The Spy Who Loved ID? What James Bond can teach us about a career in ID

Buddy Creech: [00:00:12] Hi, I'm Buddy Creech, and this is Let's Talk ID. What if you found out that on a cellular level, you're actually more microbial than human. And what if it just wasn't your body that's more microbial than it seems, but that almost everything, all life on Earth is made possible by microbes. Well, this is the tagline for new documentary shorts by Michael Graziano, founder of small-r films in Nashville, Tennessee. The company creates both feature length and short documentaries on a variety of topics that have been featured on Netflix and National Geographic, and I met Michael as he was working on the feature length documentary, Resistance, which premiered on Netflix in 2015, has been translated into 18 languages and was actually recognized on the floor of the US Congress and entered into the Congressional Record because of its contributions to the discussion on antibiotic resistance. His new work, Holobiome, focuses not only on antibiotic resistance, but the impact that microbial disruption can have on human health. And so I thought it would be good for us to have a conversation today about the importance of how we talk to our patients, how we maybe talk to each other about what we do, about the microbiome, and about those things that maybe come easy to us, but not to those around us. So, Michael, thanks for joining me today.

Michael Graziano: [00:01:28] Hey, thanks for having me. That was good. [laughs]

Buddy Creech: [00:01:31] Well, I try you know, you deserve it. We've known each other for a while now. And what I love about you is you've got this ability that that I don't have to take these really complicated issues and distill them into this sort of digestible nuggets that the world can really get a grasp on. So I always like to ask people their origin stories of how they got into doing what they're doing, because you're in that weird spot where you're an artist, you're a creative, but you also have a really deep understanding of the scientific features of all of this. So tell us your origin story a little bit.

Michael Graziano: [00:02:07] Well the ability to process and synthesize a bunch of complex information pretty quickly was earned in grad school. So I'm like a recovering academic. I was on path to be a college professor. Um, had a job offer at a university, was almost done with my dissertation, yadda yadda. Anyways, I chose the lucrative, [laughs] super safe career of independent filmmaking instead. And then I was working with some food brands back in 2010 through 2013. A brand in particular that is part of the good food, quote unquote, good food movement. And they do a lot of animal protein. And they were telling me about the overuse of antibiotics and animal agriculture at the time, and I didn't know anything about it. So I started to look into that. And it doesn't take long, you know, you scratch the surface and you're like, wow, this is a real issue. Whatever you think about it, it's an issue I got from there into the human side of things. I started making the film, Resistance, and that's when you and I met, and so I kind of fell into it. Not super intentionally. And then since Resistance, I've done several public health medical science-related film projects.

Buddy Creech: [00:03:21] Well, you know, and I think it comes across because some of the things you're doing, there's an artistry to them. But in the setting of that artistry, there's still a great deal of complicated content. One of the things I know I struggle with in talking with patients and giving lectures or whatever it might be, we're always looking for that ability to distill, to meet someone where they are, to be able to answer their questions, to be able to convince them of something sometimes. So that ability to be content driven, creative, compelling, boy, that's really hard to do. So as you're starting a new project, how do you, I'm curious, just not your process, that sounds kind of silly, but like, how do you do that? How do you get started on something?

Michael Graziano: [00:04:05] One of the key aspects of the process in that regard is thinking about narrative. And like, what's the hook or what's the window in to talking about whatever complex thing it is? Narrative is the way that people make sense of the world. So if you can figure out how to put this complex information into a narrative context and then add some emotion to that, people are going to not only hear it more readily, but they're also probably going to remember it better.

Buddy Creech: [00:04:40] Yeah. And I think so many times, I think, I see colleagues doing this, I see myself having a tendency to do this. Sometimes in patient encounters in particular, there can almost be it can almost devolve into a transactional arrangement where there's a call and response, right? There's a question, there's an answer, or there's an agenda of one or both folks. But I always come out better when there is that narrative aspect to the encounter, where sometimes its story driven right when I talk to a patient and I ask, why are you so anxious? And they say something like, my grandfather died of MRSA, and that's why I'm scared to death about my daughter who has a boil on her leg. Right. I mean, there's that disconnect. And if you can get to. Well, maybe if you can get to their narrative that they're playing in their heads and we can start to rewrite that narrative, maybe that's an important piece of it.

Michael Graziano: [00:05:34] Absolutely. I think that when those kinds of interactions between because there is a power imbalance, you know, that's not always bad. Sometimes people come to you, I think, and want an authoritative figure to kind of give them, like, this is my honest take. Here's what I think based on my expertise, I also think you'll probably have better buy in, better responses from patients if you do the thing that you just said and allow them or enable them or facilitate their personal engagement with what's happening. And it's like self-knowledge too, by talking to you about that thing that's behind the way they feel about it, it enables them to have a better experience.

Buddy Creech: [00:06:17] Yeah, my team hates this about me is that I usually have to hear myself say something before I realize how stupid it is. And so once I say it out loud and I hear it with my ears, I'm like, who is that fool saying that dumb thing? And I'm like, oh wait, it's it's me, unfortunately. So okay, so we've talked about like maybe how important that that narrative is and that our ability to tell stories and be compelling to patient encounters. I'm curious about these films that you've done. How have you used them? I guess more broadly, especially for I mean, I'm thinking you've probably been able to see some fruit of that from trainees or students or those that are still very in those very formative years of their training where they've got a lot of knowledge, but they may not have that that storytelling component.

Michael Graziano: [00:07:03] With the Resistance film. I mean, we showed it all over the place, dozens, probably hundreds of universities, medical schools, whatever, all around the real value of that film, because it's pretty comprehensive about how we discovered this miracle with Fleming and yadda yadda yadda, and then potentially squandered or at least squandered a big not all of it, but a big part of it in less than 80 years. And then it offers some ideas about how do we change the situation. So it's pretty comprehensive. And the value of that film is that it enables a more robust and engaging conversation about the issues. Even among physicians, the way that an epidemiologist thinks about drug resistant infections is different from the way that an ID thinks about drug resistant infections, and is different from the way that a microbiologist thinks about it, and a health economist and a hospital administrator. Everyone's thinking about it kind of differently, but there's a load of common interest when you see it all presented in one.

Buddy Creech: [00:08:09] Oh, that's a great word.

Michael Graziano: [00:08:10] Two-minute narrative. Then everybody recognizes their common interest, like, oh, we're actually all pushing in the same direction, even though in our professional day to day lives we're kind of siloed. But there's this interdisciplinary common interest. And so when that's presented to a group of diverse people at the same time, then all of a sudden the conversation after that is way better.

Buddy Creech: [00:08:32] So that's really interesting. One of the things that I'm struck by sometimes in the way that we are pedagogy within medicine is it’s also often transactional. I have knowledge, you have less. I'm going to give you some of my knowledge so that you have more. That feels very transactional. There's another pedagogical approach, which would be I'm going to impart some knowledge. I'm going to put it in a context, and then we're going to engage that content in a question and answer, and we're going to try to figure some problem out. It seems like your films promote that idea of we're going to present the issues, we're going to present a problem, and now there's an opportunity to dialogue that, like you said, from a lot of different angles of expertise.

Michael Graziano: [00:09:20] Yeah, we're going to present the problems, the problem set, but we're also going to in that, show how they're interconnected. We're going to reveal some of the interconnections. And I think that's where some of the cool collaboration happens is those touch points.

Buddy Creech: [00:09:36] Yeah so you could see this being used for ID fellow lectures, grand rounds, I don't know what, red book and red wine like our colleagues at Emory do. There's a lot of different options we could do there.

Michael Graziano: [00:09:46] Totally, and with the new films so far, there's two interconnected short films. There are 18 and 20 minutes, respectively. That's a really nice length for something like grand rounds, I think, and it presents this emotional. So one of them is a more straightforward doc about a young woman that had to have a liver transplant develop cholangitis and had really pretty gnarly consequences from these resistant infections that she developed after transplant. And what's revealed in there is just like nobody did, no one was wrong. No one did a bad thing. It's just, this is the world we're living in.

Buddy Creech: [00:10:27] Right.

Michael Graziano: [00:10:27] That's why the title of the project is Holobiome. It's like, it's their world, you know, we're just living in it. Something where there's opportunity for growth is around that narrative, around the kind of worldview around these things. Like what is the role of medicine? What is health look like when you consider this broad microbial substrate that all life sits on?

Buddy Creech: [00:10:53] That hurts my brain so much. And in part, I think it's because 50 years ago we had a language around resistance. Of course we did, right? We could understand the genetic transfer of resistance from one organism to another. We could understand when an antibiotic stopped working. I think we are just scratching the surface of what it means to disrupt an individual's or a community's microbiome in such a way that could have remarkable effect on metabolic activity, obesity, anxiety, any number of things that, quite frankly, we just don't understand. And I love this, that it's not just about resistance. That's not the only reason that we want to have better use of antibiotics, more targeted therapies. It's also because we don't fully understand what we're messing with when we disrupt it.

Michael Graziano: [00:11:47] That's why I think this one health framework is so important. I feel like that's kind of the future. I mean, the WHO and UN have adopted it. I know CDC has adopted it as well, and it, it just makes sense. It's smart. If one health is kind of the future paradigm, but there's also this big demand for precision medicine, right?

Buddy Creech: [00:12:10] Yeah.

Michael Graziano: [00:12:11] Everybody wants this medicine. Who sits right in the middle of that? Infectious diseases docs.

Buddy Creech: [00:12:18] Absolutely.

Michael Graziano: [00:12:19] And I think that you guys are not valued appropriately within the medical ecosystem. And that's like truly I don't have a dog in that fight at all. That's just my observation. Having worked in different aspects of public health and medicine, in storytelling or filmmaking, if these surgeons like transplant surgeons and orthopedic surgeons and all the surgeons are like James Bond and they kind of are, they're like badass men and women, then the IDs are like Q.

Buddy Creech: [00:12:56] This is outstanding. Yes. Keep going with this.

Michael Graziano: [00:12:59] You guys have this technology and this knowledge that enables them to perform better in the field. They can do these super heroic things. But what is James Bond without Q? If he doesn't have the laser watch he's not getting out of you know, the chains as the water rises in the tank he's in or whatever. You know, he's not going to get the diamond out of the safe without his explosive pen or whatever. And like James Bond, James Bond would say the same thing. He's like, yeah, without Q, it's not happening. We're not completing this mission. And there's some marketing that can be done with ID in that similarly.

Buddy Creech: [00:13:38] This is incredible. I'm now thinking about how easy it would be for ID recruitment of fellows that all of us show the same marketing video of Q just going nuts, creating all these kinds of things. I think. I think we're going to lean into this one. [00:13:53] I appreciate the sentiment of that because we are often behind the scenes. We're trying to do things that, quite frankly, aren't as demonstrative as I took an organ out and put a new one in, I gave a bone marrow transplant. I did whatever, like there's not a necessarily a beginning and an end to it. Our beginning is, can you help? Our end is thanks. You know that that's what our book end is. It's not an opening and shutting of a of an abdominal cavity. So I do think there's a little bit to that.

Buddy Creech: [00:14:29] so let's stay on this value proposition for a little bit. Because I think one of the challenges that we're running into, and IDSA and PIDs have been incredibly active in this space, because we feel like there's going to have to be some government lobbying and some real federal assistance in what we're doing. You know, one of the challenges for us to do the things that we're talking about right now, which is better use of antibiotics and thinking about the whole person and what kind of disruptions, you know, the perfect agent would be one that's really targeted for a, for a particular pathogen, so that once we identify it, we can cool the jets and just focus on that one pathogen.

Buddy Creech: [00:15:08] And we have some antibiotics like that. But they're not moneymakers for the drug companies. And right now, drug companies might make a new drug, and they've reached the finish line, and then they may go bankrupt, as we've seen recently, because no one's using their drug yet. Right? As ID docs, we put it on the shelf and save it for a rainy day. And there's been a lot of work trying to support the Pasteur Act, which is making its way through Congress slowly, in an effort to have both push and pull incentives for US drug manufacturers to make new antibiotics. So can you talk a little bit about what you've seen as you've been in this space for a while, about those forces that might hurt us in our quest to stay one step ahead of these microbes?

Michael Graziano: [00:15:52] Yeah, it's just the political economy of antibiotics is a real thing. It has been for a long time, and now it's finally like caught up with the medical reality. But I, in resistance, I interviewed Stuart Levy, you know, the OG of like sounding the alarm before he unfortunately passed away. And he was talking about it and I interviewed John Rex while he was still at Merck. We were there at Merck and he was talking about it. And it's like now with Pasteur, it doesn't seem like a perfect solution to me, but it's doing something different that needs to be done. One of the challenges is when it comes to the storytelling, again around it, like the narrative around it, generating public sentiment around creating more support for innovation in drug development and AMR is one of the purposes of the new project. It's important for leaders to know that people, that regular people care about this, decision makers and policy makers. But if it's a question about economics and like, hey, big Pharma is going broke, guys like regular Joe doesn't care about.

Buddy Creech: [00:17:09] Doesn't care. That's right.

Michael Graziano: [00:17:10] Cry me a river, big pharma, you know.

Buddy Creech: [00:17:13] Sure.

Michael Graziano: [00:17:13] But what we try to do with these new short films is show people why it's important. And it really doesn't have anything to do with economics. It has to do with health in this more hollow biologic way of thinking.

Buddy Creech: [00:17:33] Yeah. This is this is great. I worry sometimes that we don't have. And by we, I really mean I don't always have the most comprehensively compelling story to tell. Sometimes we focus on we have a need. Well, but it's going to cost a lot of money. And I don't have a great answer for how we're going to find the money to do something right. Or let's talk about the economics of it. But that takes the personal aspect of it out or what, whatever it might be. And I think some of that is, again, that transactional idea of I'm going to give more knowledge to someone that may not be the way to win the day here. The way to win the day here may be to say, let me tell you a story. That story will have woven into it a lot of these facets that you just said. Some are going to be explicit, some are going to be more implicit, but it's still there in the story. And like a good story, you can read it multiple times, you can see it multiple times, and new aspects will come out of it. How have you? I know you had this experience with Resistance, with congressional leaders, or with key opinion leaders and thought leaders in that space. What did you see as their response to some of these aspects? Was it one of I didn't know that or I didn't know it in that way. Tell me a little bit about what is the typical response to something like these films that you're making

Michael Graziano: [00:18:56] A lot of times it's like, whoa, I had no idea. With Resistance, that was the big one. And Resistance was fortunate that there was a member of Congress named Louise Slaughter, who was a trained as a microbiologist. She was a dynamo. Unfortunately, she's passed away. I think at the time she was like the only actual scientist in Congress. She really championed the film. So we had a screening on Capitol Hill. We met with a bunch of other leaders, and that really did shift things, because the film and these new films especially allow people to imagine themselves into this narrative. If you just talk at them about the economics and danger and the dangers, people, I think, can start to glaze over. One of the things that we try to do with the new Holobiome project, and hopefully we're going to add more films to it, but is add a little bit of the wonder and a little bit of this, you know, Carl Sagan kind of thing, like, whoa, we live in this microbial universe. And we need to better understand that in the hypothesis is that if people understood that better, they would be more circumspect about misusing antibiotics in whatever way that happens.

Buddy Creech: [00:20:13] Well, and maybe not even oh gosh, now I'm thinking about the fact that we wouldn't just be trying to avoid a negative. Right? We're trying to avoid the overuse of antibiotics. It would also allow us to promote those things that are positive for health, whether that's good nutrition, whether that's the role of exercise and weight management, whether that's vaccine uptake. Right. And leaning into the not do this so bad things won't happen to you. But look at how we're made. Look at how we work. Look at the amazing wonder of our human systems and how they work together. I mean, that's pretty that's pretty compelling.

Michael Graziano: [00:20:55] Yeah. And I think IDs can be a real linchpin in that, can be shepherds there, you know, like combining the microbial, like bridging the gap between the microbial and the macro. Health and the micro health. You know, you could be there like translating and bridging the gap there in ways.

Buddy Creech: [00:21:16] And we already sit there in many subtle ways. But like Q, maybe we've got to, uh, to have a few more cameos in the movie.

Michael Graziano: [00:21:25] And I think like a big, a big place. And I've already talked about this with a few of your colleagues at different institutions, is overprescription. One guy that I spoke with gave me this anecdote, and I think it was it was interesting to me as an outsider, as a non-specialist. But he was like, you know, if a surgical fellow comes to me and is like, my patient's not doing so well, I want to roll out this big gun, you know, antibiotic. And then he's like, well, where did he get the infection? Oh, it's community acquired okay. No, that's not this big. Gun's not indicated. But he's like no I know, I know that, but I still want to give it to him. So that comes from a good place. That surgical fellow, he wants to help his patient like. Or she wants to help her patient. That's like it comes from a good place. So it's not a knowledge problem per se. It's fear. And I think IDs should be trained in having those conversations with their colleagues, because fear can be counteracted with this conversation.

Buddy Creech: [00:22:32] Man, uh, I'm going to riff on that for a second because I love this. A good friend told me one time, you know, you never want to make decisions out of fear, anger, shame, and I would probably add hunger to that. Um, but you never want to make decisions that are potentially incredibly biased by an emotion that's very difficult to wrangle. Right. And I think you're exactly right. When we are in the cardiac ICU and someone wants meropenem for the classic story is a kid who's totally stable, but they have some CRP elevation. So they've got this high inflammation or maybe not even high, but just moderate inflammation. And because no obvious source is there, there's a desire to escalate. And we all want the same thing. We want that child. We want that patient to do well. We want them to flourish. And we might know that it's not the best thing to do, but it feels like we're trapped and we have an anxiety and a fear. And so I love the idea of using these types of narratives, these types of stories, films that might be a little more accessible, quite frankly, to our younger learners who are developing their own narratives for how they do things, their own scripts for how they do things, being able to use these to try to disentangle that issue of fear. Because I think you're exactly right. It's not always about a lack of knowledge. Sometimes it's it's a matter of fear and anxiety that maybe we can absolve our colleagues of a little bit.

Michael Graziano: [00:24:05] You want to do the right thing. These people got into medicine because they want to help people, and they want to feel like, oh, we didn't leave anything on the table having a real conversation. I think we could make a film about, honestly, there could be some an interesting film or films about this having like senior people on both sides, sort of from ID, but also in surgery talking about, yeah, that's normal. It's a normal to feel anxious when you have a kid in the situation that you described. And here's why we should talk to consultant ID on this because they understand this. And then together you got in your therapeutic alliance for that kid. You can come up with the appropriate explanation for that kid's family. That's not just the surgeon kind of winging it, and it's not the ID coming in, like, who is this person coming in and dropping some science on the people? But there is a real thoughtful explanation. But I think that that should be modeled by senior people who've been through the trenches and have learned the hard way. I think it's showing that type of film to younger physicians and training. One, it shows the value of the ID, and two, it shows the value of collaboration in this therapeutic alliance.

Buddy Creech: [00:25:24] Man, what a great note to put a cap on this, because I've learned a ton from you over the years that we've known each other. And one of those things is, is that it's not only what we say, but how we say it when we say it, and the context in which it's said that comes together to actually to pull something off, whatever that is that we need it to be, whether that's imparting new knowledge or being compelling or whatever it might be, there's a lot more to it than just the what of things being said. And for those that are listening, that the idea that we use these films and we use these media to train our colleagues, to train our junior learners, to compel some of our more junior folks who are yet undifferentiated about what their specialties will be, to maybe impart on them a little bit of the wonder and the uniqueness of ID. And I guarantee I'm going to use the James Bond analogy constantly over the next few weeks, and we'll continue to workshop it a little bit. Michael, you've been incredibly gracious with your time, and I'm really grateful for you doing this. How can we see some of the work that you've got? I know Resistance is on Netflix. I know Holobiome you're rolling out to a variety of venues, and they'll be coming to conferences and other venues near our listeners soon. But tell us a little bit about where we can find your stuff.

Michael Graziano: [00:26:42] Well, Resistance, it cycled off of Netflix and it's on a platform called Gaia, but it's still, if you go to ResistancetheFilm.com, you can find out where to see resistance perfect, how to get it for your institution. And then Holobiome, we just in the early stages of of getting it out there. And so you guys should contact Buddy Creech and he'll connect us. And I mean, we want to show these films at your school or at your hospital where you work or whatever in your community, because I think it's a great way to reach the community and decision makers, hospital administrators, get everyone in the room, show these films. Maybe people start crying because they're some of them are. One of the stories in particular is like pretty emotional. And then you all have this great conversation about why the stuff you guys already do is so important.

Buddy Creech: [00:27:35] This is amazing, I love this. You know what, I will take you at your word and I will gladly receive any and all emails that we can then connect dots with. Because I think this is important. I think we have an opportunity to really make a difference and to move the needle in how we do things in infectious diseases. And Michael, I'm grateful that you're a part of that community. So we're grateful. We will look forward to meetings where this is shown. I'm not saying that when you screen this, that you should dress in a really nice European suit and have a great laser watch on, but it wouldn't be a terrible idea, so we'll look forward to those times. Well, I appreciate it. We're grateful for the time. If you have any questions about what IDSA and PIDS are doing as it relates to the Pasteur Act, the issues around antibiotic resistance, or if you want to hear more about screening these films, come to the IDSA website. Contact me personally. And until next time, this is Let's Talk ID. Thanks for joining us. Let's Talk ID is produced by the Infectious Diseases Society of America, and it's edited and mixed by Bentley Brown.