not paying attention anymore. My speculation is, and you've nailed something too, there's a variable that we can't necessarily account for, which is the modern world, that it's It's clickbait, it's 24 hour news cycles, et cetera. I hadn't really thought through that. So damn you, David, I had a very clean theory and you've ruined it. but I'm gonna go back to my clean theory and I'm going to say you messed it up. But if it was calculated, then I would expect an outcome that's much more cohesive than we're seeing. Initially when this administration took office, that was calculated. That was flood the zone. they had stacked up 30 things that they wanted to do and they just rolled them out so fast. Well, a hundred. Okay. David (21:49) Hundreds, hundreds. It wasn't thirty it was hundreds. It was like two hundred and something things. Rob (21:54) Okay. So they stacked them up and they rolled them out so fast that it was almost impossible to respond to them. And what we're seeing now, a year and a half plus out, is that finally the court cases and the things that actually stopped those things. a significant portion of those things have actually been halted, stopped, whatever, because of legal things, but it took forever because they flooded it. So that was calculated. I think we're at the point now where that if it was calculated there'd be more cohesion, there would be an ends to a means. And I don't think we're seeing that. We're just seeing kind of random activity now. the things that should be focused on don't seem to be getting the kind of attention that they should. The attention's everywhere. So I'm actually of the opinion that this is more psychodynamically driven. And then I'm fascinated how we, particularly his supporters, take that and make it into four dimensional chess. And I don't think it is. I don't think it is. nor do I think four dimensional chess exists. It's not a thing. David (22:58) yes, I think the primary driver of his actions are psychodynamic in that he wants to be the center of attention. I don't think he is playing 4D chess. but I do think there is method to this madness from the external sources in some ways because it has this feeling as though psychodynamics is powering the vehicle that is driving the benefit from the external sources. So his willingness to participate in this. Is seemingly driven by his own desire to be center of attention, but the benefit to those around him in getting the things that they want to achieve. And I think they've said this before. It's been said that people don't necessarily like him or the things that he says or does, and they don't necessarily even approve of his flaws. But what they do like about Donald Trump is that He gets things done that they like. so if there was any 4D chess being played, I think he is more of a pawn than player, if that makes sense. Rob (24:03) It does. It does. That's very very possible. David (24:05) a willing pawn, because he's getting to play the role that he wants to play, which is center of attention. but why is he able to be the center of attention all the time? one, because he gets clicks, he gets views. two because the more attention that he gets for the things that he's saying or doing, the less attention that is put onto the actual outcomes of the things that he's saying or doing. I would argue that his lack of long term focus on anything that's not central to him. he has a really long memory when it comes to people who have wronged him. But a very short memory when it comes to outcomes of decisions that he's made. I think that really plays into his ability to task switch to things that just bring him more in his mind positive attention. you were talking, the thing that I was thinking about was this hypothetical person you keep talking about with narcissism. Generally the burnout doesn't come from them. it's not that they get burned out of being the center of attention. What happens is the people around them get so fucking burned out from having to deal with the douchebaggery that comes with having a narcissistic personality structure that that person can no longer get the attention that they're seeking. And they have more losses than wins and then they burn out. but when has there been situation where Somebody's wins, we'll call them, are perpetual with the people around them all seemingly colluding to keep the wins happening even when there aren't wins. we look at cabinet meetings where It's a parade of humiliation and praise upon him, do we really believe that they actually believe the things that they're saying out loud? Rob (25:46) No. I don't know. I've just been flummox this week, David, so David (25:51) I don't want to tear a hole in your theory 'cause I think you have a real point, but the image I kept thinking about as you were talking about these things, it's like a snake eating its own tail. This is just something that it's not gonna end because it's this continuous cycle of somebody who really, really wants and needs praise and people who are more than happy to give it because it's getting them to where they want to be. So it's two competing sides or even three competing sides all getting what they want as long as they all ignore reality. Rob (26:23) Yeah, I guess where I'm stuck is that it it really feels like there's so many things that are being mismanaged right now in a pretty profound way. irrespective of evidence at hand, it's being pushed forward, tariffs being a good example, the Iran war being a spectacular example, that we're throwing good money after bad and then i step back from it and i think theoretically in the world of someone with a narcissistic personality structure their ability to mentalize a world in which they're not the center of it is so limited and when you can't mentalize a world where you are not the center stage, you're not the core of that world. it's really difficult to make good decisions for the whole, because what you're really doing is making decisions for yourself. And you can't imagine a world in which you don't exist anymore. So making decisions for a future in which you do not exist, that's just non existent. That doesn't happen. So what we're doing right now is making incredibly short term decisions with no real thought for what's the world look like in five years, ten years, fifteen years. it feels very muddled to me right now without a cohesive plan of how we're walking into the future. I think there's a reason for that. it's just a touch unsettling, frightening. Terrifying. We have a blind man driving our bus. David (27:56) you gave me a lot more hope in what you said just now than I've had in a while. I actually feel quite uplifted in this moment. Maybe it's the caffeine finally kicked in. But I feel good because what you described and what we're seeing, it actually lays out really nicely in something I think is really positive. because we've had examples of this before. in fact, we have a lot of examples of scenarios just like this. The scale is different than what we're used to seeing, but it's not unheard of. When you have a system that is being built upon the internal needs of one person and for that person to be the center of attention, at first things can look okay, because time hasn't elapsed yet. living in this reality that we're all in right now, time is feeling to elapse quite slowly, but it's been a year and a half. but you have the makings of what other countries have gone through with authoritarian leaders, that's essentially it. When you have a system To just build up this one person, just do what they say and ignore the reality of what they're doing. it can last, but it never lasts forever. the hope that you just gave me though, is that while our executive branch is being twisted and changed to really fit this internal idea that Donald Trump has for himself, the other systems are just now starting to catch up to that. The judiciary specifically is handing out the losses, they're making those decisions that are starting to crash his party. that's where I have some hope that this isn't something that can last as long as our judiciary and eventually our legislative branch start to play stronger roles what you described is high control group with a leader who starts out as being benevolent, but as their need to be the center of attention grows and grows, and the group has to give more and more to maintain that, all the negative effects of that start to happen and the group erodes. And then the floor falls out from underneath them. then the leader is gone. yeah, there's going to be a lot of things broken, but this system is actually built and designed to change hands every four years. but the things that are keeping him upright right now, they're already starting to break. the people who thought he could manage the economy when he never could before. but those things are starting to fall apart as they do. But his focus isn't on what's falling apart. His focus is on how do I get more attention on myself and gain wins. he was the anti-war president, apparently, but we're in the middle of a war that he started. he's the economy businessman president, but The economy's doing terribly. He's bankrupted everything he's ever touched. So it's gonna be difficult. but I have hope because what I see is that it's not something that can last. It's already starting to happen. I have hope. Or Caffe. Maybe it might be the Caffey. Rob (30:42) We'll take either. honestly I'm to the point that if it was methamphetamine that was required, I might ponder it. I might at least give it a hard look. David (30:51) Yeah. no, I wouldn't Rob (30:52) So David (30:52) do that. I wouldn't I don't know that I do that, but Rob (30:54) Hey David, at this point in the show, let's talk about what we were gonna talk about. David (30:58) Sure. but first You know what doesn't fix politics, Robbie? Yelling at strangers on the internet. Rob (31:04) No David (31:04) that's why we built the Shrink the Nation civic desk. You pick an issue, tell us what you actually think, and we'll help you write a thoughtful letter to your elected officials without making you sound like you just escaped a mental hospital. We don't tell you what to believe. We just make it easier to say it. Less outrage, more influence. So check out the civic desk at shrinkthenation dot com. Look at that, an actual ad for an actual thing that actually exists. you're dumbster. Rob (31:26) For an actual thing. No, I'm gonna I'm gonna highly recommend that our tens of listeners take a few minutes of your life, go to shrinkthenation.com and really look through the website. There actually are lots of interesting things there. There's some features that are really quite useful, the civic help depths being one of them. and I think they'll be thoroughly impressed. it's a good way when you're sitting in the waiting room killing 15 minutes, take a look. David (31:54) Yeah. I'm proud of it. I'm having fun with it, the website has some cool stuff. you have access to the much more in depth perspectives of our episodes, which are actually really useful. It's got the links. Everything we talk about moving forward gets fact checked and you can go into our episodes and see where we're all fucking really wrong. or if there's something that we talked about that you thought, that's interesting. There's probably a link to it. So I think it's probably cool feature. Robbie, I want you to imagine that you bring your kid to the hospital and one of the docs comes in and says, We gotta operate right now. Next doc comes in and says, Yeah, I don't know that we need to operate at the moment. Maybe we should. hold off for a second while we do some more testing. Which one do you believe? Rob (32:34) boy, so two experts, different sides of the same opinion. that puts you in an interesting psychodynamic quandary. and we're assuming both are truly experts, correct? David (32:45) Yeah, Rob (32:46) Okay. David (32:46) two surgeons in the hospital, Rob (32:48) Right. David (32:48) equally accredited, they just have a differing opinion in this one. Rob (32:52) Right. So what you end up being stuck with is whatever biases and fears and anxieties that you bring to the table. so what you bring into the room, when you have two expert opinions, so that's your data that you're working on, what ends up making the decision for you is whatever is inside of you, whatever you brought into this, and that's gonna be fears and whatever pre-existing knowledge or biases that you have. you're gonna make that call based on something other than objective fact. David (33:22) Yeah. the reason I bring that up is recent articles talking about peptides and an FDA meeting as to whether peptides should be Not approved, but Rob (33:33) made available for compounding pharmacies for wider distribution. David (33:38) There we go. So not saying that they're approved. It's just saying, we'll let pharmacies that otherwise can't use these start distributing them. Rob (33:45) can you define peptides for the folks who maybe aren't read in on what a peptide is? David (33:50) I think the interesting thing is it's just a string of proteins. That's Rob (33:54) Mm-hmm. David (33:55) all it is. It's a string of amino acids that are set up in a particular way that seem to have some sort of biological effect in the human body. Rob (34:02) Right. It's a catch all phrase that just references a short chain of amino acids. and what we're specifically referencing though for this discussion, are the ones that act as hormones, neurotransmitters, chemical messengers inside the body that tell cells to do something. so for example, insulin is a peptide. the G L P ones, GIPs are peptides, oxytocin and endor and David (34:27) what are GLP ones? Give it give us an example of GLP ones. Rob (34:31) Willgovy, semiglutide. so GLP1s were initially introduced to treat diabetes. They have been found to have significant weight loss effects. they modulate both the sense of say, and they also seem to have a direct effect on the reward centers in the brain. and have an impact on reward salience, in other words, craving. and they do also slow the GI tract. So they truly do increase sayity. So not only do they feel Yeah. Thank you. David (34:59) satiety, but they well and they and they're made in the b I mean, GLP one's yeah, satiety, yeah, you say keep saying satiety. Rob (35:05) Hey, w would you do would you do a me a favor and when I say it that way, when you edit this, add a banjo in the background that really plays up the fact that I'm I yeah, David (35:14) Barbang ding ding ding ding ding. Rob (35:16) yeah. 'cause everywhere I go when I speak in public, I always imagine dueling banjos playing behind me. David (35:24) if you didn't have a piece of straw sticking between your teeth with those coveralls without a shirt, I think people probably take you more seriously, Robbie, but yeah. it is your look. Rob (35:30) Maybe, maybe. It's my look, David. It's my look. That's that's business casual. David (35:35) the thing with GLP ones, which are highly studied peptides, they're made by the body, but the volume of them, the amount that's given is significantly more than the body makes and when you give it and have it released all the time, which is kind of the whole point of the injections of the GLP ones. it has some interesting effects on the body this is the argument it comes down to should compounding pharmacies be allowed to produce these other peptides that are already being made and being distributed, but they're being done so in the gray market, these are things that if you listen to our show, you probably don't listen to the shows that talk about these other peptides. I think Joe Rogan likes to talk about one in particular. I don't know which one, but you're probably not listening to us and him. or maybe off. But see, I'm already doing the thing that I think we should talk about, which is it's attempting to delegitimize the value of these peptides, not because of the peptides themselves, but who is talking about them, who is selling them, who is saying that they're great. would I feel the same way about GLP ones, if Joe Rogan was talking about how wonderful they are? I don't know. But that's what this comes down to, I think, to backtrack a little bit, what happened at the FDA was that there were eight people on the board who were appointed by RFK Jr. And it was noted that several of them who were appointed by RFK Jr. work for facilities and clinics that sell the peptides that are in question. Then there were six members of the FDA who have been at the FDA for quite a while who were not appointed by RFK Jr. And when it came down to a vote as to whether these peptides should be allowed to be given to compounding pharmacies of which several of the people voting in favor of that happening had some kind of financial interest in those being made available. It was the people who were there long term said no, there's not enough data. The people who were appointed by RFK Junior said, Yep, let's do this because they're already out there and it's just safer to have these things compounded in a place that can do it. they all had access to the same data, but there's an obvious line drawn between who was in favor and who was against. And so Who do we trust? Who do we believe? that's the question. and why do I care? Rob (38:02) the one that Joe Rogan talks about, I think it's the BPC one five seven. Is that the one he references? The the one that the David (38:09) I don't fucking know. UFC thirty five. I don't know. He Joe Rogan talks about a lot of shit. I don't listen to Joe Rogan. Rob (38:16) Well David (38:16) do I sound like I listen to Joe Rogan? I don't give a fuck about Joe Rogan or what his thoughts are on anything. He's a comedian. Rob (38:21) Dude, you just you just crushed us. at any rate, the argument here is that these peptides are not medicines, that these are naturally produced peptides that our bodies make. and that theoretically, if you take them, you're taking them at at supra physiologic levels so at doses that go far beyond what our bodies produce and i'll use the glp ones so yes our bodies make glps they make them naturally when you eat your body makes them it just doesn't make them to the level when you utilize a glp one and Because you're taking it at a super physiologic level, it has a more profound effect. So you have a reduction in appetite, you have a reduction in what people often reference as food noise. And it it has been profoundly beneficial to many, many people as some really significant weight loss that historically we have never been able to achieve. And we have tried. I mean, there have been so many agents that have been attempted for weight loss. and they have you know universally been marginally successful, if not outright failures. and these do seem to work. they have been successful for a lot of people. And at this particular point they have taken off. there is a massive gray market for these things, and about one in ten Americans currently are in a GLP one or a GIP. So the argument is we're not approving a medicine. We know that this is a safe medicine. substance. We know that our bodies make it. So we're not introducing anything that is foreign this is a naturally produced thing and that's where the argument ends up lying is that it's safe because our bodies make them but for you and I we realize that and I suppose other people not just me and you when you introduce something at a supra physiologic level it has downstream effects that could be quite dangerous and things we can't predict. like the GLP ones, they do increase the risk of, I believe, of medullary cancers. they have downstream effects in terms of some GI side effects, biliary issues, things like that that can come up because of the changes that it causes. So ultimately folks that made the argument that look These are out there, they're being used, they're in the gray market, it's unsafe. we should just make it safe for people. They have an argument. They absolutely have an argument. The folks who are arguing, hey, we don't know what super physiologic doses of these things end up doing in the long term. We do not know the risks at this point. it would not be prudent for us to say they're safe. And if we make these available, we're basically saying they're safe. both sides have absolutely a perspective that is not unreasonable, but we're back to the two surgeons, one decision. and what ends up making the decision at that point are the things we're bringing into the room. And in this environment in particular, in this administration, in which we have seen so many levels of grift of money making. of taking advantage of being in the office for your own personal wealth, that it's very easy to start to question motive. and that's not entirely uncommon. The FDA for since I've been a doc at least and paid attention, there's always been certain speculations that medications get fast tracked or approved. for personal gain, that the board was paid off, that they have a vested interest in some way or other. this one is different and it did definitely fall on we'll call it party lines, but it fell on the group that had been recently appointed versus the group that was already there. it does create I guess an interesting question as to why. Why why did they approve them now and and was it prudent? Is this a game the FDA should be in? David (42:04) should the FDA be in the game. I don't know that I would say no, the FDA shouldn't have some say as to whether, treatments that are gonna be used are approved or not. I think that's kind of the whole point, the idea is public safety. having groups of experts to way evidence. And then make determinations b based upon that evidence as to whether or not something should be made available for widespread public use. just the safety of people. Otherwise we have chaos within a system that can result in a lot of harm to people. But the difference between my expert and your expert is a major issue. and it's something that even in this argument, trying to decide, what side am I going to fall on? and I think I'm going to find myself on the side of not RFK Jr. for no other reason than not RFK Jr. and so what do I do? I'm going to look for all the reasons why his experts are wrong. But notice that even in doing that, I'm not looking for all the reasons why my experts are right. and the truth is I know more about, and not a lot more, but I know more about the eight people who were recently appointed and potentially have conflicts of interest than I do about the six people who have been there for a long time and probably have conflicts of interest too. I just don't know or care about theirs. And I think that's the interesting mental gymnastics that even I go through when I'm reading this. But you brought up something we were talking about before, and I think you can much more eloquently overalls and all talk about, which is why this is coming up Why is it turning into that conversation of your experts versus mine? And why is this even a story? Rob (43:37) Well, I think it becomes a microcosm for where we sit politically right now. before we taped this, I was catching up on the news in the morning, which I'm wont to do. And there was a interview on one of the major news channels that does portray themselves as centrists, but they certainly have the reputation of being maybe a little anti Trump or left leaning. and they were interviewing A doc, peptide expert. And that doc was actually very pro-peptide. and the doc had a very reasonable approach to it. That she indicated that yes, she uses these peptides. it starts with an evaluation of the patient. What's the problem? What are we treating? what is the appropriate treatment? What is the time course that you you don't stay on these things forever, there's a goal to them. so she was presenting a very reasonable medical argument. The interviewer, however, absolutely wanted to bend it toward this is a yet another example of this administration misusing its power for personal gain. And it's a political issue now. It is this isn't a medical issue. This isn't you know an argument about medical evidence and what's prudent. From a medical standpoint, it has entered the realm of my guys versus their guys, red team, blue team. And that does end up making it much more interesting psychodynamically because we're no longer actually even looking at the evidence. there's no assessment of the actual evidence. we're looking at are gut instincts, and you probably said it the most that when you heard it, your gut instinct was And you went and researched the eight good people that approved it. it's interesting that I find myself more in a bind that you know, I am of the opinion that humans have been driven by evolution to seek excess. And that excess kept us alive for 99% of human history, and we now live in that. time frame of the 1% in which the excess our drive to eat fatty foods, sugary foods, the things that actually kept us alive for going backwards thousands, hundreds of thousands of years, now it's what's killing us because we were not designed to have a McDonald's on every corner. So we have to utilize our technology to save ourselves as a species. I was actually pro-release, my gut instinct was. And then I looked into it and I started thinking grift, grift, grift, grift, grift. And I found myself shifting back to this is terrible. this is a miscarriage of science. This is awful. And none of it had to do with science. It was purely an emotional response. David (46:13) that's what's so interesting even in myself as I look at it is that no, I I I totally get that there are likely benefits to peptides. but the argument didn't come down to in my own mind about the damn peptides. It had nothing to do with the peptides. The argument came down who was deciding whether to release this and maybe more gray area on it is I I think we should be spending more time researching the peptides. I think we should understand them better before we're, using super physiologic doses of anything, putting that into your body, is that there can be phenomenal harm. Rob (46:48) even wait, second and third third order effects. Drink everybody. David (46:52) Drink everyone. the reality of it is I don't know that there's a clean answer that solves that problem. And we're not here to debate whether peptides are good or bad. It's really just looking at, well, why is it that I can be very pro-peptide but think this is a terrible thing? and why is it that I can be anti FDA, anti-medication, but then think this is a really great thing. I mean, this I can be super duper anti-vax, but think, This is great. and it really comes down to that. we're all looking at the same evidence, but we're making a decision based off of this gut feeling that's driven by factors outside of. logic. Rob (47:30) I guess there's an interesting psychiatry element to this. and I'm not talking the psychology of the decision making, I'm talking about what we do on a daily basis. So our illnesses are unique I shouldn't say totally unique, neurology has their set, rheumatology has their set, but most of our illnesses, vast majority, there is no lab value, there is no imaging study that confirms or denies. there is nothing that we have that is truly objective that guides our decision making when we engage in treatment with patients. We have the symptom reports of the patients, we have their family history, their past response to medications. And we end up making decisions that are based somewhere different than purely objective medical evidence. And in fact Oftentimes we're in a position where we're utilizing agents off label. and even when we're utilizing agents on label, the studies that made them approved for that use very often involved a population that is radically different, that is just like a shadow of a shadow of the actual patient that's sitting in front of us. so we have this algorithm of relevance and what's appropriate and what's prudent to use with our patients. And I think in a real world scenario, like the doc that was being interviewed, these peptides, the decision to take them or not, is going to be based on an individual situation because right is different for different populations. If I have a 22 year old healthy young man who comes into me who is normal weight and functioning well, then the bar for giving them a peptide is going to be radically different than if I have a 47-year-old man who is 110 pounds overweight with congestive heart failure, diabetes, etc. that bar changes dramatically based on the situation. And that's the reality of the medical part of this. and for the most part, more often than not, that decision is hidden from most of the population. This is a decision. This is a, pro peptide, antipeptide that has now made it into the public square and again becomes a microcosm of our politics right now and the tribal nature of them. David (49:44) Yeah. that just goes into the well, whose side am I gonna lean, towards and when I wanna make an argument for or against it. as a psychiatrist, as somebody who deals with a lot of addiction, I've never been a big fan of silver bullet medications and treatments that are used inappropriately. earlier you mentioned methamphetamine. well, most people aren't aware that methamphetamine is a very legitimate medication that was designed in the 1950s called disoxin. it was prescribed for weight loss and it's prescribed for ADHD. but we don't prescribe it anymore. Why don't we prescribe it anymore? Because you can make the shit on the street. and if you're prescribing methamphetamine for somebody. then they are going to test positive for methamphetamine when they're being tested for methamphetamine. and we have other newer, better treatments. But does that mean that everybody should get massive amounts of Adderall just because they want it? And I think that's where the discussion goes for me Rob (50:37) But that's the medical side of it. and that's again, when we think these through as physicians, we're thinking, my gosh, now that it's been approved and it's available, everybody's making this decision for themselves without the guidance of medical input. There's not an assessment of relevance to that individual. we know how people will go into, Walmart and overdose themselves on supplements. just because the bottle said this is good for your thinking or this is good for your prostate David (51:04) or a podcaster said it was great. Rob (51:06) because we've got a podcast and peptide code and access to PubMed. We're good. Nothing can go wrong. we see the downstream dangers and sure, they're there, absolutely. but there's also downstream dangers to not. pulling them from the gray market into at least a legitimate market where we can actually track, identify these downstream consequences. David (51:27) we saw this exact same thing play out with Pete Hagsith's announcement that they're going to mandate testosterone screening for males thirty and over and that TRT is something that's gonna be allowed in the population. But you and I even had maybe a disagreement on that. although the disagreement probably wasn't super wide. It's just that The first thing that I saw when Pete Hagsith announces anything is like is fuck here we go. Rob (51:53) Ha ha ha David (51:54) then to hear TRT being used widely within our soldiers, the thing that crossed my mind initially was they're already allowed to do hormone replacement therapy in the military. just certain ones aren't allowed because they're just difficult to deploy with. So if you're doing pellets or injections of testosterone, they're not going to let you deploy because you can't bring those things with you. But if you're doing gels, okay, that's totally fine. You can do that. they just want to make sure that your numbers are within the right range. that your hormone replacement therapy is indeed effective, that it's not causing your hormone to be way too high because then maybe you don't really need it. and that your blood values are within normal ranges because people get strokes when they're using this stuff, and we don't want people stroking out in the military or especially not in the battlefield, right? Rob (52:48) so the interesting thing is is you brought this to my attention prior to me actually seeing the source. So I did not see the press conference first. My background is in treating a population that upwards of 20 to 40 percent of them did have true hypogonadism. and I experienced it as a treater of an illness process that was associated with tons of problems. the feminization of their bodies, the loss of sex drive that had downstream consequences in their relationships, just their self-esteem as a man, was profound. And I struggled mightily to get their primary care physicians To take it seriously, to engage, to test them, to treat them. They just didn't want to. that was my experience. I ended up treating these things and got reasonably good at it because I was doing so much of it. So I had a bias coming into it. And when I heard that, I thought, all right, roughly one to five percent of the male population, 30 to 50, have symptomatic low T. upwards of maybe fifteen percent of that population have low testosterone, not necessarily so low that they're feminizing, but it's low and could be affecting them. And then for specific populations it can be upwards of twenty to forty percent. So is it unreasonable that we are screening men, for this? It it isn't. It isn't unreasonable. but you and I also know that testosterone ranges are pretty damn broad and someone could be absolutely normal, functioning very normal on the low end of that scale, or at the higher end of that scale. and that doesn't necessarily isn't sufficient. And in really in order to make a diagnosis, you have to have two AM fasting testosterone levels, both showing it being lower than the reference range. and when you talked about it, I immediately thought, hey, that's great. That is fantastic. It is an underserved need and it is terrible for men to have low testosterone or hypogonatism. This is great and it's gonna force the system to take it seriously. And then I watched the press conference and I immediately thought, fuck that guy. I I immediately thought, this guy's trying to make super soldiers. He's trying to get everyone all roided out. he's envisioning, big muscles and people killing others with their bare hands. and my opinion changed completely. It changed completely in a moment. And then I started thinking, and that was the interesting thing. I had the conversation with you, I'm pro. I see the conference, now I'm against. And now I came up with the 15 reasons why this is systemically and medically bad. all the problems that are going to come from this, all the challenges that docs are going to have managing these people, all the downstream consequences of the hair loss and the potential cardiovascular disease and the skin changes and all the things that come from excess testosterone. And that was purely based on. how the information was presented to me and my own biases. David (55:46) I laugh but that's the one reason I think we're talking about it is that your own framework shifts depending upon You. we're not necessarily always following what the science says. we're making our decisions based off of the outcome that we're looking for. its confirmation bias, what makes sense to me in what it is that we're ultimately trying to come up with? so how do we avoid that? what can what can our tens of listeners do to help themselves avoid what we're all going through, 'cause we're all going through it, Rob (56:14) yeah. intellectual honesty. And this is something we've talked about from a political standpoint, and it's the same dynamic. It truly is the same dynamic. you hear about that politician sex scandal. It's terrible. wait, they're on my side. you know, people lie. there's mist telling David (56:30) Ha ha. Rob (56:30) of the truth. so we have to be intellectually honest, and part of that intellectual honesty is identifying that flip. That happened with me, which I just said, way, that's fantastic. wait, fuck that guy. that's horrible. I could have let that little blip go and just been anti right from that point forward. But you do have to, you know, at least take the time to catch yourself and ask yourself, hey. My opinion just changed radically based on one press conference. is that intellectually honest? David (57:03) You start with your prescription, you always ask me and then you go first because they're always ruin your prescription, so you fucking go. Yeah. Rob (57:06) Okay. You you often do, yeah, yeah. All right. So my prescription for the week is we must stop asking only whether the evidence supports the conclusion we prefer. We must ask whether we would accept the same evidence, the same uncertainty, and the same burden of proof if it led somewhere we didn't want to go. Before you trust an expert, before you reject an expert, before you take a treatment, before you ban a treatment. Or declare yourself medically liberated by a dude filming from inside of a sauna, you gotta ask yourself three things. What do both sides agree on? what do they actually disagree on? And who bears the consequences if their decisions are wrong? being intellectually honest doesn't mean having no preference. You're gonna have a preference. but it does mean that you have to follow the science. And if you're not following the science, you're just joining a fan club. David (57:58) All right. And if your argument starts with, Well, everybody knows, go ahead and deduct five IQ points before you keep going. Alright. One last plug. doom scrolling, it's bad for your brain. So we replaced it with something equally addictive, but at least this one teaches you something. The Shrink the Nation arcade takes the psychological patterns we talked about on our show and turns them into retro arcade games. Spot manipulation, slow outrage, defend your sanity. New games are getting added pretty regularly and they're completely ridiculous. So Stop feeding the algorithm. Start beating it. And you can play now at shrinkhenation.com. so if you're just really, really bored and wanting to distract yourself for a few minutes, play one of our psychologically minded arcade games. some throwbacks to the eighties and the nineties, which is I think always fun. But if you want to get sucked into your screen, I think they play better on a computer, or a larger screen like an iPad, but you can play on a phone as well. give a try. Stringfination.com. Have fun with that. Why why does our podcast have arcade games? Rob (58:57) Why not? Okay. David (58:58) We're bored. why not have an arcade game? How many podcasts have their own arcade games? Take that show, Brogan. Rob (59:03) Yeah. David (59:04) and your hundreds of millions of dollars. We have arcade games. Rob (59:06) Ha ha ha. David (59:07) All Anything else, Robbie? Rob (59:10) Nope. David (59:10) Other than all right, folks, we really appreciate you. Hit like hit subscribe, share our stuff, play our games, read our web comics. Why do we have web comics, Robbie? Rob (59:18) I don't know. You were bored? David (59:20) I was bored, I guess. So we have all sorts of shit on our website. check it out because it is ridiculous. shrinkthenation.com. We appreciate you. All right, I'm gonna queue up that music and we are out.