The Doctor Who Left the System to Fix It

Seventeen years, and then a wall

[0:42]

Dr. Agha opens without much preamble, and the shape of the grievance is clear immediately. You spend seventeen or eighteen years in training. You subspecialize. You reach the point where you are finally equipped to help anyone who walks in. And then a patient says they are ready to have something done, and an administrator tells you that you cannot, because that person does not have the type of insurance the hospital needs.

He does not soften what he thinks about that. We are in the best country in the world, he says, and we do not have healthcare for every one of the people living here. He is aware the position draws accusations of advocating socialized medicine, and he waves the label away. Call it whatever you want. His position is that health is a basic need, like food, and that if something is wrong with someone, we should help each other fix it.

The wheel

[2:01]

Before he gets to his own decision, Dr. Agha describes the structure that keeps most physicians from ever making one. You finish training and you are handed a good salary, ten weeks off, a retirement plan. You get married, you have children, you buy the biggest house the salary supports. Your neighbor buys a bigger one. You take the raise, you move up, and you are inside a wheel you now mistake for your life. Then you blink and twenty years are gone.

Alex asks whether he means as a physician. Dr. Agha confirms it and sharpens the point. He was doing what he thought he was supposed to be doing, and still felt he was not practicing the medicine he entered medical school to practice. Instead he was balancing which patients he was permitted to treat and which he was not.

The morning five became three

[3:09]

Asked whether he remembers the moment, Dr. Agha says he remembers it very clearly. He was at a hospital in Phoenix performing TIPS procedures, a transjugular intrahepatic portosystemic shunt, which is used in patients with advanced liver disease who are bleeding or accumulating fluid. It is a difficult procedure, and at the time he was the only interventional radiologist in a group of twenty-five able to perform it, covering six or seven hospitals. He would schedule five or six in a day.

That morning there were five. By noon there were three. He asked his tech what had happened and was told the two had been cancelled, and that the CFO and her assistant had gone to speak with the families to tell them the procedure was dangerous and should probably be held off.

He walked to the administrative office. The answer he was given was that the three remaining patients had insurance. The two cancelled patients had none. He points out that he had never had a death or a complication with the procedure at that hospital, that nobody had consulted him or the hospitalist, and that one of the patients was bleeding. The stent in question cost a few thousand dollars.

He drove home that day and it stayed with him. That was the moment he began working out how to open his own place with no financial backing, somewhere he could perform outpatient interventional radiology and offer it to anybody who came through the door.

“I said, the guy’s bleeding. You didn’t even ask the hospitalist. That is the moment where I remember leaving, driving back that day, and it stayed in my head. I said, I will do whatever it takes.”
— Dr. Ayad Agha

Cookbook medicine

[6:54]

Alex asks whether patients were being handed a one size fits all approach. Dr. Agha’s answer is that it is not past tense. He calls it cookbook medicine. You arrive at a hospital with a problem, someone looks it up, and the protocol says what happens next. His objection is not that protocols exist but that nobody interrogates their shelf life. How do we know a paper from decades ago still describes the people walking in today? People drink differently, smoke different things, eat differently, take different drugs. A study of three thousand people is being applied to hundreds of millions.

He is careful to say he is not throwing any of it away. His question is whether we can tweak it, improve it, and bring it into the present. What he believes in is medicine that is tailor made.

From nuclear pharmacy to interventional oncology

[7:55]

The background explains a lot about how he thinks. Dr. Agha trained first as a pharmacist, which he describes as a field that forces you to understand anatomy, chemistry and physiology together: where a pill goes, how it is absorbed, how it breaks down. He then became a nuclear pharmacist, working with radioisotopes that are injected and imaged, which is the basis of molecular imaging. His framing is that nuclear medicine let clinicians stop looking at a static picture and start watching what cells were actually doing.

Because that work centers heavily on cancer, he moved into compounding chemotherapy drugs, then went to medical school, became a radiologist, and from there an interventional radiologist and interventional oncologist. The pharmacology never left. It is why, when he looks at a pancreatic cancer, his instinct is to ask what is different about this one: the genetics, the environment, where the person grew up, what they ate, whether their parents smoked, whether they worked around metals or chemicals.

Vaccinating the cancer

[10:45]

This is the segment that will get the most attention, and Dr. Agha frames it as an idea he arrived at roughly twenty years ago from the pharmacology side rather than from reading anyone else’s work.

His starting premise is that everyone produces cancer cells, and that the immune system recognizes and kills the vast majority of them. The ones that cause problems are the ones that escape by looking like ordinary liver or breast tissue. His question was: what if you infected that cancer cell with a virus, so that if it tried to move from the liver to the bone or the lung, the immune system would catch it as a virus rather than failing to catch it as a cancer?

In practice, he describes taking very small quantities of conventional chemotherapy agents, selected according to the specific cancer, rather than a single large systemic dose delivered through a port. He mixes those with TVEC, an oncolytic viral therapy derived from herpes simplex virus that is approved for melanoma, and delivers it during an interventional procedure that takes thirty to forty-five minutes. He says he has been offering this to his cancer patients for around fifteen years, and that he spends much of each procedure explaining it to the family.

He is explicit that he did not invent the components. What he says is new is the combination and the range of cancers he has applied it to, including liver, breast, prostate and lung, where the approved indication is melanoma alone.

Two days before this conversation

[12:48]

The timing of the interview gives the segment its charge. Two days before recording, a major pharmaceutical company announced results combining an mRNA cancer vaccine with a checkpoint inhibitor, individualized per patient, in melanoma. Dr. Agha describes watching the announcement and the share price move on an idea he says he has been practicing for fifteen years.

Alex asks the obvious question: why did it take this long? Dr. Agha’s answer is partly about geography, noting the approach exists in various forms elsewhere in the world, and partly about incentive. Everyone follows a protocol, and nobody wants to be the person who breaks from it, because the moment you do you become the problem for the oncology community, the surgeons, the drug companies and the administrators.

He also names his real constraint, and it is the same one that runs through the whole episode. He gets patients late. They have been everywhere else, tried trials abroad, lost a hundred pounds, and arrive asking whether anything can be done. What he wants is to have met them two years earlier.

“I’ve had patients who were given three or four months to live. I’ve had them for ten or eleven years. They’re not all happy endings. But at least I can give the patient and their family their life back.”
— Dr. Ayad Agha

His measure of success is not only survival time. It is whether a person can go to Disneyland with their grandchildren, sit in a restaurant, or watch a football game, rather than being alive for six more months and barely able to move.

Four ways to kill a cancer

[17:19]

Dr. Agha walks through the options in plain terms. You can cut it out, which works for some organs and not others. You can starve it by reducing its blood supply, placing beads in the vessel feeding the tumor, which is the basis of transarterial chemoembolization, or TACE. Alex clarifies the mechanism in real time: a tourniquet placed not on the body but inside the blood vessel itself. You can burn it with radiofrequency ablation. Or you can freeze it with cryoablation, taking the tissue to roughly minus seventy.

In his practice the second option is rarely used alone. He places chemotherapy, TVEC and the beads together in the same procedure.

The insurance paradox

[19:26]

The clearest illustration of dysfunction in the episode involves cryoablation of the breast. A patient with a small cancer who does not want a lumpectomy or mastectomy can, in his description, have the blood supply addressed and then the lesion frozen. Dr. Agha says that if he documents the procedure as treating cancer, insurers will not cover it. If the same procedure is performed for a fibroadenoma, a benign breast nodule, it is covered.

Alex has him repeat it because it sounds backwards. Dr. Agha is careful here, and says twice that he is not accusing anyone and does not know the reason. His impression is that the system is built around an expected pathway, oncologist, biopsy, radiation, chemotherapy, surgery, medication, and that a thirty minute freeze bypasses everybody who would otherwise have been involved.

Why do we guess at the age?

[21:09]

From cancer treatment he moves to the thing he would rather be doing, which is finding it earlier. His frustration is with population screening ages that move every few years without ever becoming personal. Colonoscopy at fifty-five, then fifty, then forty. Why, he asks, are we guessing, when we could look at the individual, their exposures, their history, and screen accordingly?

The example he reaches for is Steve Jobs. If that pancreatic cancer had been found at two and a half millimeters instead of two and a half centimeters, the outcome might have been different. His broader point is the one that gives preventive medicine its urgency: people wait because they look healthy, and by the time symptoms arrive it is often too late.

A hundred dollars, and nobody will pay it

[24:10]

Asked whether preventive care is becoming more accessible, Dr. Agha is not optimistic. He has been pushing for fifteen years and does not see it improving. His example is deliberately unglamorous: a CT cardiac calcium score, a quick scan with minimal radiation that costs around a hundred dollars and tells you whether calcification is present. It is not covered. Patients pay out of pocket.

He extends it to dentistry, where coverage exists but barely, typically one partially covered cleaning a year. If that is how the system treats the cheapest, most established preventive intervention we have, he asks, what chance does a two thousand dollar whole body MRI have?

What a whole body scan should actually be

[25:13]

He is equally critical of how screening is often delivered. Putting someone in a machine, generating a report, and telling them it all looks good is not, in his view, the point. What does all looks good mean to the person who received it?

His version is a sit down with the patient and the radiologist, going through it together. Here is the brain, is there any family history of Alzheimer’s or Parkinson’s, let us look more closely at this area. Here is a small thyroid nodule with no symptoms, let us follow it with ultrasound. He acknowledges the criteria that would ordinarily say a nodule must reach a certain size before biopsy, and says that if it looks wrong to him he wants it biopsied anyway. The through line is the same as everything else: not one platform, not a cookie cutter.

Why your doctor has no time

[26:43]

Dr. Agha gives one of the more useful structural explanations in the episode, and it concerns relative value units, the mechanism by which Medicare assigns value to a given clinical activity. His account is that those values are trimmed year over year, and that the accumulated effect is to require a physician to see seventy patients a week where fifty used to suffice in order to generate the same income.

The consequence is the ten minute appointment. He describes barely getting through hello and where are you from before the knock comes. And he notes the pressure works in one direction only: the physician who takes longer is the one whose numbers get flagged at the end of the month, next to the partner who saw far more people.

In his own practice, the consults are usually longer than the procedures. He asks how the mass was found, when it was found, what the first symptoms were, where the person lives, who they live with, whether there are pets, who smokes, what medications they take, what stress they are under, whether they even have a primary care physician. His claim is that once a patient relaxes, they will tell you what is wrong with them.

“Most patients will tell you what’s wrong with them. When a patient says I’ve been to three or four different doctors and I got nowhere, to me that’s not their fault. That’s the medical community’s fault for missing what they have.”
— Dr. Ayad Agha

He extends this to diagnostic labels. When a physician does not know, he argues, the honest answer is that we do not know. What happens instead is a label: hypochondriac, fibromyalgia, endometriosis. He takes the last two apart briefly. Endometriosis names inflamed endometrial tissue, but why did it become inflamed? Fibromyalgia names pain in the fibrous muscle, but why is the pain there? Naming a symptom is not the same as explaining it.

You can buy a new car

[30:36]

Alex brings up a campaign idea he has discussed with Cascaid’s founder: we service a car every five thousand miles so the engine does not gunk up, and we do not do anything comparable for ourselves. Dr. Agha completes the thought with the line that lands hardest.

“The problem is you can always buy a new car when it blows up. You can’t buy a new Alex.”
— Dr. Ayad Agha

He also includes himself in the indictment. You get used to working, you forget, and one day you cannot see properly and you have headaches.

The firefighters

[31:43]

The most concrete evidence Dr. Agha offers for screening comes from a program he ran out of a medical center in Prescott, sending firefighters from Phoenix for whole body scans. Among that group he says he found renal cancer in roughly five to six percent of those screened, in people who had no idea. Alex reacts to the number and Dr. Agha underlines it: five out of every hundred firefighters you know.

He is blunt about the coverage situation for first responders in retirement, describing their insurance as poor and their support as effectively nonexistent, which is why much of this work was done for free.

Then comes the detail that makes the segment. He began screening spouses as well, because the protective gear firefighters wear carries chemical exposure home with them. Alex stops to make sure listeners catch it. Dr. Agha confirms that he found disease in spouses too, and notes there is generally no coverage available to them either.

He widens it from there to veterans, to the wait times at the VA, to teachers, and to healthcare workers themselves after they retire. The argument is consistent: we call on these people and expect them in two minutes, and then we stop taking care of them.

May-Thurner syndrome

[37:44]

Alex raises something that happened during filming at AMC. A member of the camera crew mentioned ongoing pain he had not been able to resolve. Dr. Agha pulled up his images and identified May-Thurner syndrome almost immediately. Alex spoke to him the day before this recording and reports it is the best he has felt since his car accident.

That opens into the clinical explanation. May-Thurner syndrome is compression of a main pelvic vein by an overlying artery, and it travels with pelvic venous congestion. Dr. Agha’s framing is that it is essentially varicose veins in the pelvis rather than the legs, and his figure for how common the associated congestion is among women is around forty percent. It occurs in men too, more often in athletic and cycling populations.

The pain he describes is not sharp or recent. It is diffuse, chronic, and easy to normalize: pelvic pain, low back pain, heavy and tired legs, going on for years until the body adapts and the person simply takes anti-inflammatories. He has seen patients arrive after back surgery or hysterectomy that did not help.

His explanation of the mechanism is the best teaching moment in the episode. Blood goes down to each leg but not all of it returns. The brain registers the shortfall as possible bleeding and pulls blood away from the arms and legs to protect the vital organs, which is why the limbs feel tired. The missing volume is stuck in the pelvis.

The freeway analogy follows. Six lanes, then an accident narrows it to two. The cars divert onto side roads built for one car each, and everything backs up. His procedure closes the side roads first, then clears the freeway so the traffic can move again. In practice that means closing the abnormal pelvic veins in one roughly thirty minute procedure, then returning to open the compressed vein with a balloon and a stent.

Asked why women are told to live with it, his answer is that physicians are not informed. He describes giving a talk to around eighty practicing physicians at a university, and estimates that only ten to fifteen of them knew what pelvic congestion and May-Thurner were and how to treat them. If that is the state of knowledge among clinicians, he asks, what is the public supposed to know? He also notes he still has to conduct peer to peer reviews with insurance physicians who have no vascular background.

A video game played on a human

[41:54]

Pressed on what interventional radiology actually is, Dr. Agha defines it as image-guided surgery, minimally invasive. No scalpel and no cuts. Needles, wires and catheters, with a large monitor in front of him. His description of the work is memorable: a video game played on a human, and one you have to make sure you do not lose.

The mental model he offers is a city. The arteries, veins and nerves are roads, and he follows whichever road leads to the organ he needs. Abnormal veins get closed because a stagnant vessel is a lake rather than a river, and something that is not moving eventually causes problems, including clots.

He is clear that this is both treatment and prevention. Left alone, he says, pelvic congestion contributes to asymmetric legs, varicose veins and increased clotting risk including DVT later in life.

The building in Scottsdale

[45:50]

Asked whether this becomes a medical destination, Dr. Agha describes what he has been building toward: not a hospital, but a one stop shop. A three story building, soon to be four, roughly a third of a mile from Scottsdale Airport. Labs, imaging, a physician visit, interpretation, and a procedure or surgery, all in the same day, without the red tape.

He lists what is there: SimonMed providing MRI and CT, Cascaid handling longevity, health and wellness, plus neurology, primary care, vascular surgery, podiatry, orthopedic spine surgery, sports medicine, and a surgery center on the third floor. He mentions Dr. Cummings and Dr. Field on the sports medicine side.

Alex draws the contrast explicitly. The conventional path is a referral, a three week wait for imaging, another week for a read, then a specialist who orders more imaging, then scheduling, then a vacation intervenes, and six months have passed while symptoms worsened. Dr. Agha’s design collapses that into a single visit, which matters because the patient took the day off work and brought their family. The building opened roughly four weeks before this conversation.

Kyphoplasty, and the numbers

[50:03]

For spinal compression fractures, common in older adults with osteoporosis but possible in anyone who falls, Dr. Agha describes kyphoplasty: a small needle into the bone, a balloon to restore the vertebral shape, and polymethyl methacrylate cement to hold it. He says the pain typically resolves almost immediately.

The statistics he gives are the reason the segment matters. Roughly seven hundred thousand spinal fractures a year in the country. Around seventy thousand diagnosed. Of those, around seven thousand treated this way. He has performed the procedure on his own mother after she fell and fractured her L4 and L5.

What he is trying to prevent is the spiral. You fracture something, you spend weeks in bed, you lose muscle, you cannot get up, and at eighty-five that decline does not reverse.

Treating arthritis without replacing the joint

[51:34]

Dr. Agha describes developing genicular artery embolization, performing his first locally around 2010. The principle is the same one he uses in oncology: go in through the artery, find the joint that hurts, and place small beads to reduce inflammation in the bone. Reduced inflammation reduces pain, and the hope is that the body responds by regenerating cartilage and bone through its own marrow-derived cells.

He describes the knee application as now widely performed, and says that around the Covid period he began applying the same approach to shoulders and hips, where to his knowledge he is the only physician in the state doing so. He puts his volume at roughly two thousand shoulders and three thousand hips. More recently he has applied it to plantar fasciitis, targeting the artery driving the inflammation rather than cycling through boots and orthotics.

His summary of the philosophy: surgery is great, but less surgery is better. He does not want to be inside a person’s body for three hours. He wants to go in, nudge the system, and let the body do the healing.

Bone health, and a DEXA scan at thirty

[54:28]

Arizona has a bone health problem largely by demographics. It is a retirement destination, the population skews older, and osteoporosis, osteopenia and osteoarthritis follow. Dr. Agha mentions the DEXA scanner they have brought in, and his argument for it is the whole preventive thesis in one line: measure bone density now, at thirty or forty, not at seventy when the only remaining question is which drug to try.

Alex volunteers that through building out his own baseline for the company he discovered he has osteopenia at thirty-four. Dr. Agha’s reaction is the useful one. That is exactly why you measure. Now there is three decades to change the trajectory through exercise and diet rather than accumulating kyphoplasties later. This is also where he places Cascaid’s role: longevity, health and wellness, and the question of how you make the changes that keep people functional.

Medical tourism and the one placenta rule

[56:39]

Alex asks about the influencer-driven trend of traveling to Tijuana, Panama or Turkey for longevity and regenerative treatments. Dr. Agha’s response is characteristically direct. Everyone in the world is trying to get into this country, so why would you leave it for your healthcare? He frames the slow pace of US approvals as a feature: the reason it takes so long is the volume of work done to establish that something is safe.

He then explains a specific regulatory difference that he says most patients have never heard. In the United States, cells given to a patient must come from a single cord or placenta. Elsewhere, material from multiple donors can be combined. Someone can tell you they are giving you a hundred million cells without being able to tell you where they came from.

His analogy is a fender bender. The shop does not have a Toyota fender, but they have a Mercedes one. It is a fender, and it will look like a fender, but it is not going to fit your car. If a large share of the cells cannot find their match, the count is meaningless and the money is wasted.

MUSE cells, and what AI changed

[59:45]

The single donor rule creates an obvious constraint: how do you extract enough usable cells from one source? Dr. Agha’s answer draws on his pharmacy specialization in pharmacognosy, the study of medicines derived from natural sources, which is where his interest in stem cells began.

The cells he works with are MUSE cells, which he describes as multilineage, stress enduring, and non-carcinogenic. His characterization of how they behave is that they travel to areas of inflammation and work on repair rather than acting directly on pathogens: they will not kill a virus, but they support the immune system that does; they will not make arthritis vanish, but they work at the bone toward new cartilage.

The constraint has always been yield. Conventionally, he says, MUSE cells represent only around one to five percent of what you can extract. Working with a local lab and using AI-assisted identification via cell surface markers, he says they are now able to reach ninety-six to a hundred percent. He also emphasizes freshness, describing cells extracted from a recent C-section rather than material frozen for six months or a year.

Exosomes are carriers

[1:03:01]

This is the most immediately actionable segment in the episode. Dr. Agha’s guidance for anyone considering an infusion is to ask three questions first. Where are these cells coming from? How many am I getting? And are they actually stem cells, or are they exosomes?

His point about exosomes is that they are carriers. A clinic quoting billions of them is quoting a number that, on its own, does not describe a therapeutic dose of anything. He compares it to the word car, which covers both a Hugo and a Mercedes. Saying stem cell does not tell you what you are receiving.

“You hear about people doing stem cell infusions. The first thing you should ask is, where are they coming from? Are they really stem cells, or just exosomes, which is totally different.”
— Dr. Ayad Agha

Cost plus ten percent

[1:04:32]

Alex raises the assumption that this is Hollywood medicine. Dr. Agha acknowledges the perception, then explains his pricing directly: he adds roughly ten to eighteen percent over cost to cover the building and the nursing staff. He is not doubling the price. He points out that he uses this with cancer patients living on modest retirement incomes, against a material cost approaching ten thousand dollars, and says his intention is not to make money on it.

He would rather give a patient the highest quality preparation than dilute it, and he thinks the results argue for themselves. His patients, by his account, do well for years rather than returning every few months, and some simply do not come back.

Two stories close the section. One patient was angry that the price was so low, having paid roughly twenty thousand dollars per round for three rounds in Mexico, and could not believe it was equivalent. Dr. Agha declined to raise his price. The other, from the day before the recording, involved an elderly patient with Lyme disease quoted six sessions at around ten thousand five hundred dollars each at another clinic, a combination she was told included exosomes and stem cells. His own protocol, he told her daughter, is a single visit, and he explains why returning every two weeks makes no biological sense when the cells need three or four months to do their work.

On credentials, he is unambiguous. Check where someone trained. Twenty thousand followers does not make an expert. Chiropractors and naturopaths have real roles, and injectables are not among them. What worries him most, as a pharmacist, is the peptide market, where he says many prescribers cannot define what they are administering and long-term effects are not established.

Free Fridays

[1:11:20]

The episode closes where the origin story pointed. Dr. Agha came to the United States from Iraq at fourteen, arriving with his brother and without family or support. His reading of that experience is that the opportunity to work hard and build something was available to him, and that it is not available to everyone on arrival.

The practical beginning was his younger brother, Dr. Ahmed Agha, a hospitalist who volunteers weekly at Circle the City, a Phoenix organization serving people experiencing homelessness. His brother asked whether they could bring uninsured patients into the clinic. Dr. Agha’s answer was Free Fridays, open not only to referrals from that organization but to anyone who cannot meet a deductible or afford care, receiving the same procedures as insured patients. They perform roughly five to six every Friday.

Alex asks whether it is true that someone told him not to do it. Dr. Agha confirms that over twenty years several managers have, and he is generous about them: they are good business people, better at it than he will ever be, and by the logic of a business model they were right. The warnings were that it wastes money, that it devalues him as a physician, and that people would abuse it. He went with his gut, still does it, and reports that it has not been abused.

“I don’t know how much it lowers me. I wasn’t that elevated to begin with. It’s not that my work is so not great that I give it for free. It’s the opposite.”
— Dr. Ayad Agha

His instruction to his own team is the line the episode probably ends on. Treat them as your own family. Do not look at their background, do not look at where they are from, do not look at why they are in this position. They have their own battle.