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The following is a transcript of the podcast episode:

Rachael Robertson: Hey everybody, welcome to MedPod Today, the podcast series where MedPage Today reporters share deeper insight into the week's biggest healthcare stories. I'm your host, Rachael Robertson.

Today, we are talking with Cheryl Clark about how Tennessee is trying to fill their physician shortage and why they're facing some hurdles. Plus, Sophie Putka dives into the question of how addictive is ketamine, really? After that, I'll tell you about a new musical about antimicrobial resistance that recently made its off-Broadway debut – and it features a cast of real-life healthcare professionals. But first, let's turn to Cheryl.

Last year, Tennessee lawmakers passed a statute they thought might solve their physician shortage problems, as most of the state's counties are classified as medically underserved. But the state physician licensing agency, on its own, voted not to abide by that law. Cheryl Clark is here with the details.

So Cheryl, what went down?

Cheryl Clark: Hi, Rachael. That law you mentioned took effect July 1, and it was supposed to allow graduates of international medical schools who had never been accepted in a U.S. residency program and never trained in the United States -- or ever worked in the United States -- to apply for a license to practice in Tennessee. And that was said to be the most lenient credentialing policy of any state medical licensing board in the U.S. And of course, for many other licensing boards in the United States, that would be a deal breaker.

But Tennessee's new law said that applicants could satisfy criteria to practice and could get a temporary license if they met any one of these requirements: they demonstrated competency as determined by the board; they'd completed a 3-year postgraduate training program in the foreign country where they originally got their license; or they had practiced as a medical professional outside the U.S. for at least 3 of the most recent 5 years. And the key word here is 'or.'

They also had to show proof that they had an employment offer from a healthcare organization in Tennessee with an ACGME [Accreditation Council for Graduate Medical Education] approved postgraduate program and would only work with that health system.

But the Tennessee Board of Medical Examiners, which licenses some almost 20,000 physicians, reeled in horror during a heated 90-minute debate during its meeting on July 30. They basically refused to enforce the law, despite pleadings from two state general counsels who stood before them and said their action could result in messy and costly lawsuits from some of these physicians who wanted to practice.

Robertson: What reasons did they give for not enforcing this?

Clark: Well, a number of the board members said that with such loose criteria, they wouldn't know how competent these physicians would be. That's information they can easily get from medical schools and training programs in the United States. They worried that incompetent doctors would harm patients. The president of the medical board, Melanie Blake, MD, who's a physician, said, and I quote: "We don't know what they were doing in Iceland, or Sweden, when they were, you know, practicing euthanasia or whatever, you know, I don't know what we can know about them."

So responding to the attorneys' warning that they could get sued, another member of the board said they get sued anyway -- just that they allowed someone who harmed a patient to have a license. So in the end, the board voted not to prepare the application form, thus blocking these international graduates from entry and basically saying they weren't going to do the law.

Robertson: Okay, what about the international graduates? Have any of them sued Tennessee?

Clark: I don't know of any yet, but we received emails from about 20 physicians who said they were planning to come to Tennessee and practice and now can't. A job agent who helps match physician jobs with those foreign physicians told us he had 60 clients who were so angry and disappointed, he wouldn't be surprised if they did.

And there's another wrinkle in this story. The Tennessee Medical Association was also very vehemently opposed to this current law, and so they got other lawmakers to introduce a different statute with the word 'and.' So it just replaces 'or' for all of those requirements with the word 'and' and at least it provides a pathway. But this new law that just got passed doesn't take effect until next January, so it leaves everybody in limbo.

Robertson: Thanks so much for the story, Cheryl.

Clark: Thanks, Rachael.

Robertson: Matthew Perry, the actor probably best known for his role as Chandler Bing on the sitcom 'Friends,' tragically died last year after using the drug ketamine. On his autopsy, Perry's cause of death was listed as, "acute effects of ketamine." This got us wondering: how addictive is ketamine really? Sophie Putka dug into this question, and she's here to tell us what she found.

Sophie, to start off, can you catch us up on how the use of ketamine has evolved?

Sophie Putka: Sure, so ketamine is an anesthetic drug that's been historically used mostly in a surgical context, and it's FDA approved for that, and historically has also been a club drug that's known for its dissociative effects. But recently we've seen a pretty big rise in the use of ketamine for chronic mental health conditions, and there's actually a nasal spray, esketamine, that was approved in 2019 for treatment-resistant depression, and since then, the use of ketamine off-label for mental health has gained a lot more public attention and acceptance. In the meantime, we saw telehealth restrictions ease up during the pandemic, so doctors could more easily prescribe controlled substances, and online platforms for ketamine treatment like Mindbloom, sprang up pretty quickly.

Robertson: Okay, with that in mind, what do we know about ketamine and addiction?

Putka: So one anesthesiologist I spoke to, Boris Heifets, MD, PhD, from Stanford, told me ketamine may be less, quote, "addictive" than oxycodone or alcohol, but it can become problematic, and definitely can be habit forming. There's not actually a ton of good research on how widespread ketamine addiction is, but the internet is full of accounts of people becoming addicted to recreational ketamine, and even ketamine that's been prescribed legally. A lot of their paths sounded similar to what allegedly happened to Perry -- this escalating legal use of ketamine, followed by seeking it out elsewhere in higher doses.

There aren't fatal withdrawal symptoms with ketamine, like there are with alcohol, but you can definitely build a tolerance. There can be symptoms of psychosis, and people who go off of it sometimes do report what's called 'K cramps,' or this severe abdominal pain in withdrawal, and serious side effects, like bladder damage. The President of the American Society of Addiction Medicine, Brian Hurley, MD, told me that overdose from ketamine by itself isn't actually that common, but that its anesthetic effects can lead to accidents. Someone could fall asleep driving or in another dangerous situation, like Perry.

Robertson: Got it. So what's being done to prevent ketamine addiction from becoming widespread?

Putka: So here's the thing: we don't have great ways of tracking ketamine addictions. We know it's more widespread since it's been commercialized, and as Heifets told me: "It just comes back to this math: you take something that's not terribly addictive and give it to a million people and create a problem that you didn't have before."

There are state-level drug monitoring databases of controlled substances so physicians can check to see if someone is, quote, "doctor shopping" or getting multiple prescriptions at once. But there's not a nationwide version of this. And one addiction psychiatrist I spoke to said he was so concerned about cases that he was personally seeing in the ER that he called up his local high intensity drug trafficking area, or HIDTA office, which tracks areas with high concentrations of drug trafficking or diversion. But he said they didn't know anything, and he got the impression that government agencies are focusing most of their energy these days on fentanyl, which seems to be behind more deaths. Experts told me we do need better regulation of ketamine prescription, though, and to be able to track use and misuse more effectively.

Robertson: Really interesting story. Thanks so much, Sophie.

Putka: Thanks, Rachael.

Robertson: Cheryl Clark is going to fill in as host for this last segment.

Clark: Move over 'Hamilton' -- it's time for a public health story to hit the stage. 'Lifeline' is a new off-Broadway show about antimicrobial resistance, or AMR. On top of that, real working scientists and healthcare professionals are part of the supporting cast. Rachael went to see the show in New York City, and she's here to tell us more about it.

What's 'Lifeline' all about, Rachael?

Robertson: First of all, the show is so much fun. Its songs are inspired by Scottish folk music, and there's a live band on stage, including some really beautiful bagpipe playing. In terms of plot, the show has two weaving timelines. One of them is historical, and the other takes place in the present day.

The historical timeline follows Alexander Fleming, the Scottish physician and microbiologist who discovered penicillin back in 1928. And then the present day follows Jess, who's a fictional doctor in Scotland, and Jess is trying to save the life of her childhood sweetheart, who's fighting an AMR infection after getting surgery for cancer.

In the show, both Fleming and Jess are struggling with trying to treat patients in urgent need of care, but also experiencing pushback while they're trying to change the practice of medicine. And the show also depicts how, way back in 1945 when Fleming won the Nobel Prize, he warned about the danger of AMR. But decades later, Jess is shown struggling to treat patients affected by AMR, and she's also morally struggling with her complicity in a medical system that overuses antibiotics.

Clark: Sounds very real-life. Tell me about the cast.

Robertson: That is part of what made this production special. It's cool enough to have a musical about a public health crisis -- but it hits different when real healthcare professionals are helping to tell the tale. Each week of the show, there's a different 12-person Greek chorus of scientists and clinicians who take the stage alongside the principal cast, and hundreds of people auditioned for these 57 roles.

There's medical residents, epidemiologists, members of the CDC, mental health professionals – and so many more. And throughout the show, these people share vignettes based on real patient stories, they sing backup vocals, and then at the very end, they get to tell a bit about who they are in real life and how their work relates to AMR.

I spoke with one of the chorus members, Judy Minkoff, PhD. She's a virologist in the department of microbiology at New York University Langone Health here in New York City. And she said that "the science communication aspect of this musical is really unmatched."

Clark: That's cool. What are the creators doing in terms of science communication?

Robertson: So audience members are actually sent a pre- and post-show survey about AMR so the team can see if the audience's understanding of core AMR concepts improves, and if there's anything that people misunderstand by the end of the show. They've been kind of tweaking things in the past few years as they've been developing the show. And then there's also a Scottish infectious disease doctor who's serving as the scientific advisor to the show. Plus the creative team actually went to Fleming's lab and they talked to some of his family members when researching the show.

The show is still playing for a few more weeks here in New York City, until September 28, and there's ticketing and other information at . And if you're not in New York City, the cast released on Spotify that we'll link to, and you'll get to hear real-life healthcare professionals and scientists singing with musical theater professionals in a musical about antimicrobial resistance.

Clark: Thanks, Rachael.

Robertson: Thank you, Cheryl.

And that is it for today. If you like what you heard, leave us a review wherever you listen to podcasts (, ), and hit subscribe if you haven't already. We'll see you again soon.

This episode was hosted and produced by me, Rachael Robertson. Sound engineering by Greg Laub. Our guests were MedPage Today reporters Cheryl Clark, Sophie Putka, and Rachael Robertson. Links to the stories are in the show notes.

MedPod Today is a production of MedPage Today. For more information about the show, check out medpagetoday.com/podcasts.

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