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Dr. Peter Cram Discusses Health Care Delivery In Canada (January 13th)

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Considering the frequent favorable assessment of Canadian health care of late, by, for example, several presidential candidates and (surprisingly) the Trump administration via its recent decision to propose a regulatory pathway for US entities to import drugs from Canada, the question is begged how or how well do the Canadians deliver universal health care and at what expense.

During this 30-minute interview Dr. Cram begins by providing a general overview of population health in Canada.  He goes on to discuss moreover how care is organized and budgeted (or how spending is managed) in Canada, how care is designed (via an emphasis on primary care), the extent to which providers enjoy autonomy and patients suffer lengthy appointment/referral wait times and the prospects of Americans importing drugs from Canada.  

Dr. Peter Cram, an American citizen (a Connecticut native), is currently the Director Image of General Internal Medicine and Geriatrics at Sinai Health System and the University Health Network and Professor of Internal Medicine at the University of Toronto.  Previously, he was on faculty at the University of Iowa from 2002 to 2013.  Dr. Cram has published more than 180 research papers and is the co-founder of the International Health System Research Collaborative (IHSRC).  He earned his medical degree at the Wake Forest School of Medicine and completed his medical training at the University of Michigan.  

During this interview mention was made of Cram, et al., "Trade-Offs: Pros and Cons of Being a Doctor and Patient in Canada," it is at:


Andrea Freeman Discusses Her Just-Published Book, "Skimmed: Breastfeeding, Race and Injustice" (January 9th)

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Professor Andrea Freeman's recently published, Skimmed: Breastfeeding, Race and Injustice, explains how and why Non-Hispanic Black women are significantly less likely to breastfeed their newborn than White, Non-Hispanics and Hispanics.  Black, Non Hispanics are, instead, significantly more likely to feed their newborns formula milk.  That formula, manufactured by Pet, Mead Johnson, Abbott Labs, Nestle and others and consisting of corn syrup and among other ingredients enzymatically dydrolyzed soy protein isolate (Freeman terms junk food for babies) does not compare to breast milk (that consists of living human cells, active hormones, antibodies and hundreds of other unique components ideal for infant health) helps explains why Black infant (and maternal) mortality remains twice that of White, Non-Hispanics.  Why Black women use formula, Professor Freeman explains, is due to a myriad of reasons that include targeted Black marketing, Professor Freeman details Pet's use of the Fultz quadruplets (born in North Carolina in 1946), federal policies that support and endorse formula use by Black women and a web of other laws, polices and practices that obstruct the ability of Black women to initiate or sustain breastfeeding. 

During this 30 minute interview, Professor Freeman discusses Dr. Fred Klenner's contract with Pet to market the Fultz children and numerous other variables that explain why Black women are less likely to breastfeed.  Among others, she discusses the effect 350 years of slavery has played, stereotypes of Black women, formula milk industry motivations, federal policies that reinforce/subsidize these motivations, limited legislative and regulatory oversight and limited efforts by the medical profession to contain or prohibit marketing formula milk and encourage breastfeeding.

Andrea Freeman is an Associate Professor at the University of Hawaii's William Richardson School of Law.  She has also taught as a visiting professor at the University of California, Berkeley, School of Law, at the University of Denver Strum College of Law and has a Distinguished Scholar of Sustainable Agriculture and Food Systems at Vermont Law School. Freeman_AndreaBefore joining the faculty at the University of Hawaii, she taught at Santa Clara University School of Law, University of San Francisco School of Law, and California Western School of Law.  Professor Freeman is an active community member serving on the Litigation Committee of the ACLU Hawaii chapter.  She volunteers with the Kokua Hawaii Foundation, makes legal presentations to the Hawaii Judiciary History Center and Hawaii State Judiciary, and writes op eds on topics including Hawaiian sovereignty and race and health.  In 2015, Professor Freeman received the Community Faculty of the Year award from Richardson's Advocates for Public Interest Law.  Professor Freeman is the Chair of the AALS Section on Agriculture and Food Law and Treasurer of the AALS Section on Constitutional Law.  She is co-chair of the Law and Society Collaborative Research Network for Critical Race and the Law and a Founding Member of the Academy of Food Law and Policy.  After graduating from UC Berkeley School of Law, she clerked for Judge Jon O. Newman of the U.S. Court of Appeals for the Second Circuit and former chief Judge José A. Fusté of the U.S. District Court for the District of Puerto Rico.  Prior to attending law school, she worked in Toronto as a counselor for women and children who experienced domestic violence and in New York as a production manager in the independent film industry.   

Information on Skimmed is at:

The related CDC August 2019 Morbidity and Mortality Weekly Report (MMWR) report noted during this interview is at:


Essay: MedPAC and MACPAC Have Never Discussed the Health Effects of the Climate Crisis (December 30th)

On December 30th, The Hill published my essay titled, "Agencies Need to Discuss Health Effects Caused by the Climate Crisis."  At:  (I had titled the piece, "MedPAC and MACPAC's Historic Failure.")   As the essay or opinion piece notes neither commission has ever discussed, much less mentioned, the climate crisis despite the fact the health effects thereof will disproportionately affect the frail elderly and poor children, i.e., Medicare and Medicaid beneficiaries, or those whose health these agencies are suppose to protect.   


Harvard's Dr. Renee Salas Discusses the 2019 "Lancet Countdown on Health and Climate Change" Report (December 11th)

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The 2019 Lancet Countdown on Health and Climate Change (subtitled, Ensuring That the Health of a Child Born Today is not Defined by a Changing Climate), released in mid-November, identifies 41 indicators in five domains: climate change impacts, exposures and vulnerability; adaption, planning and resilience for health; mitigation actions and health co-benefits; economics and finance; and, public and political engagement.  Since this interview focuses on the first three domains, concerning the latter two, a few take-aways: in 2018 investment in fossil fuels increased slightly while investment in low-carbon energy slightly decreased; fossil fuel subsidies increased to $427 billion in 2018 or were 50% higher than in 2016; carbon pricing instruments in 2018 covered just 13% of global greenhouse gas emissions; in the US carbon prices averaged just $1/ton of CO2; regarding fossil fuel divestment, since 2008 investment funds committed to divestment equaled nearly $8 trillion with health institutions accounting for only $42 billion.  Concerning public engagement, in 2018 only 12% of health care companies referenced health in context of the climate crisis – however this was consistent with media and government communication that also does not typically connect the climate crisis with health.  Listeners may know I interviewed Dr. Jeremy Hess a year ago this week regarding 2018 Lancet Countdown report.   

During this 28-minute conversation Dr. Salas discusses moreover the Countdown's 2019 findings moreover regarding health impacts, exposures and vulnerabilities including heat-related illnesses, those related to greenhouse gas emissions/ambient air pollution, vector borne diseases and the disproportionate effects they have on children and the elderly.  Dr. Salas also discusses adverse effects the climate crisis is having on food security and nutrition, what, or what more, health care providers can do to respond to the crisis (including relevant changes in clinical training) and efforts during the just-concluded UN COP 25 (Conference of the Parties related to the UN's Framework Convention on Climate Change) meetings just held in Madrid - that Dr. Salas attended.

Dr. Renee N. Salas is an Assistant Professor of Emergency Medicine at Harvard Medical School and an Emergency Medicine Physician at the Massachusetts General Hospital (MGH). Salas_headshotShe received her Doctor of Medicine from the innovative five-year medical school program to train physician-investigators at the Cleveland Clinic Lerner College of Medicine. She concurrently obtained a Master of Science in Clinical Research from the Case Western Reserve University School of Medicine.  Subsequently, she received a Master of Public Health from the Harvard T.H. Chan School of Public Health with a concentration in environmental health while completing a Fellowship in Wilderness Medicine at MGH.  She now has a sole academic concentration on climate change and health. As a 2018 Burke Fellow, she is addressing the current research gaps in this field.  She served as the lead for the 2019 Lancet Countdown on Health and Climate Change US Brief and is a nationally recognized leader on this subject.

The 2019 Lancet Countdown report is at:  

The Lancet Countdown US Policy Brief is at:

Information on Juliana v the US, noted in the podcast introduction, is at:

Information on Naomi Klein's work, On Fire, The (Burning) Case for a Green New Deal, mentioned during this podcast, is at:  


SIDM's Paul Epner Discusses the Pervasive Problem of Medical Misdiagnoses (December 3rd)

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Twenty years ago last month the National Academy of Sciences published the landmark report, “To Err Is Human, Building a Safer Health System.”  The report found upwards of 98,000 people die each year in hospitals alone as a result of medical errors.  One specific medical error, diagnostic error, was, and remains today, a substantial contributor.  Defined as a wrong, delayed or missed diagnosis, misdiagnoses continue to constitute a major public health problem, adversely affecting more than 12 million annually.  Approximately one-third of whom are seriously harmed and an estimated 40,000 to 80,000 die each year from diagnostic failures in hospitals alone.  Resulting costs are estimated over $100 billion annually.  Despite the problem's pervasiveness and dire effects, the federal government spends less than $10 million annually researching the problem.  (For perspective, the 2019 NIH budget was $39 billion.)   

During this 30 minute conversation, Mr. Epner briefly describes the Society to Improve Diagnosis in Medicine's activities, discusses the use/non-use of autopsies in reducing diagnostic errors, the extent to which improved imaging technology is reducing errors and the extent to which this issue is a disparities problem.  He, moreover, discusses efforts to increase funding to address the problem, needed payment reforms, efforts to identify related quality performance measures and recently introduced legislation to improve funding and research.   

Mr. Paul L. Epner, MBA, is the Chief Executive Officer and Co-founder of the Society to Improve Diagnosis in Medicine (SIDM).  He is also Chair of the Coalition to Improve Paul-epner-new-300x300Diagnosis, a collaborative with more than fifty of the country’s leading healthcare societies, health systems, patient organizations, and organizations focused on improving quality.  He recently was named to the National Steering Committee for Patient Safety.  Mr. Epner is a Past President of the Clinical Laboratory Management Association (CLMA) where he also created the Increasing Clinical Effectiveness (ICE) initiative.  He was recently a member of the CDC’s “Clinical Laboratory Integration into Healthcare Collaborative” and a consultant to their Laboratory Medicine Best Practices program (an evidence-based practice initiative).  Mr. Epner is an Associate Editor for the peer-reviewed journal, Diagnosis.

Information on SIDM is at:

The 2015 National Academy of Sciences expert committee report noted during this interview, "Improving Diagnosis in Health Care," is at:

Recently introduced legislation to address misdiagnoses, i.e., the "Improving Diagnosis in Medicine Act of 2019" (HR 5014), is at:


190th Podcast Interview: the FDA's Captain Valerie Jensen Discusses Remedying the Drug Shortage Problem (November 20th)

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On October 31st, the FDA released the agency's Congressionally-mandated report titled, “Drug Shortages: Root Causes and Potential Solutions.”  The 124-pg report found drug shortages are increasing, persistent, i.e., the duration longer, with both the intensity and public health impact high.  These shortages can, the FDA found, “have a devastating effect,” by prolonging patient suffering, contributing to disease progression & increased morbidity.  Concerning root causes, the FDA found market consolidation has caused current contracting practices to constitute in sum a “race to the bottom.”   The FDA also found the market also fails to recognize or reward manufacturers for mature quality management systems and found a market that is unable to quickly recover after a disruption in either manufacturing or supply chain distribution.  Despite the worsening drug shortage problem, and the Congress’ considerable focus on drug pricing legislation this year, not a single drug shortage committee hearing was held this Congressional session or this year.  (Listeners may recall I posted in August a related essay I wrote on this topic for STAT).  

During this 28 minute conversation Captain Jensen begins by providing an overview of her day to day efforts managing the FDA's drug shortage efforts.  She moreover discusses the details of the FDA's report to the Congress, principally the report's recommendations, potential other related solutions including improving risk management planning, stockpiling and lengthen expiration dates, efforts by Civica Rx and Provide GX,  forthcoming FDA drug shortage guidances and potential for Congressional action. 

Captain Valerie Jensen is the Associate Director of the Drug Shortage Staff at the Food and Drug Administration.  She previously worked as a clinical pharmacist for Indian Health 13489989994_17efe0a9d4_o
Service hospitals in Arizona and New Mexico for nine years before joining FDA.  She has been with the FDA for the past 19 years leading FDA efforts to work with manufacturers to mitigate and resolve shortages of medications for the patients who depend on them.  Captain Jensen received a B.S. degree in Pharmacy from the University of Iowa in 1990 and upon graduation was commissioned as an officer in the U.S. Public Health Service.  She completed an American Society of Health-System Pharmacists Specialized Residency in Ambulatory Care at the White River Indian Health Service hospital in White River, Arizona in 1991. 

The FDA's report is at:

A related and recent Civica Rx report is at:

Again, my related August STAT essay is at:

(In my opening statement, I misspoke.  The drug shortage problem adds at least approximately over half a billion (not half a million), dollars annually to healthcare spending.)  


Chris Palmieri Discusses CCA's Efforts to Provide Its Patients Social Service Supports (November 14th)

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As has been widely reported the US spends upwards of twice what other OCED countries on medical care however with worse or similar outcomes.  What explains this is in part the fact the US spends about one-third of what other OECD countries spend on social services such as food aid, housing assistance and transportation.  This despite knowing research shows basic measures of health are more closely and positively associated with social service spending.  “It’s hard to escape the conclusion,” a 2016 Brookings Institute op-ed concluded, “that we should gradually be redirecting a lot of money from medical series to so-called upstream factors [or social factors] that are associated with health.”  This was precisely the same conclusion drawn by a recent/September National Academies of Science’s (NAS) consensus study titled, “Integrating Social Care Into the Delivery of Health Care.”  The NAS report concluded health care be redesigned to integrate social care into health care and that financing of health care integrate social care spending. 

During this 30 minute conversation Mr. Palmieri briefly discusses CCA's business lines, moreover its One Care its Senior Care Options health plans that serve Medicaid-Medicare  beneficiaries (so called "Duals") and Medicare beneficiaries under a a Special Need Plan (SNP) designation.  He discusses how his patient population is recruited and moreover CCA's  whole person care approach, accomplished in part via care navigators, that includes providing CCA's patients with social service supports, e.g., CCA's medically tailored meals plan and its mobile integrated health program.  He also discusses how CCA care is financed and the spending efficiency CCA care achieves.  He concludes with a brief description of CCA's WinterStreet Ventures, a CCA affiliate that pilots/develops innovations in care delivery. 

Mr. Chris Palmieri has served since 2015 as President and Chief Executive Officer of the Massachusetts' Commonwealth Care Alliance (CCA).  Immediately prior, Mr. Palmieri served Palmieri_Christopher_circleas the CEO of Remedy Partners, a bundled payment organization.  Prior still, Mr. Palmieri worked for ten years with Visiting Nurse Service of New York (VNSNY), as President and Chief Executive Officer of VNSNY Health Plans where he developed a $2 billion safety-net insurance organization.   Mr. Palmieri has also held senior positions with Amerigroup Corporation, Metropolitan Jewish Health System, Inc., and Faxton-St. Luke’s Health Care/Mohawk Valley Network.  In 2012, Chris was named one of Crain’s New York “40 Under 40,” a distinction for the top business leaders.  Mr. Palmieri currently serves as the Chair of the Association for Community Affiliated Plans (ACAP), and the Vice Chair of the national Managed Long-Term Services and Supports (MLTSS) Association.

For more information on CCA go to:

The Brookings' op-ed is at:

The National Academy of Science report, again titled, "Integrating Social Care in to the Delivery of Health Care," is at:


CMS' Dr. Kate Goodrich Discusses Measuring and Rewarding for Value (or Spending Efficiency) Under Medicare's Forthcoming MVPs Program (November 13th)

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On November 1st, the Centers for Medicare and Medicaid Services (CMS) published the agency's final 2020 Quality Payment Program (QPP) rule that announced beginning in 2021 CMS will begin instituting MVPs, or Merit-based Incentive Payment System Value Pathways.  These value pathways will be created to financially incent and reward, as CMS states, “high value clinicians.”  This means CMS will begin to measure and financially reward Medicare physician performance based on value or spending efficiency defined as outcomes achieved relative to spending.  MVPs may prove to be a significant Medicare payment policy reform.   This is because while Medicare program officials have implemented numerous "value-based payment" programs and demonstrations since the passage of the 2010 Affordable Care Act, these arrangements financially reward either quality - or - reduced spending growth, they do not reward “value” or spending efficiency.  In addition, as recently noted by Harvard’s Ashish Jha and his colleagues in a October 9th JAMA "Viewpoint" essay, these current "value-based payment" programs have not had large effects on quality improvement.   (Listeners may recall I discussed measuring for health care value or spending efficiency with University of Michigan Professor Andrew Ryan this past May 11th and in later May posted on the podcast website a related essay I wrote for Bloomberg Law.)

During this 30 minute conversation Dr. Goodrich discusses in sum CMS' proposal to implement beginning in 2021 Merit-based Incentive Payment System Value Pathways (MVPs).  She explains the rationale for using of global and population health measures and patient-reported outcome measures (PROMs) and how the agency will measure or evolve its MVP-related cost measures.  She discusses MVPs potential to increase provider productivity, the potential MVPs have in helping to harmonize Medicare three payment silos: fee for service, Accountable Care Organizations (ACOs); and, the Medicare Advantage (Part C) program, in influencing commercial insurance plans' payment policies through CMS' HCPLAN (the Health Care Payment Learning Action Network), and discusses the relevance or importance of social determinates or measures thereof in driving Medicare value. 

Dr. Kate Goodrich is currently the Director of the Center for Clinical Standards and Quality (CCSQ) and CMS Chief Medical Officer (CMO).   This Center is responsible for 18 quality KateGoodrichmeasurement and value-based purchasing programs including the Quality Payment Program, quality improvement programs in all 50 states, clinical standards and survey and certification of all providers across the nation, and coverage decisions for treatments and services for CMS.  The Center budget exceeds $1.2 billion annually. Prior to being CCSQ director and CMO, Dr. Goodrich served as the director of the Quality Measurement and Value-based Incentives Group in CCSQ from 2012 through 2015. She graduated from the Robert Wood Johnson Clinical Scholars Program at Yale University in 2010.  From 1998 to 2008, Dr. Goodrich was on the faculty at the George Washington University Medical Center (GWUMC) and served as division director for Hospital Medicine from 2005 to 2008.  She went to medical school at Louisiana State University in Shreveport, Louisiana, and completed her internal medicine residency and chief medical resident year at GWUMC.  She continues to practice clinical medicine as a hospitalist and professor of medicine at GWUMC.

The Quality Payment Program final 2020 rule that discusses MVPs is at:

Information on the HCPLAN is at:

The Bloomberg Law essay is, again, at:


Dr. Azra Raza Discusses Her Recently Published Book, "The First Cell and the Human Costs of Pursing Cancer to the Last" (November 1st)

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Dr. Azra Raza's recently published book, The First Cell and the Human Costs of Pursing Cancer to the Last, has been described as a "searing account of how both medicine and our society (mis)treat cancer, how we can do better, and why we must."  It has been termed "a clarion call . . . [that] repudiates the approach . . . that biomedical science has taken to attempt to find new treatments and curers."  The lack of progress in treating cancer is "an embarrassment" and "equally embarrassing is the arrogant denial of that embarrassment."  We spend over $150 billion annually on treating cancer and a patient diagnosed today is as likely to die from the diagnosis as a patient diagnosed 50 years ago.   

During this 35 minute conversation Dr Raza begins by discussing what causes cancer (we do not know or know completely).  She moreover discusses the urgent need for a new cancer research paradigm, i.e., the current use of tissue culture cell lines and mouse models have proven to be inadequate.  She also argues cancer researchers need to spend less time chasing the last cancer cell and instead ID the first cancer cell, i.e., we should place greater emphasis on early detection.  She explains her criticisms of the pharmaceutical industry and the federal government funding in researching effective cancer treatments.  Dr Raza also explains her relationship with her patients, her belief treating oncologists need to develop empathic relationships with their patients and she notes her view regarding palliative sedation. 

Dr. Raza is the Chan Soon-Shiong Professor of Medicine and Director of the MDS Center at Columbia University in New York.  She started her research in Myelodisplastic Syndromes (MDS) in 1982 and moved to Rush University, Chicago, Illinois in 1992, where she was the Charles Arthur Weaver Professor in Oncology and Director, Division of Myeloid Diseases.  The MDS ArazaProgram, along with a Tissue Repository containing more than 50,000 samples from MDS and acute leukemia patients was successfully relocated to the University of Massachusetts in 2004 and to Columbia University in 2010.  Before moving to New York, Dr. Raza was the Chief of Hematology Oncology and the Gladys Smith Martin Professor of Oncology at the University of Massachussetts in Worcester.  She has published the results of her research and clinical trials in numerous, peer reviewed journals such as The New England Journal of Medicine, Nature, Blood, Cancer, Cancer Research, British Journal of Hematology, Leukemia, and Leukemia Research. Dr. Raza serves on numerous national and international panels as a reviewer, consultant and adviser and is the recipient of a numerous of awards including the First Lifetime Achievement Award from APPNA, Award in Academic Excellence twice (2007 and 2010) from Dogana and The Hope Award in Cancer Research. 

For more on The First Cell go to:

Dr Raza's related 2006 3 Quarks Daily post, "Rx: Reductionist Vs.. Pluralist Views of Cancer," is at:

Per my mention of Thomas Kuhn's seminal, The Structure of Scientific Revolutions, the Wiki overview is at:


Dr. Rick Doblin Discusses the Potential/Real Therapeutic Benefits of Psychedelic Agents (October 31st)

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Psychedelic agents or drugs, for example Lysergic Acid Diethylamide or LSD (a cereal fungus and first synthesized in 1938), were widely researched for their therapeutic potential through the 1950s.   Among other noted users of these agents was the actor, Cary Grant.  However, when these drugs escaped the research lab in the 1960s, moral panic set in.  America's youth would, it was feared, "turn on, tune in and drop out" (a phrase popularized the Berkeley/Harvard psychologist Timothy Leary) and social upheaval would ensue.  By 1970 LSD, psilocybin and other psychedelic agents were banned for both research and recreational use purposes.  Beginning in the 1990s the FDA began giving limited approval to conduct psychedelic-related efficacy studies.  Two decades later it appears the US has now, finally, turned the corner on researching the potential wide spread therapeutic benefits of psychedelics.  This was again made evident last month when by Johns Hopkins announced opening its Center for Psychedelic and Consciousness Research.  This announcement was preceded in April by the Imperial College in London announcing the opening of its Centre for Psychedelic Research.  

During this 26 minute interview, Dr. Doblin begins by describing what effect these agents have on the brain or what parts of the brain are stimulated to what effect.  He discusses moreover his organization's MDMA (methylenedioxy-methamphetamine) research, currently a Phase 3 trial to study the effects on patients suffering from PTSD (oddly not supported by the DoD or VA), and a wide range of other current research efforts concerning treating, among other diagnoses, addiction, depression, eating disorders, phobias, OCD, schizophrenia and terminal illnesses.  He also weighs in on the future legal status of these drugs, again currently illegal or banned as Schedule I controlled substances. 

Rick Doblin, Ph.D., is the founder and executive director of the Multidisciplinary Association for Psychedelic Studies (MAPS).  He received his doctorate in Public Policy from Rick_doblinHarvard's Kennedy School of Government, where he wrote his dissertation on the regulation of the medical uses of psychedelics and marijuana and his Master's thesis on a survey of oncologists about smoked marijuana vs. the oral THC pill in nausea control for cancer patients.  His undergraduate thesis at New College of Florida was a 25-year follow-up to the classic Good Friday Experiment, which evaluated the potential of psychedelic drugs to catalyze religious experiences.  He also conducted a thirty-four year follow-up study to Timothy Leary's Concord Prison Experiment.  Rick studied with Dr. Stanislav Grof and was among the first to be certified as a Holotropic Breathwork practitioner.  His professional goal is to help develop legal contexts for the beneficial uses of psychedelics and marijuana, primarily as prescription medicines but also for personal growth for otherwise healthy people, and eventually to become a legally licensed psychedelic therapist.  He founded MAPS in 1986.

For information on MAPS go to:

Information on Michael Pollen's 2018 work noted during this discussion, How to Change Your Mind,What the New Science of Psychedelics Teaches Us About Consciousness, Dying Addiction, Depression and Transcendence, go to:

For a recent personal account of a psychedelic experience, see, for example, Helen Joyce, "My Adventures in Psychedelia," at: