Chapter 1: What are GLP-1s and why have they been controversial?
Okay, so here's something. Our show's motto, no question too big, no question too small, but there's some questions that I have on this show avoided. I'll give you an example, GLP-1s. Surge Engine has barely acknowledged their existence, which is fine, except I read a lot about them, I think a lot about them, and in my private life, I talk a lot about them.
But when they cannonballed into American culture, I had a lot of questions that I didn't want to ask in public. In 2022 and 2023, GLP-1s were just, for me, too hot a topic. Going online felt like walking into a crazy shootout at an old Western saloon, except instead of gunslingers, it was all fast draw scolders.
There were scolders out there scolding celebrities for taking GLP-1s, but then they were getting scolded by other scolders for scolding celebrities.
Chapter 2: How did Dr. Bedard first become aware of GLP-1s?
Some people got scolded because they were taking the drugs despite not being fat enough, scolded for wanting to lose 15 pounds. Rich people, of course, were getting scolded all over the place, accused of ripping GLP-1s out of the hands of the people who actually needed them. It was scolding mayhem. Meanwhile, offline, in real life, 20% of the people I knew just lost 15 to 40 pounds.
They seemed happy, and I had questions. What did we really know about these drugs? Were they helping people the way they claimed to? What were the side effects? I had questions, but I hate getting scolded, so I kept my mouth shut. Meanwhile, in 2026, the scolders have moved on to other topics, topics I'll cover in 2029.
But today, we can finally get some answers on these fascinating drugs, which it turns out are much weirder than we ever knew.
So this week, we're going to talk to a doctor who's going to tell us the story of GLP-1s from her perspective, which is a very unique one, because she's a doctor to a particular patient population that we don't hear from much in the media, almost never, and who were very absent from the entire early discourse around these drugs.
Chapter 3: What unique patient population does Dr. Bedard serve?
Can you say your name and what you do?
Sure. I'm Rachel Bedard. I'm a physician and I'm a writer. I'm a contributing writer to the New York Times Opinion. And as a doctor, I am an internist and my subspecialties are geriatrics and palliative care. But I've had this sort of unusual career where for six years I was a physician on Rikers Island and I now work in a homeless clinic a couple days a week.
Can you tell me about your work at that homeless clinic? Like, where's the clinic? What's it like? What's your work like?
So the clinic is, it's a safety net clinic run by the city. The city has a network of these safety net clinics that are embedded in the public hospital system. And so my clinic is at Woodhull Hospital in Brooklyn. So the clinic's in the hospital, but it's an outpatient clinic. It's primary care. We serve people who are either... unhoused or sort of in precarious housing situations.
They were recently, you know, housed or they are staying on friends' couches or something like that. But the majority of the people that we take care of are living in shelter or people who are sleeping on the streets. So we do sort of all of their primary care. That population has a very high rate of comorbid mental health issues, very high rate of comorbid addiction issues.
but also is just very medically sick. So the majority of folks that I take care of have at least one chronic medical comorbidity, like high blood pressure, diabetes, or other diseases like that for which they're taking daily medications.
I have a bunch of questions in a bunch of different directions. One is, your work puts you... I think a lot of people who live in New York City, the weird thing about New York, maybe more than other places in America, is that it's both incredibly class-stratified. You have very elite, very wealthy people, and you have working people, and you have very poor people.
But the people in those worlds don't always really run into each other, besides maybe on the subway or literally on the street. You have this unusual life where you're moving between highly elite worlds, like the New York Times, and then working with populations that are so far removed from it.
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Chapter 4: What are the primary benefits of GLP-1s for patients?
And I just wonder, the thing that I think so many people block out in their minds in order to just live in a city, you've chosen to give yourself a life where you can't. I'm just wondering what that's like.
Yeah, so, you know, one thing I'll say about New York is although the rates of inequality here are astounding, there is, I think, actually more mixing in New York City than there is in a city like L.A., for example, where people are always in their cars, right? Like, you are sort of interacting on the streets and on the subways, et cetera.
You know, and because of the density, people are just on top of each other much more. So it doesn't feel... My life certainly feels extremely stratified for lots of reasons, but I think I like living here because it feels as though humanity is in continuity with itself in a way that in some other parts of the country or other very wealthy cities, you can be completely sort of cloistered off
That having been said, yes, my clinical work puts me in not just contact with, but I think just an extremely intimate relationship with people whose lives are really, really difficult in ways that my life has never been. And gives me a different sort of level of insight into what it's like to live in those circumstances.
Right. You get this very, very intimate view into lives that are very different from your own.
Right.
Like my patients, their experience of the weather is really different than my experience of the weather because they are exposed to the elements in ways that I am not with fewer ways to protect themselves, ranging from like they come to the clinic and they don't have a coat and they don't have gloves and it's really cold outside or it's really hot outside and they don't necessarily have a place to take care of themselves.
cover from that, right? And so, like, that's a really different way to be in a body in the same spaces that I'm in my body in, if that makes sense.
It completely makes sense. How did you end up working at the homeless clinic?
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Chapter 5: What unexpected effects have been observed with GLP-1s?
You can only drive on the island. You aren't allowed to walk on the island. It's sort of a fortress unto itself that the Department of Correction for New York City runs. And it is a complex of multiple jails that are all on this island, a bunch of different buildings. The buildings house people sort of in different special populations.
There's one for women, there's one for people who are sicker, there are ones for specialized mental health units. And depending on the kind of medicine you practice, your day can look very different. So For the first few years that I worked there, I would basically print a list of everybody in the system who was older than 65.
And I would go sort of try to find those people where they were and call them down to a clinic in that building. There's no freedom of movement in the New York City jail system, which means that every time a guy moves from one place to another, he has to be accompanied by an officer. Like somebody has to come pick him up and unlock a door and take him out and bring him to you.
So things move very slowly. Like it's like being in the airport all the time, right? Yeah. emergency room. It's an incredibly sort of congested system that requires a huge amount of excess human contact. It's hard to have real privacy during clinical encounters because you're not actually sort of behind a truly closed door ever for safety reasons.
But you can imagine that there's like a tension there with being able to provide care to people who are ambivalent about revealing themselves in that kind of environment, right? And so it is a clinical dynamic that's very much constrained by the security concerns of the system. And some of those security concerns are really well justified, and some aren't.
One of the first patients I had with advanced cancer, I went to visit him while he was in the hospital, incarcerated. There was a corrections officer sitting outside his room. He had told me he really likes Skittles, the patient. I brought Skittles. I had to open my bag and show the officer what was in my bag before I was allowed in the room.
And I was too sort of junior to know that I should play it cool. And I said, I brought him Skittles. And the guy said, he's not allowed to have those. And I said, why? And he said, well, Skittles aren't on commissary. So he's not allowed to have things that aren't on commissary. That's like obviously not a real security concern, right? That's just a rule.
And that's not a law, you know, even though the guy saying it to me is in a uniform. And I was like, I'm going to give him the Skittles. You know, and you can imagine that that's hard to do. And you have to have like a fair amount, you have to really feel empowered by the folks who run the healthcare side of things to be able to use your judgment like that.
And I was super lucky in who my bosses were.
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Chapter 6: What are the potential side effects of GLP-1 medications?
I was there for COVID. That was really wild. It made me feel incredibly bonded to a bunch of my colleagues and my supervisors. And then I left at the beginning of 2022 quite burnt out. And a bunch of people who I worked with at Rikers moved on to work at Woodhall. And it was like, you know, like in Mad Men when they like remake the first, you know what I mean?
They're like, season three, we're doing a new one. That's like the same guys. That's what it was like. We'd like Mad Men'd up at Woodhall, which is a bunch of people who I loved working with at Rikers. We're super mission driven. And so that's how I ended up there.
And so you're there now, and it sounds like the thing that, I mean, there are many things in common, the people you're working with in common, but the other thing that sounds shared is that I think when a layman thinks about a doctor, it's a person you go to and they figure out what's wrong with you and they give you medicine.
And your experience of medical care is that oftentimes the job is as much about the social structures around people as just like treating their bodies because the things that are happening to their bodies and the social structures they're enmeshed in are so inseparable.
Yes, although I would say that's truly true for any practice environment, any patient population. Really? Yeah, it's just the challenges are really different, and it's more visible, I think, with my patient population. But if you are paying out-of-pocket to see a concierge doctor, which in New York there's this incredible stratification and access to primary care.
And one, at the high end, people are paying out-of-pocket to see concierge doctors, which means that they're paying some huge amount of money to have this person basically be on call to see them. And
the dynamics of that relationship are totally determined by that payment model, by that person's socioeconomic status, by their access to be able to get care from other kinds of specialists, by their ability to, like, you know, that doctor says maybe you need a massage for this back pain, and the person can pay for that massage, right? It's sort of impossible to separate
the body from the social. And that's just particularly visible. And the social sort of circumstances for my patients are just so particularly crushing and throwing up obstacles so they're being able to take care of their bodies the way that we would
want them to, that a lot of what the doctor ends up doing is sort of negotiating with the world on behalf of my patients to get them things I think they need. The other thing I would say is that because my patient population, you know, health is socially determined to a large degree.
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Chapter 7: How are GLP-1s changing the landscape of primary care?
Like, some version of GLP-1s have been around for almost 20 years. There were sort of like first-generation GLP-1 medications that were only used for diabetics. So I've known about those medicines for a really long time. But the sort of GLP-1's class that is like the ozempic generation and then everything that's followed really came on the radar like 2021, 2022.
And I think the first time I sort of started paying attention to them was when I read about them in mainstream media, not in medical literature. Because, especially like those very early months, like they weren't accessible to be prescribed. Extremely expensive.
There are lots of medicines that are being invented all the time that are really promising but that are too expensive and are just like not going to be on formulary for my patients that I don't actually know that much about. I think the way that I personally got really interested in the GLP-1s was I actually think that somebody I know who worked at Vogue Called me and was like, what's the deal?
Everyone I know wants this medicine. What's the deal with this medicine? And I was like, the diabetes drug? It was sort of not on my radar. And then I started to be interested in it as the weight loss effects became... Clear, well-known, and then the drug started to be sought by a patient population that didn't have diabetes but that wanted to use it for weight loss.
And it became sort of this, like, cultural phenomenon. Like, I think 2022, 2023 is really when that happened. Like, 2023 is the year, to me, of the Ozempic first-person essay.
Yes. 2022 was the year for me of people whispering about it.
Right.
Yeah.
And then 2023 was people being like, all right, I did it. I tried it. Or like, or what does it mean for the body positivity movement that this is happening or whatever? Like that, right? It was this really interesting thing where this diabetes medicine became this other thing. And at that point, like really controversial, right?
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Chapter 8: What ethical concerns arise from off-label use of GLP-1s?
It's really, can be really terrible, right? Like millions of people in this country have had a limb amputated because their diabetes was sufficiently bad that they had vascular complications where they stopped getting blood flow to a limb and they had to lose a leg, you know? That's really terrible. There are half a million people in the U.S.
who are on dialysis, which means that three times a week they go for several hours and sit in a recliner in a room full of people in recliners hooked up to huge IV catheters that are exchanging their blood through this, like, blood-washing machine, dialysis machine. That's a wild way to live, right? Imagine if you had to do that.
And those experiences are never reflected in first-person writing about illness in the mainstream media. They're almost never actually described, I think, in, you know, the publications that, like, I read, both for news and pleasure. Whereas I'm 43.
I think for as long as I can remember, I have been reading an essay a week about what it's like to be a white lady who doesn't feel great about her weight. That is a constant in my life through many changes in the world. And the idea that this breakthrough class of medications that had the potential to revolutionize, like, chronic disease population health in the U.S.
potentially changed the expected mortality for Americans, like, that it was all sort of being funneled into this same discourse and also processed using the same types of anxieties and neuroses that were sort of the themes that I've been reading about my whole life, like, was really annoying to me.
To Dr. Bedard, what was annoying in 2023 was how the conversation about these drugs gave almost all of its oxygen to their cosmetic attributes. What did it mean for everybody's body image that thinness was now much easier to buy than it had been before? I can feel even now saying that sentence, the heat and excitement of all the arguments it provokes.
But for Dr. Bedard, those arguments made her want to yell at the screen. Forget, even for a second, the cosmetic implications. GLP-1s were transforming the lives of some of her most vulnerable patients. She thought more of the oxygen in the conversation should have gone there, and that the discourse certainly should not have been so focused on the very particular lives of media elites.
We're going to take a short break. When we come back, we're going to move away from discourse, away from the conversations of yesterday's internet to today, the actual science behind GLP-1s and all the weird things doctors have been learning about them in their last three years of widespread deployment.
I'm Katherine Nicolai, and I help millions of people around the world sleep better, rest their nervous systems, and shut their brains off when they won't stop spinning. On my podcast, Nothing Much Happens, I tell cozy, calming stories where nothing dramatic ever happens. Just soft narration, sensory detail, and gentle repetition designed to lull you to sleep.
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