Transcript of Dr. Mararchi’s Interview

Neil Haley: Hi everyone. Welcome to the special simulcast of the Neil Haley Show and Doc Tales with our host Dr. Royal Doc Allen Lindemann. Doc, what’s going on, man? How are you?

Dr. Alan Lindemann: We’re doing really well here, Neil, and you?

Neil Haley: Doing fantastic. And who is our guest today?

Dr. Alan Lindemann: Well, this is Fred or Ferdinando Mirarchi, I think, is the way you say your name. And-

Dr. Ferdinando Mirarchi: Yeah, that’s me. [inaudible 00:00:54].

Dr. Alan Lindemann: … we have some things in common. We’re interested in temporary encephalopathy. But tell me a little bit about MIDEO.

Dr. Ferdinando Mirarchi: Oh sure. Well first, thanks for having me on. Happy to be here. And MIDEO is something that was basically a product of some work I did as far as research in patient safety. I’m an emergency medicine physician by trade, and I made a mistake years ago. And I figured I didn’t want to have to make that mistake again, looking at video or paper-based advanced directives. And I created a concept called MIDEO, which stands for My Informed Decision on Video. It’s a video advanced directive tool. It’s basically a prescription for your advanced care planning, no different than getting a blood pressure pill to treat your hypertension. And it’s much more accurate than what we do today with paper- based documents.

Dr. Alan Lindemann: I’ve seen your MIDEO. As a matter of fact, I went to your site, and there’s an example of it. And it’s very clear what you’re doing, and it’s certainly the lady who was talking about it was also clear. So it’s hard to read these documents sometimes and make sense of them. And of course, a lot of times people don’t really understand what they’re signing, and their relatives don’t either. So-

Dr. Ferdinando Mirarchi: Absolutely.

Dr. Alan Lindemann: You said… Not everybody dares to say, “I made a mistake,” but we should all learn from our mistakes, which of course we do. Most of us do anyway. So I’m glad you did that. And it sounds like people are benefiting from that.

Dr. Ferdinando Mirarchi: Well, thank you. And I hope they are. What we’re what we’re seeing in early results, as far as everything that we’ve done, we have patients in 42 states now with four countries that are using MIDEO today to help guide their medical care. And if ever there was a time to really need something to guide your medical care, my God, is it today, with everything that’s happened with COVID and the disasters that happened in hospital staffing and so on, and just what’s happened in medicine alone?

Patients are strangers to us. We’re medical strangers. And there’s a concept that we describe called Medical Stranger Danger. And you go into a hospital today, and you get treated by people like me who don’t know you. We don’t know who you are, we don’t know what your goals are, we don’t know what your plans for the future are, but we got to make these very quick relationship establishments or establish these relationships that really can be life or death at times. And if they’re not life and death at that moment, they could impact your life or death within the next step or two in your medical care.

And the tools we use are pretty antiquated. We use these paper-based legal documents. And I don’t mean anything against attorneys, but we’re doctors. We’re not trained that way into looking the law and the letter of the law and so on. But we do know how to provide care. So we got to get better at providing care when it comes to these documents.

Neil Haley: Now, so let’s talk about how this works. I’m interested, Doc, in finding that out. How does this work? Explain how this works if you’re a patient, utilizing MIDEO.

Dr. Ferdinando Mirarchi: We have platforms that are made that are available in iOS or Apple products. We have platforms that are made in Android products: the Galaxy phones, the Google phones and so on. And we have a web-based process as well. And there’s two ways you can get MIDEO. You can do it yourself. And in that respect, you go online or you download the app, you sign up for the account, and you go through the videos. And each data point creates your prescription that you then read into video. And after it’s read into video, it gets signed by you, it gets witnessed, and then it comes to our servers where we have a medical team that reviews that video to make sure it’s appropriate and it’s appropriate for your level of care and so on.

The other way that we have MIDEO get created is what we call a facilitated approach with advanced practice providers: nurse practitioners, physician assistants or physicians, both of which who are trained to actually have these kinds of conversations and have these types of risk-benefit conversations rather than people who think they have the training to do it but really don’t have the training to do it. Everyone has tried to say that advanced care planning can be done by anybody, but quite frankly, it really can’t. It really needs to be done by trained individuals who can give you risk and benefit to either accepting or declining a life-saving therapy. Because I have a lot different of an understanding, and I don’t mean any offense to this, I have a lot different understanding to this than a social worker does or than an attorney does just because of the type of work I do.

Dr. Alan Lindemann: Well, I like this term you used, stranger danger. And can you tell me a little bit more about that?

Dr. Ferdinando Mirarchi: Yeah, if you remember, back in the day, there was stranger danger for kids. We use that concept with McGruff, the crime dog, and so on. And quite frankly, we have that today in medicine. Your primary care doctor doesn’t come to the hospital anymore. That doctor is now in the office eight to five, seeing patients, and some other team of hospitalist physicians are taking care of you. Not that they’re doing a bad job, but that’s just what’s happened as far as the change in medicine.

So you have a stranger who’s seeing you, taking care of you as an ER doctor, you have a stranger who’s admitting you to a hospital, you have a stranger surgeon who’s taking care of you. So all of a sudden, nobody has established relationships with people, so no one really knows what the patient’s wishes are. But everybody is having to try and figure out what the patient’s wishes are if they’re critically ill because they have this document now, and no one really knows what the patient wants. Whereas what we do with MIDEO is essentially make it so that we have something that’s very clear, produces comfort to the patients as well as to the medical teams. And it really then looks to instill the confidence in the medical teams that they can follow the patient’s direction so as to make sure that we provide the right level of care at the right time rather than what commonly is described as discordant medical care, which is basically a medical error.

Neil Haley: Wow. And how’s this company grown since you started it?

Dr. Ferdinando Mirarchi:  I’m sorry, say that again?

Neil Haley: How’s the growth been to getting it out there?

Dr. Ferdinando Mirarchi: The growth has been great. MIDEO itself has just been acquired by US Acute Care Solutions, which is a national large multi-specialty physician practice. I think it’s the largest multi-specialty physician practice. So right now we’re at the point where we’ve expanded all the platforms, and we’re training hundreds of physicians now across the country, and hopefully thousands of physicians across the country soon, to actually go and provide MIDEO services.

Neil Haley: That’s fantastic. Go ahead, Doc.

Dr. Alan Lindemann: Yes. One of the things that I’ve been aware of stranger danger for a while in my practice. And of course I live in a town… Well, actually I live out of town, but our town is 650 people. And we practice medicine the way it used to be 50 or 60 years ago. So when I saw a patient in the clinic, I would also see that same patient in the emergency room.

Dr. Ferdinando Mirarchi: Absolutely.

Dr. Alan Lindemann: I’d take care of that patient in the hospital, I’d do the follow up. I knew who they were. I knew what they wanted because I had seen them before, and I had a relationship with them. And what you’re saying is you’re trying to make up for the absence of those things.

Dr. Ferdinando Mirarchi: Absolutely. And quite frankly, the way we did it before was better. It wasn’t better for the physician, quite frankly, because they started their day sooner and it ended later, but it was much better for the patient because the patient had a primary advocate. That physician knew who that patient was. That physician knew that that patient had two children and that that patient was hoping to see that one child graduate or whatever their particular goal is.

Today, we don’t have any of that. Again, we have these vague, sterile scenarios where we’re getting to meet patients and having to figure out quickly what the right care is, which is really at times a swag, right? We’re taking a scientific guess essentially at times, with a piece of paper and a patient we don’t know, and we’re only.

Hoping that we do it. So with our concept of MIDEO, we decided to figure out a way to personalize this. Because it doesn’t matter how good of a conversation you have with someone, if the next person involved in that medical care screws it up, frankly. So what we’re looking to do is make sure we have patients, have conversations, good conversations, that lead to good treatment plans that then get communicated to the next treatment provider in the scenario in a way that’s understood so that we can get it right for the patient.

Dr. Alan Lindemann:  We’ve talked a little bit about temporary encephalopathy.

Dr. Ferdinando Mirarchi: Yeah, scary.

Dr. Alan Lindemann:  Yeah, it is. Can you explain that a little bit for our audience?

Dr. Ferdinando Mirarchi: Yeah, most of the time what ends up happening and the way documents come into play is that you’re supposed to lose capacity. And in a permanent fashion. There are many things that cause patients to lose capacity in a temporary fashion. They can get infected. And if they get infected, they get some sort of bacteremia or bloodstream infection that causes them to become what we call an encephalopathic, meaning they get confused, they get disoriented, they get rambunctious.

And then all of a sudden, people think they need to go follow their document because that paper document is there, which is scary because they should be focusing on the underlying condition that caused them to become encephalopathic. ‘Cause lots of times that’s reversible. You treat them with antibiotics, you get them some rest and so on; they wake up the next day, and they’re fine.

So it really is a clinical course and spectrum that we have to get better at watching before deciding to say someone’s out of their mind, quite frankly, or they’ve lost capacity, or they’re behavioral and starting to hit them with a whole boatload of what we call Haloperidol and so on, to calm them down and just keep them from being annoying.

Neil Haley: Wow.

Dr. Alan Lindemann: Yes. One of the things [inaudible 00:11:05] we met is I did this article on nursing home patients. And I gave several examples, but one of them was a twin, 95- year-old twins and one of them. So one had a bladder infection and had temporary encephalopathy. So his family just decided that he should not have any treatment because he wasn’t making sense. But I ended this story by talking about another 95-year-old man whose family allowed me to treat him and he was returned to normal the next day. So yeah, these people need a chance.

Dr. Ferdinando Mirarchi: Yeah, and the scary thing is that most of the people who are making the decisions really don’t have the appropriate level of training and understanding to know when to follow those types of documents. People themselves seem to think that if they give somebody a healthcare power of attorney document that all of a sudden they have the control over that person. No, that’s not the case. There are triggers in that healthcare power of attorney document that say when this other individual gets to make decisions for them. And quite commonly that’s when it’s with permanent incapacity. So it’s scary that we have people making decisions and other people following those suggestions when legally they’re not the appropriate people to make such decision or followings.

Neil Haley: Wow.

Dr. Alan Lindemann: This is a very subtle difference, I think, for some people, but it’s very easy to jump on that bandwagon of, “Oh, this patient has taken leave of his senses. Why should he be living?” And a lot of people think that way.

Dr. Ferdinando Mirarchi: That’s a very common thing. And you have to remember too, everybody thinks for some reason just because you hit a certain age that you’re not worth saving anymore, quite frankly, at times. Right? They’ve lost that respect for life and what that person contributed to society. That’s a wrong approach. We have to get back to the points of taking care of people, taking care of our parents, taking care of our grandparents and so on. Believe me, they’re going to die. Everybody’s going to die. They’re going to die. You taking a minute or two to make sure that you actually look out for their behalf is not really extending their life, it’s just doing what’s right for them.

Neil Haley: Exactly. And what do you think patients should do to protect themselves?

Dr. Ferdinando Mirarchi: It’s very difficult, and patients really need to learn how to navigate. And the one problematic thing is they don’t have people around anymore to follow them in different venues, different hospital settings, the skilled nursing facility and so on. So what they have to do is they really have to have conversations with their people that they’re going to then put in charge of them if they can’t make decisions, so that they can make sure that they understand what’s going on, when they should do certain things as well.

Additionally, I’m not the one to say, “Hey, don’t do an advanced directive.” I’m not. I think patients need them, especially as they age, but I think we need better tools and we need to communicate to patients better that there are better tools, like MIDEO, so that we can make sure that if they have the documents and they go into the healthcare system, that they know how to navigate the system better and have a better chance to get out of the system healthy and alive rather than, quite frankly, unhealthy or, God forbid, in a black box.

The goal here is to provide patient safety and care as they navigate the system. So ideally they need to have the appropriate documentation in place. But I’m going to talk selfishly here. You need to have patients now, or their agents, create MIDEOs for those patients because that’s the only thing that’s going to be the true intention of the patient at that point in time, rather than us again guessing off of paperwork.

Neil Haley: It almost has to marry with a will, doesn’t it, in certain ways?

Dr. Ferdinando Mirarchi: Well, in a sense that’s essentially what advanced directives have done and the healthcare power of attorney documents have done. When you go see an attorney, you get a will. You get a power of attorney, a financial power of attorney. And then the second portion of that plan is to get a healthcare power of attorney and a living will. That’s the typical estate plan that you get. So essentially what we’re hoping to do is make it so that we also become part of the estate plan. We’re the functional piece of that estate plan to keep that patient safe. And if we can get to that point of making sure attorneys are into the concept as well, to make sure that we actually capture the patient’s wishes, then I think we have a lot of good transformation that can occur.

Dr. Alan Lindemann: Well, I tell you, I’m 75 now, so I’m very aware of what’s going to happen to me if I’m not speaking for myself. But I do not intend to go to a nursing home anytime in the near future.

Dr. Ferdinando Mirarchi: Well, I’m with you. I don’t know that we always get a say in that, but I told my kids if I end up in a nursing home, I’m writing them out of my will.

Dr. Alan Lindemann: Well, I asked my son if I could sleep under the hood in his car. He said I could.

Neil Haley: All right, so where is the best place we can find information on you and stuff? Where can we go?

Dr. Ferdinando Mirarchi: If people go to, they can get a whole host of information. And they’ll be able to see the tools, they’ll be able to see educational videos. And at as well, they’ll be able to even go through the web-based application or download the appropriate apps to their appropriate phone, whether it’s an iPhone, or whether it’s an Android, galaxy or some other type of device and so on.

Neil Haley: All right, well, we appreciate it so much, Doc. This is such great information. And what a find for Doc Tales for sure, as another episode. I appreciate it, Dr. Ferdinando. Take care.

Dr. Ferdinando Mirarchi:  Take care. Thank you.

Dr. Alan Lindemann:  Thanks a lot.

Dr. Ferdinando Mirarchi: Thanks, Alan.

Neil Haley: That was the Doc Tales podcast and the Neil Haley Show, guys. Take care.


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