Zubin Damania wears funny costumes and makes poop jokes on the Internet.
Under the pseudonym ZDoggMD, he uses puns, props and parody to make online videos that simultaneously celebrate and skewer the health care industry.
The videos are an outlet for the self-described megalomaniac's comic creativity and give voice to the frustrations and joys he and countless other doctors experience while practicing medicine.
They also are a big reason Damania and his wife, radiologist Margaret Lin, heeded the call from Zappos CEO Tony Hsieh to drop everything and move to Las Vegas and "help fix health care."
Hsieh, who has been friends with Lin since they were in college at Harvard, was in the midst of creating the Downtown Project, an urban community-building effort based on bringing talented people together in Las Vegas to pursue their passions, when he first pitched the move.
In the Bay Area, Damania was doing the occasional video in between time spent as a husband and father of two and as adjunct clinical assistant professor at Stanford University and hospitalist at Stanford University Medical Center.
" 'So you want us to stop being doctors and come and be with you and work at an online shoe emporium?' " Damania said of his initial response to the invitation. "You're high."
The months went by and Hsieh persisted by challenging Damania to articulate what he wanted to do with his life and career, then suggesting he do it in Las Vegas.
"Tony just said, 'Do whatever you are passionate about,' " Damania said. "Obviously health care in Vegas has a bad reputation. Figure out what is wrong and figure out what you want to do."
Eventually, Damania relented.
New regulations had made his medical work less rewarding. And Lin, who was also taking a risk by leaving behind her own professional network, was urging her husband to follow Hsieh to Las Vegas.
"Even though you think he is crazy, he is probably onto something," Damania said, describing Lin's logic.
So now what?
Since moving in March, Damania has been producing ZDoggMD videos he hopes will help inspire young doctors to come to Las Vegas and join whatever health care system develops downtown.
"I can make a video and reach tons of people in residency who are just forming what they are going to do. If I can get just five of them to switch to primary care and come work with us, that would be a huge thing," Damania said. "We are going to treat it as kind of a startup, incubated by Downtown Project."
But amusing skits aren't going to fix health care in Las Vegas.
According to the United Health Foundation, Nevada ranks near the bottom of the 50 states for immunization coverage, prenatal care and availability of primary care physicians. It ranks high in smoking and lack of health insurance.
A reputation for low quality and high cost has landed Las Vegas some unfortunate health headlines over the years.
An influential 2009 article in the New Yorker by Atul Gawande, a physician and journalist, mainly focused on high-cost, low-quality care in McAllen, Texas, but also included a Las Vegas mention and laid bare some hard truths about the business of medicine and health insurance.
Chief among them, medical culture can influence cost and quality. In places where high-caliber research and collaboration-heavy providers like the Mayo Clinic do business, prices and outcomes are better, Gawande wrote.
"Just as an anchor store will define the character of a mall, anchor tenants in biotechnology, whether it is a company like Genetech, in South San Francisco, or a university like M.I.T., in Cambridge (Mass.), define the character of an economic community," Gawande wrote. "They set the norm."
In places where much of medicine is chasing high-margin services and insurance reimbursement, cost goes up and quality goes down, the article stated.
"Imagine that, instead of paying a contractor to pull a team together and keep them on track, you paid an electrician for every outlet he recommends, a plumber for every faucet, and a carpenter for every cabinet," Gawande wrote. "Would you be surprised if you got a house with a thousand outlets, faucets, and cabinets, at three times the cost you expected, and the whole thing fell apart a couple years later?"
Damania's medical reconnaissance mission upon landing in Las Vegas yielded similar results to Gawande's findings. That is, health care in Las Vegas tends to look more like sick care as patients are herded between specialists who poke, prod and order procedures but don't put more attention toward healing.
"Health care institutions are integrated around trying to do too many things for too many people at once, and they never do anything right," Damania said. "It is a quality problem."
Can he find solutions?
Even though he lacks experience in health care policy or managing medical bureaucracy, Damania thinks he is zeroing in on potential solutions to implement sound practices downtown.
He is doing it by reaching out to others looking to bring down health care costs while improving results.
People such as Samir Qamar.
Qamar is a Beirut-born U.S. citizen. His parents are diplomats, and he spent his childhood traveling the globe.
He also is the house doctor at the prestigious Pebble Beach golf club near Carmel, Calif., and founder of MedLion, a low-cost, subscription-style primary care clinic company founded in 2009. It started in Monterey, Calif., catering to laid-off Silicon Valley workers who had lost employer-subsidized insurance. It later expanded to work with businesses seeking to reduce health costs.
The idea behind the clinic is that by charging a monthly fee-for-access of about $40 to $60, MedLion can provide quality care aimed at prevention instead of ordering as many procedures as possible.
The clinics contract for low-cost lab services, and the pricing structure includes health monitoring, flu shots, sugar checks for diabetics and other routine services such as physicals.
Proponents of direct primary care say it improves quality by giving doctors incentives to keep people healthy through prevention and reduces costs by shifting insurance to something people only use for rare, high cost procedures such as surgery.
"If we can do our jobs and provide high-quality, high-impact preventative and primary care ... then we can effectively decrease downstream hospital visits and specialist visits," Qamar said.
Qamar moved MedLion to Las Vegas in part because the high ratio of patients to primary physicians in Nevada means people are clamoring for quality care and also because Nevada has a better business climate than California.
He is working to open the company's first local clinic, near U.S. Highway 95 and Summerlin Parkway, in the Longford Medical Center.
"We came here to save Las Vegas' primary care independently," Qamar said, but he is open to working with Damania, Hsieh and the Downtown Project.
"Part of (Damania's), I think, role in the Downtown Project is to see what health care models are out there working," Qamar said. "They liked what we had to offer. We know they are trying to produce some type of clinic. We have already told them we are prepared to help."
Damania said he still doesn't know exactly how to proceed. He wants to get a clinic opened downtown sooner rather than later and takes inspiration from people like Qamar and other innovators.
Even though Damania hasn't settled on a specific model for downtown Las Vegas, he is clear when it comes to describing what he wants to accomplish.
He recalls an experience on rounds at Stanford when he was assigned to care for a relatively young man dying from cancer.
Damania said the man was an engineer and aware he was dying, but he and his family couldn't settle on a course of care.
The man's wife sought to reduce his pain and protect his dignity.
The patient wanted to be lucid to communicate with his loved ones in his final days.
But no one, not the patient, his family or specialists who had come through the room, were able to forge agreement on a plan.
After taking time to sit and listen to the patient and his family, Damania said, they were able to settle on a balance of care that reduced pain but kept the man lucid and able to return home for his final days.
"When they left they were so happy and at peace and grateful," Damania said.
It was one of the last patients he cared for before moving to Las Vegas.
"I was thinking, remember this," Damania said. "This is what you are going there to do, even though you don't know what the hell you are getting into."
Contact reporter Benjamin Spillman at bspillman@review journal.com or 702-383-0285.