Month: February 2020

Cutting the Crap on the Gut Microbiome with Frank Cusimano, PhD

Dr. Frank Cusimano, PhD, has a doctorate in Nutrition and Metabolic Biology from Columbia University and is currently a medical student at the Arizona College of Osteopathic medicine. Having done his PhD on the gut microbiome, a hot topic, we dive into the science of prebiotics, probiotics, postbiotics and antibiotics. What can we actually recommend to patients to help them with GI upset while on antibiotics? How does the microbiome influence inflammatory bowel disease? How can the gut actually influence our brains? A previous guest discussed how the colon is the window to the soul. Turns out there’s science behind that!

Having been a sponsored athlete as an adult, Dr. Cusimano is currently a medical student uniquely blending his understanding of biochemistry with human physiology and human potential. In college he received both a BS and BA from SMU in Chemistry and Biology and then went on to complete a MS from Johns Hopkins University in Biotechnology concentrating in Bioinformatics, all in addition to his PhD. He is the host of the Surviving Medicine Podcast and a regular contributor for Medscape and Doximity.

Find this and all episodes on your favorite podcast platform at PhysiciansGuidetoDoctoring.com

Please be sure to leave a five-star review, a nice comment and SHARE!!!

Instagram: https://www.instagram.com/dr.cusimano/

Twitter: https://twitter.com/frank_cusimano

Instagram: https://www.instagram.com/surviving.medicine/

Website: http://survivingmedicine.org/

Podcast: http://itunes.apple.com/us/podcast/surviving-medicine/id1276029472?mt=2

Cutting the Crap on the Gut Microbiome with Frank Cusimano, PhD

Dr. Frank Cusimano, PhD, has a doctorate in Nutrition and Metabolic Biology from Columbia University and is currently a medical student at the Arizona College of Osteopathic medicine. Having done his PhD on the gut microbiome, a hot topic, we dive into the science of prebiotics, probiotics, postbiotics and antibiotics. What can we actually recommend to patients to help them with GI upset while on antibiotics? How does the microbiome influence inflammatory bowel disease? How can the gut actually influence our brains? A previous guest discussed how the colon is the window to the soul. Turns out there’s science behind that!

Having been a sponsored athlete as an adult, Dr. Cusimano is currently a medical student uniquely blending his understanding of biochemistry with human physiology and human potential. In college he received both a BS and BA from SMU in Chemistry and Biology and then went on to complete a MS from Johns Hopkins University in Biotechnology concentrating in Bioinformatics, all in addition to his PhD. He is the host of the Surviving Medicine Podcast and a regular contributor for Medscape and Doximity.

Find this and all episodes on your favorite podcast platform at PhysiciansGuidetoDoctoring.com

Please be sure to leave a five-star review, a nice comment and SHARE!!!

Instagram: https://www.instagram.com/dr.cusimano/

Twitter: https://twitter.com/frank_cusimano

Instagram: https://www.instagram.com/surviving.medicine/

Website: http://survivingmedicine.org/

Podcast: http://itunes.apple.com/us/podcast/surviving-medicine/id1276029472?mt=2

 

EPISODE TRANSCRIPT

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Dr. Frank Cusumano has a doctorate in nutrition and metabolic biology from Columbia University and is currently a medical student at the Arizona College of Osteopathic Medicine. Having done his PhD on the gut microbiome hot topic right now, we dive into the science of prebiotics, probiotics, post biotics and antibiotics. He teaches us what we can actually recommend to our patients to help them with gi upset while on antibiotics. How does the gut microbiome influence inflammatory bowel disease? How can the gut actually influence our brains? Now previous guests discussed how the colon is the window to the soul and turns out there science behind that, having been a sponsored athlete as an adult. Dr. Cusumano is currently a medical student uniquely blending his understanding of biochemistry with human physiology and human potential. In college, he received his BS in ma from SMU in chemistry and biology and then went on to complete an MS from Johns Hopkins in biotechnology concentrating in bioinformatics, all that in addition to his PhD from Columbia He’s the host of surviving medicine podcast and a regular contributor to medscape and doc SimCity.
Welcome to the physicians guide to doctoring A Practical Guide for practicing physicians, Dr. Bradley Block interviews experts in and out of medicine to find out everything we should have been learning while we were memorizing kreb cycle. The ideas expressed on this podcast are those of the interviewer and interviewee and do not represent those of their respective employers.
And now, here’s Dr. Bradley Block.
Dr. Frank Cusumano.
Thanks so much for being on the podcast. Thank you. Thank you so much for having me on the podcast. It’s an honor.
Well, Antarctica. You’re welcome.
All right. So let’s get started. Give us the short version of your PhD thesis.
Yeah. So I guess I should have introduced with that or a second ago that when I say when you called me a doctor, a doctor Cusumano, technically it’s a it’s a PhD. So I have a doctorate in nutrition and metabolic biology, and I am in medical school. So I’m doing additional training. I’m a third year medical student, or seventh year, if you add the PhD to it, and I have my PhD is in nutrition and metabolic biology, and I’m uniquely trained in that and the only medical professional I will be the only medical professional with that specific PhD because it’s the only PhD of that kind that is housed in an institute of medicine, which is very unique, and that I was lucky and fortunate to be able to do that. But my PhD thesis was on the gut microbiome. So in the nutrition area, obviously, the bacteria in our stomach and in our small intestine colon played a huge role in the pathophysiology of many disease processes. But my specific topic that I worked on, you know, over the course of my PhD career was I engineered bacteria to modulate intestinal physiology, you know, deal with inflammation and also modulate behavior. You’re along the microbiome gut brain access. So specifically engineering bacteria to serve a specific physiological process in. For me, the most work that I did was in the large intestine.
So GMO for the gut microbiome,
essentially GMO for the gut microbiome, and that is the right way to think about it, because we were using genetically modified bacteria to serve specific purposes. I think
that’s gonna make some people’s head explode because you’ve got this whole, and we’re going to talk about this, but this whole area of pseudoscience, that’s that’s orbiting around the actual science, and these are a lot of hippie dippie people that are non GMO, and then they’re finding out that the person who’s one of their, you know, one of the people that they look up to because of the research that you’ve done in the gut microbiome, you’ve actually used GMO in this secret area of the gut microbiome. I think there’s some people that have head’s gonna explode. Okay, so can you give us any more detail about what that will do? I know there were, you know, for some time there was you weren’t actually talking to people about it because it was so Hush Hush.
Correct? Yeah, there was I mean, there’s still there’s patents filed on our research that we were doing. It was at Columbia University. The patents are have gone through so I can talk about it. We haven’t published our paper on it. We have a big one that’s in revisions that we were really excited about. So I may spare out some of the good details. But other than that, we’re going to talk about it. And I think when when I introduce the microbiome, when we talk about the microbiome, the microbiome is something that you know, is has to be specified for location. So when you’re talking about the microbiome, it’s just a collection of bacteria in genes that make up microbes, or any type of bacteria or fungi or Flora on a surface. And so I say gut microbiome, it’s specifically talking to the cashier intestinal tract, versus a colonic microbiome is just the microbiome found in the colon. And they all are very different. They serve different purposes. They have very different compositions. And they have very different genetic profiles. And I think that that’s more of the important part. The research is, as you said, rife with pseudoscience. And it’s it’s rife with pseudoscience, not for the specific reason that we think about pseudoscience and just being blatantly wrong. It’s that they’re early on microbiome research was very naive. And it was done in a way that our tools now are showing us that a lot of the regional research we did was not specific enough or it didn’t hone in on the level of specificity or detail on the research that we needed. Case in point that you may think about is none of the none of the labs doing microbiome research. actually started as microbiome research labs, they typically did not they started as gastroenterology s or gastroenterologist or microbiologists that wanted to do microbiome research. And so most of the P is the primary investigator. We’re not people that trained doing these techniques. I hear researchers talk about the gut microbiome extensively or you know, or medical professionals talk about the gut microbiome, and how they use it for all sorts of treatments. But when you ask them, if they’ve ever sequenced someone’s in fecal samples, if they’ve ever sequenced anyone’s gut microbiome, typically they’ll say no. And that’s the that’s the major issue that that I want, you know, people to understand is that the techniques and tools that we’re using to study the bacteria in your stomach, the tools are advancing so rapidly, that things that we were doing five years ago, are, you know, they’re not only rudimentary, but they give us misinformation. And so understanding where that misinformation lies, and it all comes down to sequencing techniques to genomic preps, to understanding how to analyze the data, the changes that we’re seeing in the past few years, just showed us that our initial findings were sometimes wrong. That’s the important part. I think for a lot of the microbiome research.
Well, there are labs out there that if you send them a sample of your gut microbiome, right, you give them a little fecal sample, they will tell you things about yourself. Like this is what you should be eating more of this is what you should be eating less of this is what diseases you’re at risk for. And that, to me sounds like there. That sounds like there could be some fear mongering and capitalization capitalizing on lack of science literacy, or am I just an old curmudgeon that don’t bully that doesn’t believe in new areas of science?
No, I mean, you’re not. Most of that is is accurate in your perspective. And those companies dealt with a lot of litigation already early on. And now they’re having to use specific wording or they’re having to do things in a specific way where they can’t talk about medical conditions, or they have to give it to a third party to talk about medical conditions. And the reason why is that, you know, we In 2007, the I think it was the NIH decided that they were going to put like 170 million dollars into understanding the gut microbiome so that we can understand what was best for patients. And what was the healthiest microbiome. And their conclusion after five years in 2012? Was that, you know, we spent 170 million dollars and all we decided was that there is no one correct microbiome. And in fact, it wasn’t which bacteria you have in your stomach. So when you when you send a sample to a lab to sequence your microbiome, they’re gonna tell you, not how many bacteria are, which bacteria are there, they’re going to tell you what relative ratio or population of bacteria are there and they’re only going to go as deep as maybe the genus level. But typically they stay at the family level or the phyla level. But the difference between two bacteria in the same genus is, you know, night and day. It’s not even the different I mean, it’s The difference between me and an elephant, like it’s really is that far. And what matters more is what genes are present in someone’s microbiome, right? So out of all the bacteria in your stomach, each bacteria has a number of genes, and they have, you know, their DNA, which genes are present and which ones are being transcribed, you know, translated into proteins that can do serve a specific function that is way more relevant than which bacteria are there, because the difference between, you know, an E. coli and your stomach for an E. coli in my stomach? Well, it depends a which genus is it? It depends which species is it, and then even to bacteria that are the same species, maybe as far as a rhino and an elephant, and the genes in those are so different that it’s really hard to say, and so that, you know, a lot of those tests, I would say, I don’t recommend for that reason.
So what are some other misconceptions that are out there about the gut microbiome?
Yeah, misconceptions. The gut microbiome is probably the most fun thing to go over, and a lot of it You know is is around fermented foods like probiotics everyone wants to know which probiotics they should take or if they’re useful well probiotic if you look at the definition of it, it’s a live organ microorganism that when you know taken an adequate amounts, it has some type of health benefit. Well, most bacteria over the counter probiotics don’t have a they haven’t been tested to show health benefits. And most of them aren’t living anymore, or they don’t reconstitute because most probiotics are pill forms and most pill forms, that means the bacteria has been life alized basically dried completely. When placed back into a host, they can come back and become active but over time, their efficacy drops drastically and a lot of them won’t survive the Trent, you know, the transition from your mouth all the way down to let’s say, your small intestine or colon, where your colon is actually where most bacteria are most useful. Most of the microbiome until you get to the colon. You know, it has some function and there’s depth events, some things that we’ve learned, but the majority of the bacteria that at least is beneficial, or that can provide a lot of metabolic benefits actually has to get all the way down to the colon, which studying that in humans is very difficult. So,
like if you go to GNC or CVS and buy probiotics, because you’re worried about getting an upset stomach, after antibiotics, or in the situation of myself and our listeners, you’re recommending that to your patients, what you’re ultimately recommending is dust. Right? So what’s contained in the pills of probiotics that you’re buying over the counter, laugh alized bacteria, that doesn’t make it to all the way to the place it needs to be. It doesn’t sound like that’s really what’s recommended, or that would be helpful in any way.
Correct. And this is where there’s a lot of good research on it, to show that most probiotics for almost every instance isn’t recommended because As a we either don’t know enough, or they haven’t shown any efficacy. I don’t take probiotics. I’ve been studying the microbiome, you know, for five plus years, but I don’t take a probiotic supplement. And if anything, the only thing I recommend to most people is just increase the amount of fiber in their diet. We all know about the different types of fibers, whether it’s soluble or insoluble, and they both have, you know, different motility benefits. But in terms of the gut has many different types of fiber that you can consume, feed the bacteria that are already there, and instead of focused on trying to introduce new strains or new bacteria from pills on the shelf, it’s more important to go to you know, the part of your grocery section where the vegetables are and buy different high fiber foods. Some of them are the ones that are high in you know, a fiber called inulin, which is one of polysaccharides that really does help your bacteria live that’s basically the food that they eat. In going to buy some foods like leeks or bananas or spinach or kale or onions or garlic, anything that can be used for your bacteria as food is actually way better than taking any pills over there on the shelf.
So what we should be telling our patients is if they’re on antibiotics, they should eat more fruits and vegetables.
Yes. And this is actually when they’re off antibiotics. They should also be eating more fruits and vegetables. Frank, this is groundbreaking. No, great. It’s totally groundbreaking. It’s actually really interesting. So it used to be that when someone gave someone antibiotics, the recommendation was to take a probiotic to help you know, your bacteria, bolster it up so that it could return after the antibiotics to, you know, to a faster position to you know, two papers came out from one of the one of the leading experts in this area, and they actually found that when you when you take an antibiotic, it does wipe out you know, a lot of the bacteria, but taking a probiotic along with that antibiotic actually delays progression of the bacteria coming back that you normally colonize. Why is that? Well, most probiotics that you take over the counter, don’t colonize your gut. Could they potentially be beneficial for a short period of time after you take them? Yes, there’s possible but the bacteria that is present after you take an antibiotic, you need to re you need to get that bacteria that’s still there that survived to the antibiotic, you need to get it to build up its amount and needed to replicate and to survive. And by introducing additional probiotics, what you’re doing is you’re basically competing it for resources. So think of it like, you know, like a war. If you get rid of half of the bad guys, if you get really rid of the majority of the good guys, you don’t want to throw more random soldiers that can’t speak the same language in there. No, what you want to do is you want to let the let the good ones you know, start to grow and repopulate and get back up to speed and that’s the best way to do it, is by increasing your fiber intake when you take a antibiotic to let the good bacteria grow and repopulate.
So this is completely different from any of the questions that I sent you but it just in a I don’t feel comfortable answering it, I completely understand. But with regards to the increasing fiber in your diet, there’s a lot of, there are a lot of fiber supplements. There’s a lot of food that has increased the amount of fiber from other sources, like protein bars with added fiber or fiber one makes a breakfast bar with added fiber. But it’s not like it’s like eating an apple where the fiber is innate to the food, it’s been extracted from somewhere and put somewhere else. Do you know if there’s any difference between actually eating it in in its raw form? versus have it having been extracted? Now we know what the hippie dippie answer is going to be, which is, yes, you should eat it in its natural form, if that’s the way it supposed to be. But ultimately, you know, does the gut know the difference between the fiber that starts out in an apple or the fiber that was extracted from an apple put in a breakfast bar and then consumed that way?
So this is a great question. And I love this question because it talks about you have to use real science to answer it, but it’s confusing. Science. And so I’ll try to explain this to the listeners taking exogenous fiber from any type of supplement powder or bar. For some reason in our gut, it doesn’t have the same effect as eating whole foods. Why is this? Okay, so So what the the conclusion has come from amongst most of the experts is that when you eat fiber, you’re doing it for mainly two reasons to feed the bacteria that are in your stomach. But also because fiber is broken down by bacteria in our stomach into beneficial secondary metabolites. Some of those are short chain fatty acids like butyrate eisah, theater a acetate propriate. In for some reason, those bacteria that produce the short chain fatty acids are that produce these beneficial secondary metabolites. They have to be present to do this. But people that don’t eat a naturally high fiber diet don’t have these bacteria present in high enough quantities to produce the benefits that you need from the secondary metabolites. So just taking you know having a poor diet you’re eating you know, No fiber in your diet, but taking a powder, it doesn’t actually serve the same benefit, you get added benefit if you can actually eat a high fiber diet. And then they see an additional benefit if they are taking fiber on a supplement form which typically in that case, it doesn’t eat it because you’re already eating the fiber. So you can’t eat McDonald’s and then put some Metamucil in your coca cola? Yeah, well, it may it may help you on a constipation front, but it won’t help you get the you know, it won’t help you, you know, establish a healthy gut microbiome and it won’t help you get the secondary benefit or the benefits from the secondary metabolites are being fibers getting converted by the bacteria to to produce, you know, the beneficial compounds
in your gut. But if you take some Metamucil and you’ve just eaten a salad, then that mute Metamucil is beneficial.
Correct? that’s what that’s what is implies in the Metamucil. I can’t remember what the exact formula in there with the fiber is. But the one that most of these research has been done On his insulin, which is typically the prebiotics that you see on the shelf, so when we’re talking about fiber, not only are we talking about the fiber for motility, but we’re mainly talking about what you consider on the shelf as prebiotics. And that is a term that’s been thrown around a lot recently, on shelves and on supplements and on the news has been way more beneficial than probiotics.
Okay, so. So what we should be recommending is, and this is where a place where I know you, you mentioned before the show, you’re reluctant to give, make recommendations because you’re still a medical student, but you do have a PhD. So what you’re saying, you’re recommending we eat more fruits and vegetables, but specifically, if the patients are looking to decrease their gi upset, they, they should they should do that more so maybe than they usually do. And I don’t think you should feel uncomfortable making that recommendation to anybody.
Yeah, I think. Yeah, there’s only about one or two really solid indications for adding probiotics and one that’s for the treatment of diarrhea resistant diarrhea in in, you know, adolescents or children. Probiotics have been shown to be pretty have pretty good efficacy, depending on which probiotic it is. So that’s still definitely an indication and I think PT pediatricians will know that. Although the research in the past few years has gone to say maybe that’s not the case, but I think the jury’s still out. So I would say that that’s still probably a general guideline that a lot of people are following. And then also, for patients that have C diff patients that have C. diff, that are receiving antibiotics, probiotics can prevent not only c diff, but they can also prevent the recurrence of people that have had c diff in the past. So I think that those are kind of the three main indications that we’re still seeing a good use of probiotics in a clinical setting. But other than that to patients that are having some gi upset let’s look at your your water intake, your your overall fiber intake and your fruits and vegetables and go from there as opposed to just recommending probiotics blank Need to say, Oh, well, probiotics gonna help your gut immediately, if that makes sense.
So you’d mentioned before, rather than consuming ly off alized bacteria to actually consume something that’s fermented. So there’s still bacteria in there. So what about things like yogurt or, you know, the big craze now as kombucha or maybe even a beer with still some yeast in the bottom? Right? What? What about consuming that directly?
So in most of the in most of the sense, most of those haven’t been shown to have good efficacy long term or in the clinical setting have not been shown to be effective at all. We see we hear that, you know, yogurts, great but when you look at the actual really good science that’s being done on these, we don’t see any benefit. And there hasn’t been there hasn’t been a good systematic review to show that the researchers conclusive that they’re beneficial. There’s actually most of them saying that they’re inconclusive and they haven’t helped at all or they’ve seen very little. Now most of the time for dairy based yogurts. The reason why they say they help motility is tends to be less from the bacteria that you’re introducing. But for patients that have constipation that take their yogurt help them, you know, have modal you know, better bowel movements, most of that tends to be because most patients are slightly lactose intolerant and so the dairy in there will instigate you to have a have a bowel movement, and that sometimes has been pretty has shown shown pretty good efficacy, but it’s not from the probiotics in the yogurt. It’s from that other side effects. Typically, yes, but it’s a beneficial side effect. So I don’t know if that’s most of the other fermented foods that we think about our you know, kimchi or kombucha, or Kieffer. Most of those To be honest, the benefit is in actual fiber that’s in those kombucha there’s almost none. So there’s your answer right there. They haven’t been shown to have good efficacy. There’s typically most computers as well. yeast and two different bacteria that you know, that colonized but do they pass the stomach with any efficacy there hasn’t been any good research showing it. fermented foods like kimchi Kimchi is actually one of the ones that I do recommend, but I recommend it to patients that are having issues or that have zero issues. patients that are kind of you know, want to increase increase the health of their microbiome, they can try Kim cheese and the benefits from Tim cheese typically is from the fiber that’s present in the cabbages that they typically using cheese. It’s not from the bacteria that’s being added. The bacteria that’s fermented in cheese is so little, and most of it is soil based bacteria, which typically tend to be good but they don’t they don’t survive very well in the acidic environment of the stomach, even though they’re locked in even though they’re lactate producing bacteria, they just don’t survive at a pH of two. So I tell people most people that consume kimchi I say if it if it helps you or if it’s great and it doesn’t upset your stomach, great, but if it does upset Your stomach, don’t think taking more of it is going to help just don’t eat it. Right? Because it is going to produce maybe some discomfort if it’s if it’s producing a lot of gas, which you know, some high fiber foods can produce gas and flatulence and if that’s a discomfort for you, then don’t worry about it because it’s not you’re going to get you’re not getting added benefit from it than just eating other types of fruits and vegetables.
Interesting. Interesting. So your your PhD thesis, you had mentioned the gut brain access, right? And this is another area that sounds more to me, like pseudoscience and science fiction. But thankfully, you’re on the show and you’re going to help to sort me out on this. So just explain to me what is the gut brain access, like how are these things actually communicating with each other? Although, Episode Number three, was with a gastroenterologist who says that the gut is the window to the soul. So you know you have agreement agreement With her on that, definitely so so just just help clarify what what that means because we’re we’re hearing that the gut microbiome can have an influence on issues like autism and Parkinson’s and dementia. So So how is that? Is that real? And if so, how is that possible?
So some of these are tricky, especially for the ones like Parkinson’s and dementia, the newer research is coming out is actually pretty good. But the initial research that’s showing these indications was actually very poorly done. And that’s because you also remember that a lot of this is a chicken in the egg phenomenon of is, is the, you know, what they typically do is they’ll sample 100 patients that have Parkinson’s and then 100 that don’t and they’ll say, Oh, well, these bacteria popped up as being the issue with people that have Parkinson’s. Well, are they present? Is that a chicken or an egg situation? Right? Was that were these the cause of Parkinson’s? Or are these just being predisposed to patients that already have Parkinson’s? Maybe for dietary or motility issues. Because remember, a lot of the gut is affected by the neurons, right? They there’s a term that the gut is a second brain. The guy who coined that phrase was actually the father of neuro gastroenterology. And that was Mike Kirsch on at Columbia who discovered the serotonin receptor in the gut. He was one of my, he was on the committee of my thesis. So he’s someone that I worked with closely. I spent three months in his lab talking to him about it, and kind of wrestling around some of these ideas, but also doing research on what the gut microbiome was affecting the neurons in the gastrointestinal tract. So the enteric nervous system. When you think about the gut brain access, most of it is a communication between anything that’s happening in the gastrointestinal system with the brain. That could be anything from that can be modulated through the neurons through the parasympathetic nervous system through the sympathetic nervous system, through the defense of a ferentz and then also through systemic circulation. Most of the systemic circulation isn’t we originally didn’t think was that much because Most of this is neuron based right? And something like serotonin or something like dopa mean. Most of those won’t survive that long and systemic circulation right for serotonin platelets take it up. And then it doesn’t cross the blood brain barrier. But there are things that are right. One of the precursors of serotonin is tryptophan, tryptophan, when you eat it, it gets absorbed and increasing higher amounts of tryptophan can increase the amount of tryptophan in the brain. And that’s kind of one of these fundamental areas of research right now is trying to figure out from a nutritional standpoint, what we can modulate to affect the brain, some fundamental or some kind of pivotal research went back. Back from McMaster, I think it was back in 2011 or 2013. And that’s when they figured out that one of the major implications between the gut and the brain is the Vegas nerve, right? We all remember learning about the vagus nerve but vaguely remember about its role in the gut. Well, the vagus nerve has He has projections all the way to the V Lie of the small intestine and the colon. And when you sever the vagus nerve in an animal model and you feed it certain bacteria versus not, you do see changes in the brain, that have been recapitulated with specific bacteria. Now, there’s only one that they’re thinking has real proof of being clinically useful. But their clinical trials that they’ve been using for this bacteria, which called JB one hasn’t been shown to have good effect in humans, but in mice, they see that the level of the gamma receptor does increase in can’t remember the exact same spot of the brain. But that is one area that they’re that they’re looking at the research that I was doing was your weight. You’re
losing me here, you’re losing me here. What’s the significance of that?
So the significance of it is that there are bacteria that could have effects on the brain through the vagus nerve. That is an area that we should really think about and really say okay, are there other bacteria that can do this, how is the bacteria doing this? We don’t necessarily know. But we have to remember that when you think about the bacteria in your stomach, it’s not the bacteria isn’t totally wiped out from, you know, if it’s in your gut, then it’s beneficial bacteria depends on the location of where the bacteria is. So certain bacteria aren’t, they don’t have no efficacy for having any benefits to the gut unless you put them right up against the epithelial layer where they can interact with some of these neuronal projections that are that are between the epithelial cells of the gut. And that’s the that’s the things that we’re learning and that we’re now doing research on that we didn’t do five years ago, because we didn’t have the tools. We didn’t have the knowledge and we didn’t have the understanding to be able to do that.
Then how does it get so so it’s influencing the vagus nerve, but then how does that translate into something like dementia? That seems to me like such a big leap? Yeah, correctly, I would think it would, the bacteria might have Something to do with you know, the parasympathetic nervous system and gut motility, but specifically influencing brain activity, like complex centers of the brain, I just don’t see that. I can’t I can’t make that leap. And that’s I also don’t have the the physiology background of a lot of the stuff that you’re discussing. So it is it is a little harder for me to follow. But But still, I just can you help us get there?
Yeah. So that’s the hard part is I think that we there’s still a lot of areas that we don’t know, we don’t know how it’s making that now we, we know that on the neuronal side of the GI of the GI system, there are specific bacteria that can increase the amount of neurons in the gut. So that means that they’re increasing. How many neurons make up the main turret Plexus or the Auerbach’s Plexus in the intestine that helps with motility now translating that up through the vagus nerve or up through the parasympathetic nervous system to the brain to create neuronal changes in the brain. That is where we typically fall short. And there are some researchers that are trying to do it live in Italy. There’s there’s good research, and there’s also want to do that trying to do this. But your questions are good to have, because I think that your skepticism is a skepticism we need in science because we’re not finding, for example, the bacteria that I was working on, we haven’t figured out directly we saw some behavioral issues. But when we say behavioral issues because of probiotics that we’ve engineered to do stuff, yes, we know what it’s doing in the gut. But on the brain, we don’t know what it’s doing. And we don’t know where it’s having these effects. Maybe it could be having these effects because it’s affecting motility. And as you know, as anybody knows, go through have diarrhea for five days. And next thing you know, you feel terrible, you can’t sleep properly, you’re up at night, you have a little bit more anxiety or a little more high stress, or vice versa. You can’t prove For a few days, and now you’re stressed out, your stomach hurts, you’re not eating as much you’re trying to drink. But these issues fundamentally do affect our emotion and our behavior. But it may not be as much as just directly affecting a specific spot in the brain, if that makes sense.
Yeah. Yeah. So it seems like my follow up question is, is there evidence in using probiotics to alter or prevent disease in these non bowel diseases? We’re still in our infancy and learning about them. So to think that we can take something, especially after all you said about probiotics. It doesn’t it doesn’t seem like we’re there yet. But what about for bowel diseases? Right. What is the effect of the gut microbiome on say inflammatory bowel disease?
Yeah, for inflammatory bowel disease. I think that there’s been some trials that have that have shown that, you know, some of the probiotics work or could help and then in the majority of them, there hasn’t been so I think the most recent reviews that they’ve done for inflammatory bowel disease. Were there Crohn’s or ulcerative colitis, probiotics haven’t been shown to have a big effect. Why is that? Well, you have to think when someone has inflammatory bowel disease, you’re not just thinking about the bacteria in there, the the tissues inflamed, right? The immune cells are activated. And the area that Everyone misses, whether in gastroenterology or not, is the mucosal layer that protects protects the epithelial lining of the GI tract. If that mucosal layer is degraded, or it’s completely destroyed, because in inflammatory bowel disease, a lot of cases it’s completely destroyed. Throwing back probiotics at it isn’t going to help. You need to let the actual cells heal. Let the epithelial cells heal and then you need to have them build back up their mucosal layer for the bacteria to live because mostly bacteria live in the mucosal layer, not, you know, right up against the epithelial cells. Does that make sense? That’s really interesting because
as an otolaryngologist, we think a lot about the size of the sinuses. mucosa ciliary flow and a lot of what you’re trying to do is restore mucosa, ciliary flow, and that mucus blanket and the direction that the cilia are pushing it. So, in this, this is an era ago, we used to just strip away the sinuses and remove the mucosa and think that you remove the disease, but then it gets replaced with scar and you just you need that mucosa and you need that mucus layer.
Yeah, yeah, well, you need you not only need that mucus layer in the gut, that bacteria actually eat that mucosal layer, right there specific bacteria like Akram, Anthea, you could send affiliates that actually use that mucosa layer as a new nutrient source. So if that’s not present, these bacteria aren’t going to be very happy or they’re not going to be able to thrive. And they’ve actually some newer research is showing out that patients that are in the ICU, that have some of this degradation of the mucosal layer, giving them probiotic, this actually could increase their risk. Have septicemia Now you may be thinking, Okay, the link, the link between taking a probiotic and getting it into your blood system seems like that would never happen. But if you look in PubMed, there are multiple articles now proving that it’s the same exact strains with some modifications that have gotten from probiotic form into the blood system of some of these patients, where that’s happening, how that’s happening. I think that there’s still a lot of room for explanation. I think the science is still at its infancy. But that’s an area that this idea of just throwing probiotics or bacteria or trying to make the microbiome more robust. I think there’s going to be some times where we have to pump the brakes and think about, okay, what are the real indications? And what are the potential cause or harm that we’re doing, you know, recommending these or taking these on patients that maybe don’t need it?
But it sounds like it ties into what you said earlier about introducing the probiotic actually being competition that you’re introducing rather than improving the function of the backend. that’s already there. Exam sounds like that sounds like what they’re doing what they tried to do with the best of intentions in the ICU.
Yeah. And when I when I’m saying this a lot of it’s from specific strains. Now there are strains out there that researchers are looking at specific ones that could help patients with pouch itis or patients with inflammatory bowel disease. Those are specific strains. They’re not, you know, are there specific species, they’re not just a blanket over the counter recommendation. And so those until one of those is approved by the FDA, as that a probiotic on the species level is being recommended for a specific disease process. Until we get there the row the science is not robust enough to recommend it for most diseases except the you know, the indications that I mentioned earlier.
Yeah. So something that we had talked about before that I want to definitely don’t want to miss is antibiotics. Right? So antibiotics, we were concerned about antibiotic resistance. We’re concerned about gi upset. We’re concerned about C. diff. But you had mentioned there are some other unintended consequences of antibiotics. So could you discuss that?
Yeah, the unintended consequences, I think actually mentioned in a roundabout way, and that is that mostly antibiotics will basically slough off the mucosal layer of the gastrointestinal tract, or they have unintended consequences of patients that take antibiotics for years at younger ages are at increased risk of having metabolic syndrome or having increased risk of having obesity or type two diabetes. Some of these we’re not sure why now, there’s a lot of theories and a lot of research that’s indicating that it could be a meta genome level. So some antibiotics may affect the meta genome in the epithelium of the gastrointestinal tract that’s translating to the pancreas and translating to the liver. And then there’s other research that indicating that using antibiotics for long periods of time can affect the amount of short chain fatty acids that are produced later in life, which is basically the beneficial secondary metabolites that our bacteria produce, to actually give us benefit. doing that, you know, for a long period of time is really you know, damaging.
So one thing that we also talked about before the show is your your lifestyle choice. You are plant based, and again, being an old fogy myself. I’m only 40 But still, the term plant based for me is new and I have no idea what the difference is between plant based and vegetarian or plant based and vegan. I know the difference between vegan and vegetarian. I understand enough about that. But this new term plant based to me sounds like someone who mostly eat plants, but couldn’t quite give up bacon. Or it’s a vegetarian with a PR problem. Right? Like, like prunes prunes have a PR problem. So they tried to rename themselves dried plums and it didn’t work out so well for them because still prunes but plant based may may be a little stick stickier. So so you describe yourself as plant based. What does that mean to you? And what does that mean to the public?
Yeah, so so first before we talk about this issue, one of the things that I do want to set straight is there’s now in the news, a lot of hype for plant based or veganism, especially because a lot of documentaries are, you know, the advocates that are really pushing for it. Now, I’ve been plant based for over 10 years. And so when I say I’ve been plant based, it’s not because it’s a fad, or it’s not something that you know, happened overnight and I want to talk about it. I’ve been playing bass for 10 years and I don’t talk about it that much, because that’s just a part of my lifestyle who I am. What is the difference between plant based veganism and vegetarianism? So plant based, it used to be that plant based was someone who was vegan, who chose not to be associated with the PR issue with veganism or vegetarianism. plant based was you know, fully vegan, no animal products. It was no no meats or no cheeses. It was just fruits, vegetables. Nuts seeds, whole grains, beans, lagoons those specific nutrients and it was a focus on eating whole foods as opposed to eating processed foods. So you can obviously be vegan or vegetarian and eat only processed foods right? You can buy those at the grocery store whereas plant based was focusing on whole food plant based foods. Good
example is Oreos are vegan.
Correct? Exactly. Oreos are vegan, but would it fall into plant based? Well, I mean it depends how strictly you’re you’re saying your whole foot whole food plant based vegan person, you know follows that diet. Now the difference between vegan and vegetarian is obviously the difference between dairy consumption cheeses and milk. And then there’s a lacto ovo vegetarians that consume eggs. And then some people will say they’re vegetarian but they’re more pescetarian and occasionally have fish but plant based now in the past probably six months because of the the hype of the word plant based. It has now a lot of people Do consume animal products, whether they’re it’s, you know, chicken or whether it’s bacon, or whether it’s fish associated themselves with dog plant based because they say oh, and primarily plant based. And they do deviate from being strictly plant based, if that makes sense. So I think that the, the terminology is so new that a lot of people don’t necessarily know where they fall. I just say plant based because it doesn’t turn heads. And if I say vegan, everyone thinks I’m gonna yell at them because they’re wearing leather. I prefer when, but that’s not my focus at all. My focus is typically on on just the food, and it’s for the reason of most of the science that I’ve studied.
So you’re plant based because you want to be left alone. All right, everybody, please take the hint. When you see Frank at a restaurant, just you can ask him for his autograph. Please. Don’t harass him about his food choices. He’s plant based. Leave him alone.
Yeah, and my wife laughs because my wife I mean, she’s an omnivore but she’s jokes and she tells everyone she’s a carnivore, and she does that specifically Because she thinks it’s funny, I’m playing bass, she’s carnivore, she doesn’t follow the same diet, and it has never really gotten in the way of our relationship we’ve been married for over four years. And that really hasn’t been an issue. So the idea that it’s a stigma that it’s, you know, as political as left first write isn’t necessarily the case for everyone.
You do what works for you, and leave you alone.
Exactly. Right. Well, is
there anything related to the gut microbiome that we haven’t discussed yet that you think bears mentioning?
I mean, there’s obviously a ton of research that could be mentioned, right? We know that the microbiome is affected by certain things in in our diet, whether that’s the amount of Coleen or the amount of carnitine that someone’s consuming and that gets converted by the bacteria in our stomach to TMA which then in our liver gets converted to tmo, which now baby maybe a new linker for cardiovascular disease or some other illnesses. A lot of the sciences pretty good is pretty good and pretty robust on it. But using it as a clinical indicator hasn’t been hasn’t been established well enough yet. But I think that there’s there are a ton of topics that we could obviously talk about and go over. I would I would kind of be more interested in just to tell people that if they are interested, if they have questions about the gut microbiome, they can always email me or asked me, obviously, I’m a medical student. So I’m busy. I’m studying a lot. And I’m actually still working on papers, I’m still doing additional research, which as anyone knows, in the medical profession is difficult to balance. But I’m happy to answer other questions if you have any specific ones. And you must be so tired all the time from not eating any meat.
That’s what they say. But you know, for
just kidding, I’m just kidding. I’m just
so yeah, well, I mean, I think that that’s actually a great area that people need to be wary of is most people that transition to this day, under consume calories drastically. And if they’re plant curious or they’re eating curious or whatever, most of them, just don’t consume enough calories, whereas if you consume enough calories, I mean, it could really, it actually is the opposite. He can have a huge energy boost. But you know, it really just depends on on hair consuming, but you don’t I mean, this isn’t necessarily the healthiest way for everyone. And I tell people that because it depends on what level of scrutiny, you’re gonna look at your food. And if you’re just removing things and not replacing it with other things, and you’re going to have real issues.
And be sure to send a sample of your poop to an unlicensed lab so they can tell you what diet you should be using. And
take your mind zactly. Exactly.
Right. So where can people find you online?
Yeah, if they want to find me online, I have both a personal Twitter and Instagram, Twitter, I’m not that active on Instagram a little bit more active. And I share some of the science. I don’t give medical advice, but I share some of the science about what some of the newer research is showing or where it’s going in the nutrition front and microbiome front. If you’re interested. I do have a medical podcast as well. It’s not we don’t talk anything about the gut microbiome. We never really When talking about plant based really except a few episodes, majority of it are for medical students and for residents where we interview physicians or residents that are about to finish their training and talk to them about the medical education process. It’s called surviving medicine because we all know medicine is hard. It takes a lot of time it takes a lot out of you and burnouts a real issue. So we discussed topics like that on our on our podcast, but it’s typically only focused on that, that that area, but from every different specialty, and then been the links, I’m sure there’ll be in your show notes, but that is surviving medicine.org there’s five more minutes in podcasts and on Instagram, that’s surviving dot medicine. If you look us up, you can find this.
Dr. Frank Cusumano. Congratulations on the PhD and thanks so much for being on the show. Thank you so much.
That was Dr. Bradley Block at the physicians guide to doctoring. He can be found at physicians guide to doctoring calm or wherever you get your podcasts. If you have a question for previous guests or have an idea for a future episode, send a comment on the web page. Also, please be sure to leave a five star review on your preferred podcast platform. We’ll see you next time on the physicians guide to doctoring.
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A Panorama of Human Glitches Seen in the Musculoskeletal and Reproductive System with Professor Nathan Lents, PhD

Professor Nathan Lents studied biology at St. Louis University and then completed his PhD at St. Louis University’s school of medicine in Pharmacological and Physiological Sciences.  PhDs need residencies, too, so he did his postdoctoral training in cancer genomics at NYU and loved New York so much that he stayed and is now a Professor at John Jay College in Manhattan and director of the honors program. 

His book, Human Errors: A Panorama of Our Glitches, from Pointless Bones to Broken Genes, discusses the beauty of our flaws.  We are not the well-oiled machines that we think we are. This is part three out of three of my interview with Professor Lents. For the orthopods, we discuss how the wrist and ankles developed in such a nonsensical way, and why standing upright causes problems from herniated discs to ACL tears. For the OBs, we discuss reproduction and why infant mortality is so high, our ability to procreate is so inefficient, and if we are already so inefficient, how menopause can actually be advantageous for natural selection. 

He maintains the Human Evolution Blog and his podcast is called This World of Humans. He can be found at NathanLents.com

Find this and all episodes on your favorite podcast platform at PhysiciansGuidetoDoctoring.com

 

Please be sure to leave a five-star review, a nice comment and SHARE!!!

This episode is brought to you by Orange County Bookkeepers (OCB) Healthcare Accounting: an all in one accounting firm for small healthcare businesses and private medical practices. One thing that I personally love about OCB Accountants, is that they are QuickBook professionals with over 20 years’ experience, focusing specifically on healthcare. They utilize a tailored approach individualized to your needs. They are a full-service bookkeeping firm specializing in accounting, payroll, taxes and financial planning. For our listeners, for a limited time, they are offering 25% off their services for the first 3 months. You can visit them at OCBmed.com or call 833-671-3873 or 949-215-6200.

A Panorama of Human Glitches Seen in the Musculoskeletal and Reproductive System with Professor Nathan Lents, PhD

Professor Nathan Lents studied biology at St. Louis University and then completed his PhD at St. Louis University’s school of medicine in Pharmacological and Physiological Sciences.  PhDs need residencies, too, so he did his postdoctoral training in cancer genomics at NYU and loved New York so much that he stayed and is now a Professor at John Jay College in Manhattan and director of the honors program.

His book, Human Errors: A Panorama of Our Glitches, from Pointless Bones to Broken Genes, discusses the beauty of our flaws.  We are not the well-oiled machines that we think we are. This is part three out of three of my interview with Professor Lents. For the orthopods, we discuss how the wrist and ankles developed in such a nonsensical way, and why standing upright causes problems from herniated discs to ACL tears. For the OBs, we discuss reproduction and why infant mortality is so high, our ability to procreate is so inefficient, and if we are already so inefficient, how menopause can actually be advantageous for natural selection.

He maintains the Human Evolution Blog and his podcast is called This World of Humans. He can be found at NathanLents.com

Find this and all episodes on your favorite podcast platform at PhysiciansGuidetoDoctoring.com

 

Please be sure to leave a five-star review, a nice comment and SHARE!!!

This episode is brought to you by Orange County Bookkeepers (OCB) Healthcare Accounting: an all in one accounting firm for small healthcare businesses and private medical practices. One thing that I personally love about OCB Accountants, is that they are QuickBook professionals with over 20 years’ experience, focusing specifically on healthcare. They utilize a tailored approach individualized to your needs. They are a full-service bookkeeping firm specializing in accounting, payroll, taxes and financial planning. For our listeners, for a limited time, they are offering 25% off their services for the first 3 months. You can visit them at OCBmed.com or call 833-671-3873 or 949-215-6200.

EPISODE TRANSCRIPT

Disclaimer: This is the transcript to the episode. This transcript was created by a talk to text application and the function of having this here is to improve the page search engine optimization. This transcript has not been proofread, so please listen to the episode and don’t read this. The information contained herein will inevitably contain inaccuracies that affect that quality of the information conveyed and the creator of this content will not be held liable for consequences of the use of the information herein.

Professor Nathan lens studied biology at St. Louis University, and then completed his PhD at St. Louis University School of Medicine, in pharmacological and physiological sciences, PhDs need residences to. So he did his postdoctoral training in cancer genomics at NYU, and love New York so much that he stayed and is now a professor at john Jay College in Manhattan, and the director of the Honors Program, his book human errors, a panorama of our glitches from pointless bones to broken jeans discusses the beauty in our flaws. We are not the well oiled machines that we think we are. This is part three out of three of my interview with Professor lens for the orthopods out there, we discussed how the wrists and ankles developed in such a nonsensical way. I’ve heard him describe it as obnoxious and why standing upright causes problems from herniated discs to all the way to ACL tears. And for the OBS, we discuss reproduction, and why infant mortality is so high. Our ability to procreate is so inefficient. And if we’re already so inefficient, How menopause can actually be advantageous for natural selection. He maintains the human evolution blog and his podcast is called this world of humans. He can be found at Nathan lense.com.
Welcome to the physicians guide to doctoring A Practical Guide for practicing physicians. Dr. Bradley Block interviews experts in and out of medicine to find out everything we should have been learning while we were memorizing Krebs cycle. The ideas expressed on this podcast are those of the interviewer and interviewee and do not represent those of their respective employers.
And now, here’s Dr. Bradley Block.
This episode is brought to you by Orange County bookkeepers, healthcare, accounting, and all in one accounting firm for small healthcare businesses and private medical practices. One thing that I’ve personally love about OCB accountants is that they are quickbook professionals with over 20 years experience focusing specifically on healthcare. They utilize a tailored approach individualized to your needs. They’re a full service bookkeeping firm specializing in accounting, payroll taxes, and financial planning. And for our listeners for limited time, they’re offering 25% off their services for the first three months. You can visit them at OCB med calm that’s OCB m Ed or call at 833-671-3873 or 949215 6200 and check out the show notes for more information. Okay, so we have equal inefficiencies in other other specialties. And I love your description of the human hand. So let’s talk about how evolution has has allowed orthopedic surgeons to thrive As a specialty,
right? Well, I’m more thinking of the wrist. I mean, the wrist seems to me like a really funny arrangement because you have these bones, all these little bones in there, the carpals. And what function Do they really serve separate from one another, the fact that there are seven sort of crammed in there, you know, if you were to design a robot, for example, with a joint, something like our wrist, there’s no way that you would put all of these independent parts together, and they’re mostly fused to each other in the sense that they don’t move relative to one another. So what’s the point? The point is that there is an evolutionary legacy there, and that that arrangement in all of the limbs of our ancestors were it was very similar in terms of the numbers of bone and their relative positions to each other. But we would not design a joint like that today. And in fact, the similarity to our ankle and our wrist, despite them performing almost entirely different jobs, harkens back to that shared ancestral history because our four limit ancestors really did use all their limbs in very similar ways, but we don’t but yet we have that that sort of parallel anatomy and the wrist has weird constraints. I mean, if you try to like twist it around while well bending it, you know, it doesn’t really work nearly as well and the ankles even more rigid. But of course, that’s a good thing. We want a rigid ankle, and we have so much power that we can drive from our, our big toe and so forth. I mean, they really have evolved, well, they just didn’t fix every problem along the way. That’s sort of the theme of
Yeah, if you were to design them de novo, you would not do it this way.
Right? There’s no animal whose anatomy is perfectly designed for how it lives and you could in any engineer could have a field day redesigning the skeleton of almost any creature. But that’s not how evolution works. It doesn’t work with a floor plan, and it certainly doesn’t create new structures de novo, it really takes what’s there and makes tweaks and tugs and even the bones of our middle ear, you know, grew out of brinjal bones previously in our reptile ancestor, so we have to take something and retool it, we don’t really invent new structures. And what that means is you’re stuck With the constraints, because it’s not just that you stuck with what you have, every step of the way has to at least offer a non disadvantage. But really, every step really needs to be advantageous in order to get fully formed something in the future. So you can’t start evolving a structure in the hope that one day it will be useful. That’s just not how evolution works. So if we wanted to grow wings, for example, we’re not just going to sprout new structures out of our back, wouldn’t it be great because then we’d still have our four limbs when they finally got around to being finished. But that’s not how it works, right? You have to, you have to co OPT the anatomy that you already have. So the three times that wings have evolved in vertebrates, all three cases, they lost their four limbs in the process. So birds, pterosaurs, and bats, none of them really can grasp. They can’t, there’s so much functionality with their four limbs that they lost in the process of evolving those into wings. So evolution always just has to work with humanity. that you have. And slight advantage overcomes a slight disadvantage, hopefully. And that’s really, that’s how you get directionality to it.
So it sounds like the wrists and ankles could have been done better, but they’re nonetheless still pretty efficient. Whereas walking upright, seems to be seems to have created a significant hurdle from us because it’s, it’s almost like a domino effect. Right? It doesn’t just affect your back.
Right. I think the back I think our lower back is really the biggest problem with walking up right in terms of sort of incomplete evolution. If you look at the vertebral column of a chimpanzee, for example, or a gorilla, it has this sort of sloping slow sloping bend to it. It’s like a j looks like a capital J, but even a gentle sloping J. And when we wanted to sort of stiff in the back and walk more upright rather than straightening it out. We just introduced another curve. So we have an S shaped back. So we threw this curve into our lower back. And part of that was to accommodate how the organs were going. To attach and to make room, there’s some reasons why it did just straight now, but it did cause a tremendous new point of weakness. And the cartilage in his discs in between each vertebra can now slip out of place much more easily because of that, that bend. So if you can, if you can just picture like a stack of pancakes, but it’s curved, it’s really easy for the little discs of cartilage in between to slip out of place when they’re undergoing strain. And that’s what happened. That’s a herniated disc, a slip disc. And that does not happen in the other apes. It’s never been documented in a chimpanzee or a gorilla to have a slip disc, because their back is optimal for their posture. But our back is sort of, okay. It allows
us to stand upright, but it has a number of weaknesses. So this can also
affect our knees, right?
Yeah, yeah. And I think one of the big problem with our knees is that if you look at how a gorilla or a chimpanzee walks, a lot of times, their legs are bowed and there’s slightly bent and that means That the muscles are doing a lot of work, even just in a resting state. And whereas when we stood upright, we’re now putting the burden of our weight on just two limbs instead of four. And just compensate so that the muscles aren’t doing all this work all the time we straightened our legs. So we stand with a straight leg posture much more often than the other age to, which means that our bones are bearing much more of the weight that our muscles and a lot of, you know, the anatomy evolved to accommodate this, but they’re at least one piece. Well, there’s two that I can think of, but one that definitely didn’t really fully optimize for this is the anterior cruciate ligament, which is right behind your kneecap, and it’s the primary not the only but the primary ligament that holds the upper and the lower leg together. And that’s the ACL as you know. And so anytime you change directions or your your your weight, your momentum changes quickly. If you straighten your leg when you do that, the ACL is bearing the full brunt of That change in momentum, the full force and it just simply isn’t up to the task. It is a very thin ligament compared to the job it’s supposed to do. And it’s not up for because it was in evolutionary lineage, it was that burden was shared by the muscles and four limbs and it was spread more evenly. And now we have this little ligament that’s doing all the work. And there’s no way to get it stronger, through exercise that you can’t like, go to the gym and work out your ACL. There’s just no way to do that. And so what you have to do is hope for the best and try to not let your legs lock when you when you change directions like that. But if you do, and the other problem, of course, is that our athletes are getting larger and larger and larger. If you look at the average weight. Some of these linemen For example, I mean, they’re just massive individuals who are moving way faster than I ever could. And, you know, if they want to change direction quickly, that poor little ACL just snaps
and there’s no way to fix it except for surgery. Evolution keeping our orthopedic surgeons in business.
Oh, definitely. I mean, I’ve had I had surgery myself on my ankle when I was in high school. And it’s one of the things I think about a lot. But if I had been born just 150 years earlier, I’m not talking about Stone Age, I’m talking about 19th century I would have been crippled for life, I would never have walked. Normally again, I had a biomolecular fracture, it had had to be repaired. And simple surgery nowadays. You know, I was in a cat, I was young. So the cast was, I think about eight weeks, and full recovery, full range of motion. You know, I was playing soccer within six months, it’s totally fine. But I would never have walked again. Or at least not normally. Because of that my daughter broke her arm last week. She didn’t need surgery, but it needed to be set. And I just wonder her just just a few hundred years ago, if she would have been a cripple for life, I don’t know. Oh, yeah.
But yeah, I mean, it’s and the amount that our knowledge has increased. Just, it’s incredible. It’s astronomical.
Yeah, I think granted, you know, there’s so much that we’re down about the modern world, and we were talking about dying. And things like this. And we forget that the prehistoric world in some ways we would we were living in better harmonies with our body. But there was really nothing in the way of intervention when
Yeah, if something if something went wrong. Like, yeah, we lived in harmony, fine. But as soon as something goes wrong that
yeah, I think about that with all birth all the time. They’re like, well, women were doing it naturally for millions of years when they were and 80% of the time it went, it went well.
If you’re fine with the 20% mortality,
yeah, that’s that would be good.
Yeah. I don’t think women should give birth in hospitals because it’s required for every birth. I think it’s because the chance of going wrong is high enough that you would really be mad at yourself if you tried to do it at home and something went wrong.
Yeah, it’s it’s nice to have that. Yeah, it goes smoothly most of the time. But when it doesn’t, and it tends to not when things go wrong, they go wrong fast. They go wrong fast. And a quick intervention can save your mom and baby Yes, yeah. So actually let’s let’s talk about that. If you have I’m not sure if you have time, but the OB GYN section of your book, which had a lot of great information in it. So the the inefficiency, let’s just before we get to childbirth, let’s talk about the inefficiency of human reproduction. Right. Yeah, we’re seeing that more and more in the modern world. Why is it so hard? Why do we Why do we have you know that? I feel like every family has a story of difficulty conceiving of miscarriage of stillbirth of like, there’s, there’s you either it’s either happened to you or you know, someone that that has happened to why are we so inefficient at reproduction. It’s remarkable for a lot of ways and people think this is silly to talk about as being inefficient reproducers considering it, there’s like 7 billion of us on the planet now, but can’t remember how recent that population boom really is. And in fact, we were thin on the ground for most of our existence, and in fact, our closest relatives all went extinct. So our success was by no means a foregone conclusion. But anyway, the efficiency is really still, it’s still not every step of the way. Yeah, you’re
right, you’re right. But every step of the way, when it comes to reproduction, we have inefficiencies. And many of them, we don’t even share with our close relatives. So for example, we made sure very late compared to other animals. So we reach reproductive age several years later than the other African apes who have similar lifespans to us. And that creates a lot of inefficiency in terms of evolution, because it’s a lot more chances that you might not live long enough to reproduce. So just that in and of itself is strange and really calls out for an explanation and then how many people have trouble making gametes that are that are viable and successful is really high to now that that rake might not be so different from other animals. But the reasons behind it to me are remarkable. I mean, something like 40% of conception events failed to implant for some reason or another. And I think that 40% is probably an underestimate, but that’s that’s what we do. The best we can do 40% of, of successful sperm and egg union result in a failure to implant. Now a lot of those are chromosomal abnormalities. Others, we just don’t know why failure to implant itself could be the problem. We don’t really know. But there’s just a lot of embryos that just don’t take that aren’t successfully formed or or don’t get the signals out to stop ministration. In enough time, we don’t really know. And that’s why drugs can really tweak this up just a little bit when it comes to the implantation event itself. And that’s just about it. There’s no drugs that help with chromosomal abnormalities, for example. Um, the other thing that’s that’s sort of weird for us is that childbirth is so difficult in humans compared to other species. I mean, if you’ve ever been on a farm, I mean, most of these animals just sort of barely notice when they give birth. It’s it’s really, and and the infants kind of shake themselves off and they’re often on their way. There’s a video you can find on YouTube of a gorilla giving birth and she is Eating, she’s continuing to care for other children. It’s It’s like she barely notices. It’s not a dramatic affair at all. And that’s nothing like what we know, human human mothers experience. And, of course, the obvious explanation is that our, our heads are massive. And so our cranium grew so much over the last, really the last million years, sorry, 2 million years. And it got to this point where we are born too early. That’s really what’s going on. So evolution is pulling on both ends of this road, because a big, big brain is great. It’s good for us. And it allows us to do all kinds of clever things. But it also makes it harder for childbirth. And so this sort of tug of war between the two, the compromise that was made was that we are born at least I would say, two or three months early.
It’s interesting because we, you know, we’ve we’ve three kids, and they refer to the first three months of life as the fourth trimester.
Exactly. That’s the best way to think of it. Yeah,
we were not mixed. Since
Yeah, but if we wait any longer, you know, maternal mortality would be unacceptably high for the species. So that’s sort of the compromise. And it’s not just the big brain. By the way, we also have a fairly narrow pelvis. And that’s because as we transition to upright rocking, we actually narrowed the bottom part of the pelvis in order to so that our legs can go straight down. Because if you watch a chimpanzee walk, for example, they can walk on two legs, but they sort of swing their legs outwards because their their legs go much more out and then down. Whereas our legs go straight down so that we can stride in a smooth way, our center of gravity does not bounce back and forth from the left and the right as we walk. It’s, it’s kind of remarkable. But to really accomplish that you need your legs to be close together. And so but that transition happened two to 3 million years before the expansion of the brain. Right? So those events were not connected. Evolution doesn’t think ahead. So by bringing our legs close together, it was great for walking, but it also put constraints on how big the head could get millions of years. Later. And so when that expansion finally happened, we were fully committed to upright walking. And now we had this big brain. So what was the compromise? We’re just born too early, and our infants are incredibly incapable. Again, if you look at other animals, the infants are much more independent, even in the other eight. Now, the other apes, the nurse, and the babies are, by no means independent. But they’re more successful than our infants are.
Okay, so it’s not just my kids. No, no,
not really. And, and I think you’ll find How old is your oldest three and a half? I think you’ll find he or she is still pretty dependent.
Yes, yes. If we put him out in the wild, he’d be in trouble.
Yeah. And and that’s, that’s sort of the theme of human biology in the sense that our bodies just really cannot make it on their own right. we survive through our cultural status, right? So we help each other we take care of one another, not just kin, but we we take care of one another. We pay people to take care of our kids when we can’t and we solve problems with our brains instead of our bodies and so So the result of that has been a lessening pressure on our bodies to navigate the world on their own. We really are. Our cultural evolution has taken over for biological evolution. And this goes back several million years. I don’t, I don’t just mean since farming. I mean, we’ve been taking care of each other for a very long time. And what that allows is the cultural drive to collect information to have skills that are taught not just learned, but taught. We’re the only species that really teaches everybody, every species learns, but we teach intentionally. And that’s been going on for a long time. And I think that the lesson of that is a happy one. So our bodies are kind of are kind of crappy. But the reason is because we don’t need them to be perfect anymore. We really, we really are solving our problems other ways. So that’s why I like to say the theme of my book is actually pretty happy. It’s pretty uplifting in the sense that aren’t you glad you don’t have to solve the problems with your bodies anymore? Well, I am. I mean, my ankles a perfect, perfect example. Right? This would have been a life altering injury and it’s just not anymore. cultural evolution provided us the tools to fix broken ankles, so that we don’t have to, to try to heal them through, you know, biological means no, we heal them through technological means and, and like my vision was terrible, absolutely terrible part of that is the way we live. Now. We can talk about that if you want, but I had like 2450, and I had these minus 4.5 lenses. But with the advance of this book, I paid a surgeon to shoot lasers in my eyes. And now I see perfectly so. And we just keep solving all of the deficits of our bodies by using our brains or other people’s brains. And I think that’s a good thing.
So another thing that you that you discussed in that reproduction section section of your book is the C section. And I thought that was really interesting that the C section is is just much much older than I than I ever thought it was.
Yeah, yeah. I think that people have been slicing into mothers in distress for a long time, and I think it’s So there were, you know, ancient Roman tales of it. And part of the there was, you know, of course lore about it and supernatural beliefs about this than the other and it became a public health policy around these fetuses and so forth. But I think there was a long been the recognition that particularly during breech delivery, which you can, you can feel you can you can tell when a baby’s in the breech position, that the success rate of just a regular vaginal delivery was so low, that it was worth the risk of opening up her abdomen, knowing that she probably wasn’t going to make it but the baby could, and the baby probably would, in that case, and then with the mother, you so we’re up and hope for the best. But I mean, it’s called the Syrian for a reason. It really does. I don’t think that Julius Caesar was delivered that way, but it does go back to Roman times. And it’s also been documented in other cultures as well, because it’s not rocket science in the sense that you sense through your feeling you through your hands, excuse me, your tactile senses that this baby is not in the right position and every other time that happened, you know, it’s been unsuccessful and we lose both what, you know, what else do we have? What else can we do with the tools around but get a sharp stone and do our best, then that learning and teaching in that institutional memory? Exactly. You have the knowledge and it passes on and but the idea that a woman would die in childbirth was also not altogether, you know, unusual. That would have been, you know, just part of the expectations that at a certain number of women don’t survive. And so well, she might not make it anyway, we might be able to save the baby let slicer open and hope for the best. And so I think that that practice, I think it’s overdone. Now, I think you’d probably agree that we probably do a little, little too many of them. I also am not a big fan of induction, but we can that might be a conversation for another day. But the point here is that it is an ancient practice and it’s worked and it’s been in response to the fact that we have this huge head.
Yeah, I’d rather not just lacking any expertise in in that area. I definitely am not going to criticize my ob GYN colleagues with with regards to the frequency of the C section or induction because they’re they’re definitely working with much, much more information much more than institutional memory.
But you and I have aware that our the infant mortality rates in the United States are the highest in the industrialized world. I mean, we’re Yeah, yeah. And so it’s some combination of factors. And I don’t blame the doctors at all. I actually blame a lot of the legal culture around health care in this country for a fair number of for amount of it. But I do agree with you in the sense that we don’t have the information we need to really know what’s going on there.
Well, there’s also, you know, there, it’s higher in some populations than others. So it’s much higher in African American women, then it is in white women. So there there, there are a lot of factors at play here.
Then, yeah, I mean, the tragedy in this country is that that we do treat populations differently. And some of that provides for a natural experiment. But the problem is, there’s so many confounding variables, and unfortunately, in this country, race and wealth are so tied, that you can’t know You know what’s at play in those cases? I mean, you really have to bear down in the data to separate socioeconomic status from race. And, and but we do have the natural experiment of if we just consider wealthier populations and compare them to say, Canada and other UK with otherwise culturally similar populations. And we just don’t see the rate of infant mortality that we see in the United States. So something’s going on.
Yeah, I definitely don’t disagree with that. There. Were there were two more parts. Before I let you go. There were two more parts of the book that I think bear mentioning and and when we were talking earlier about the inefficiency of human reproduction, and one part that plays into that is hidden estrus? Yeah, right. I don’t know when my wife is. And neither. Neither she so I mean, we have an app now. Right? Yeah. So that can that can be pre app. Right? You just, you know, yeah. Well, there’s no you had to just you had to just keep trying, even though that adds the inefficiency. So what would be the advantage?
Well, it’s a great, it’s a great conversation because we really are unusual in our hidden population. I mean, if you when a chimpanzee is in heat, you know, it is visibly conspicuous. She knows, everybody knows. And that’s how it is with with other mammals is population is advertised and in humans it is hidden even from the woman herself. And there’s a lot of theories about this but the one that I think holds the most water is that it represented this transition to this group living communal living. And it was a trick that women’s bodies played on themselves in men to create a family to to get a man for, for example, to stick around and to protect his investment and to no BS be assured of his paternity and it was also her way to make sure that she got parental investment out of him. So they were both sort of playing. It’s sort of this battle of the sexes and a lot of people would say That the the concealed population was sort of the first step in that in creating a nuclear family where the reproductive interests were there only aligned if you’re if no one’s Sure. And so you had a lot of sex you had a frequently, that was the only way. And it was essentially mate guarding in a sense, but it was made guarding in a way that the female has a lot more agency over the process. And I think that’s where hidden estrus came from is this idea of keeping men interested in sticking around and and protecting their reproductive investment and then also from the female point of view, getting some parental investment out of dad, by allowing him to ensure that it’s his biological offspring that he’d be investing into. So it was them sort of finding a way to align their reproductive interests, and I say finding away meaning none of this was intentional or conscious. Yes, sir. Yeah, and it corresponds well with menopause as well. So from the best we can tell menopause kind of came about sort of right around the same time and what menopause does Is it stops reproduction before the end of the lifespan, which is very unusual. all mammals, with a couple of exceptions, reproduce all the way through their lifespan, a female can can reproduce in, you know, all the way. Yeah. And humans can’t they stop at some point. And that was always unusual. You will see this presented in a weird way. Like, why is she still alive if she’s not reproductively capable, which is, besides being horribly misogynistic, it’s also framing it backwards. It’s not that she continues to live after she runs out of eggs or whatever, it’s that she purposely shuts down reproduction even though she has like lots of life left.
Why did she stop white right, he’s able to reproduce not why she’s still alive.
And thankfully, we’ve now discovered an inch into two species of whales, the pilot whales and the killer whales. And which, why I say this is great is that we can allow we can study them, and we can see how it works in those species. And we can extrapolate so the idea is, what it what it reduces is what we call intergenerational conflict. So when mothers and grandmothers are both reproducing at the same time, their children and it will be siblings versus aunts and all that start competing with each other for attention, for resources and for investment. And so to have, from a grandmother’s point of view, there’s nothing to be gained by continuing to have more children that will just simply compete with her for her children and her children’s children for limited resources. So instead, her better reproductive strategy is actually to stop reproducing herself and invest all of her resources in her children and her children’s children so that they can compete against other grandmother’s children. So it’s sometimes called the grandmother hypothesis. But it’s not just about conflict parties is what a lot of people miss about this. It’s not just about Oh, grandma’s can spoil their children and their grandchild, they could do that anyway. But the reason the real thing that they’re trying to avoid is intergenerational conflict, because for her it becomes a zero sum game to have her children outcompete her grandchildren or vice versa. You know, either way, but she’s so if she could Invest in their success another way, and it frees her up to do that. And remember, it doesn’t matter these grandmothers also have are older by definition. So they have more cultural wisdom, they have more cultural knowledge to share. They are a commodity a precious resource, and so that what they are passing on to their children isn’t necessarily food, literally food, it’s the knowledge of where to find food, how to prepare food and all of that. So it is valuable.
It doesn’t make sense for her to have a two year old when her daughter or son has a two year old because then those two year olds are going to be competing with each other and that’s what she said, is a zero sum game. So it’s better for her to give more advantage to her grandchild two year old than to have her you know next.
That’s right. That’s right. And the powerful evidence for this has been found in these killer whales. So if you look at pods of killer whales, for the most part, they are families and they are led by older menopausal females because they know where the seals are. they’ve they’ve fished those routes, for jet for decades and they have all the wisdom and the knowledge and that’s that’s a good lesson for us. You know we should be we should be electing grandmothers to our, to our highest office in the land, although we had a chance to do that we had an opportunity. But it just shows that that actually care for elders really is a cultural phenomenon that was born out of their value, their wisdom, they’re not they just know more because they’ve been around. And it’s not just women, women seem to be more generous with their wisdom and knowledge. But we we have fossil evidence of older men really, really old men going all the way to humble Erectus that could not possibly have been physically fit. They must have been a burden on the group physically, but they were kept around and they were aided people chew their food for them and so forth, because they knew things. And that was valuable to the group. So that’s another I think uplifting story in my book is that freeing us from just our bodies being well, it also allows us to live longer, in a happy way in a productive way. You can contribute long after Your body has seen its best days and that’s that’s what that’s what being human is fantastic.
Well I really appreciate you coming on the show a second time. My pleasure I love a human errors a panorama of our glitches from pointless bones to broken genes. really a fantastic read. I really recommend it to all physicians. Well, everybody, but certainly physicians because it really gives us a lot of great perspective like what we talked about today on on how we ended up where we are and and when you’re doing especially if you’re doing a surgery, right everything just kind of makes a bit more sense when when you’re looking at through this lens. So I really appreciate your taking your time.
Thanks for the kind words is my pleasure.
That was Dr. Bradley Block at the physicians guide to doctoring. He can be found at physicians guide to doctoring calm, or wherever you get your podcasts. If you have a question for previous guests, or have an idea for a future episode, send a comment on the webpage. Also, please be sure to leave a five star review on your preferred podcast bye form. We’ll see you next time on the physicians guide to doctoring.
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A Panorama of Human Glitches Seen in Otolaryngology and Nutrition with Professor Nathan Lents, PhD

Professor Nathan Lents studied biology at St. Louis University and then completed his PhD at St. Louis University’s school of medicine in Pharmacological and Physiological Sciences.  PhDs need residencies, too, so he did his postdoctoral training in cancer genomics at NYU and loved New York so much that he stayed and is now a Professor at John Jay College in Manhattan and director of the honors program. 

His book, Human Errors: A Panorama of Our Glitches, from Pointless Bones to Broken Genes, discusses the beauty of our flaws.  We are not the well-oiled machines that we think we are.  This is part two out of three of my interview with Professor Lents. In this episode, we talk about how anthropologists have actually informed our current knowledge of nutritional science from the perspective of “how were we designed to eat?” We then get into the weeds with a few medical specialties. For the ENTs, we discuss how the recurrent laryngeal ended up in the chest, why humans are the only primates who choke on their food, and what the heck do the sinuses really do?

He maintains the Human Evolution Blog and his podcast is called This World of Humans. He can be found at NathanLents.com

Find this and all episodes on your favorite podcast platform at PhysiciansGuidetoDoctoring.com

 

Please be sure to leave a five-star review, a nice comment and SHARE!!!

 

This episode is brought to you by Orange County Bookkeepers (OCB) Healthcare Accounting: an all in one accounting firm for small healthcare businesses and private medical practices. One thing that I personally love about OCB Accountants, is that they are QuickBook professionals with over 20 years’ experience, focusing specifically on healthcare. They utilize a tailored approach individualized to your needs. They are a full-service bookkeeping firm specializing in accounting, payroll, taxes and financial planning. For our listeners, for a limited time, they are offering 25% off their services for the first 3 months. You can visit them at OCBmed.com or call 833-671-3873 or 949-215-6200.

A Panorama of Human Glitches Seen in Otolaryngology and Nutrition with Professor Nathan Lents, PhD

Professor Nathan Lents studied biology at St. Louis University and then completed his PhD at St. Louis University’s school of medicine in Pharmacological and Physiological Sciences.  PhDs need residencies, too, so he did his postdoctoral training in cancer genomics at NYU and loved New York so much that he stayed and is now a Professor at John Jay College in Manhattan and director of the honors program.

His book, Human Errors: A Panorama of Our Glitches, from Pointless Bones to Broken Genes, discusses the beauty of our flaws.  We are not the well-oiled machines that we think we are.  This is part two out of three of my interview with Professor Lents. In this episode, we talk about how anthropologists have actually informed our current knowledge of nutritional science from the perspective of “how were we designed to eat?” We then get into the weeds with a few medical specialties. For the ENTs, we discuss how the recurrent laryngeal ended up in the chest, why humans are the only primates who choke on their food, and what the heck do the sinuses really do?

He maintains the Human Evolution Blog and his podcast is called This World of Humans. He can be found at NathanLents.com

Find this and all episodes on your favorite podcast platform at PhysiciansGuidetoDoctoring.com

 

Please be sure to leave a five-star review, a nice comment and SHARE!!!

 

This episode is brought to you by Orange County Bookkeepers (OCB) Healthcare Accounting: an all in one accounting firm for small healthcare businesses and private medical practices. One thing that I personally love about OCB Accountants, is that they are QuickBook professionals with over 20 years’ experience, focusing specifically on healthcare. They utilize a tailored approach individualized to your needs. They are a full-service bookkeeping firm specializing in accounting, payroll, taxes and financial planning. For our listeners, for a limited time, they are offering 25% off their services for the first 3 months. You can visit them at OCBmed.com or call 833-671-3873 or 949-215-6200.

 

EPISODE TRANSCRIPT

Disclaimer: This is the transcript to the episode. This transcript was created by a talk to text application and the function of having this here is to improve the page search engine optimization. This transcript has not been proofread, so please listen to the episode and don’t read this. The information contained herein will inevitably contain inaccuracies that affect that quality of the information conveyed and the creator of this content will not be held liable for consequences of the use of the information herein.

Professor Nathan Lenz study biology at the St. Louis University and then completed his PhD at St. Louis University School of Medicine, in pharmacological and physiological sciences, now PhDs need residency to so he did his postdoctoral training in cancer genomics at NYU, and love New York so much that he stayed. And he’s now a professor at john Jay College in Manhattan, and the director of the Honors Program, his book human errors, a panorama of our glitches, from pointless bones to broken jeans discusses the beauty of our flaws. We are not the well oiled machines that we think we are. This is part two out of three of my interview with Professor lens. In this episode, we talk about how anthropologists have actually informed our current knowledge of nutritional sciences from the perspective of how are we designed to eat. We then get into the weeds with a few medical specialties. We start with EMT In this episode, something near and dear to my heart, and we discussed how the recurrent laryngeal nerve ended up in the chest. why humans are the only primates who choke on their food. What the heck does scientists really do? It maintains the human evolution blog. This podcast is called this world of humans. He can be found at Nathan lense calm.
Welcome to the physicians guide to doctoring A Practical Guide for practicing physicians. Dr. Bradley Block interviews experts in and out of medicine to find out everything we should have been learning while we were memorizing Krebs cycle. The ideas expressed on this podcast are those of the interviewer and interviewee and do not represent those of their respective employers.
And now, here’s Dr. Bradley Block.
This episode is brought to you by Orange County bookkeepers, healthcare, accounting, and all in one accounting firm for small healthcare businesses and private medical practices. One thing that I personally love about OCB accountants They are quickbook professionals with over 20 years experience focusing specifically on healthcare. The utilize a tailored approach individualized to your needs. There are a full service bookkeeping firm specializing in accounting, payroll taxes, and financial planning. And for our listeners for limited time, they’re offering 25% off their services for the first three months. You can visit them at OCB med calm. That’s OCB m Ed, or call at 833-671-3873 or 949 to one 560 200 and check out the show notes for more information. Dr. Nathan Lance, thanks so much for being on the show again.
It is my pleasure.
So how have the anthropologists driven our current knowledge of nutritional science?
That’s a great question because I think a lot of the public gets a little frustrated by every five or 10 years. We’re told a different diet is the way to eat and minimize this and maximize that and I think suddenly reached clarity by trying to answer the question of what were we eating as we evolved as our metabolism evolved, and I don’t mean over a few thousand years, but over millions of years, and the anthropologist the evolutionary anthropologists have have made a lot of progress and understanding what we ate, really, as we transitioned out of the rainforest into the grasslands, and became, you know, omnivorous opportunistic feeders. And what they’ve really shown us is that the vast majority of the world’s cuisine right now, every, every culture that you go to the main staple food is carbohydrates, and they put other things on top of that, but we are getting something like 70 to 80% of our calories from carbohydrates. And that just wasn’t the case. For millions of years of our history, carbohydrates were always there, but they were a much smaller percentage of our total calories. And so what we find in a carb hydrate based diet is that the blood sugar swings a lot more. So you get spikes in blood sugar, which are also followed by troughs, because the insulin response gets exaggerated. And so you have this really up and down blood sugar insulin reaction after every meal instead of a more of a slow roll. And the advantage of the slow roll is number one, you don’t get hungry between meals as much you can go long periods without eating without being consumed by that hunger. And then also Most importantly, the way that it affects the energy metabolism of the excess calories that you have after a meal. So a slow roll of glucose and insulin actually promotes this the temporary shortage storage of calories in the form of carbohydrates, glycogen and so forth. But a spike promotes long term deposition of calories in the form of fat. So paradoxically, a high carbohydrate diet is a good way to get fat and a high fat diet is not the It seems paradoxical. But you know, these these molecules are all inter converted into one another. So you can eat carbs, and it gets turned into fat by your body. But I think the anthropologist really led the way by looking how we evolved and how hunter gatherers eat now. And it was really the invention of farming that produced all these carbohydrates as a key part of our diet.
I guess they were much harder to come by previously. And also you were able to mass produce them and refine them.
Yes, yes, exactly. The mass production in the form of farming is what allowed it because carbohydrates are always there, we ate tubers and routes, but imagine, you know, all the digging that you have to do to get, you know, one route that you then usually have to cook and you know, it’s just not going to be a big part of everyone’s diet. And sugars, especially, you know, would have been great when they were found here and there, but it would have they would have been sprinkled through our diet. Whereas nowadays, the amount of sugar that you can eat in one big breakfast can be more than hunter gatherers eaten in several weeks.
Well also even if it is sugar, like it’s If sugar in the form of an apple, the Apple has fiber in it, fiber slows gastric emptying. And fat does the same thing they slow gastric emptying. So that’s that slow roll that you’re talking about.
Exactly. And so one way you can, if you have a lot of sugar, just minimize how much it is per meal and fill it with other things that can help but it really just just the total amount of sugar in an apple. Well, also you have to realize the apples we eat now are not like the apples. We were eating. For most of our history, right? cultivation has made them big, rich and much more sweet. So the amount of sugar that we previously got from apples was much less also. Yeah, but my apples
have a little sign on them that says non GMO.
Yeah, you know, they’re modified. There’s almost no food in the supermarket now that hasn’t been genetically modified through not through artificial selection. So we selected apples to be very big, very sweet. The original apples would have been more closer to the size of a large cherry and not near as sweet, much more mealy and fibrous and I don’t think almost any of the food that we evolved eating would be very palatable to us now.
Yeah. So is that what you’re saying is are you saying we should be eating roots and grubs?
No, I’m not actually I think you can eat a modern diet that is better balanced in terms of the of the macromolecules. So, you know, what I eat a lot of is nuts. I eat a lot of nuts, especially for lunch. And I tend tend to reduce meat for environmental reasons. I do think meat is a healthier way to eat, but I can’t justify it right now in terms of just for environmental reasons. So I try to substitute with nuts, that’s what I think is is you get a lot of fat, a lot of protein. And I can have two pieces of fruit, and a couple handfuls of nuts for lunch, and it’s really um, good until dinner. Now I’m hungry at dinnertime. Don’t get me wrong, but I think it’s a healthier way to eat and I don’t get those spikes and insulin that cause you to become ravenously hungry in between meal to use modern nomenclature that would be hangry. Behind grades hecklers, right? And I also don’t get tired. I don’t need a nap during the day either because that’s another thing. That the sugar and insulin spikes will do to you is just zap your your energy.
Yeah, when I was a medical student it just baffled me that after lecture I would go to Wegmans get a big sub that had all this white bread on it. And and then I’d be so tired I’d have to say I was useless. I couldn’t study I’d fall asleep it was and I had no idea that you know, the cause and effect was right in front of me but I but I had no idea. Yeah, now it’s you know, now it’s become a now I’m so attuned to that. Like, I only the only time I’ll have something that’s that’s carb rich is when I know I’m going to bed soon just because I’m so like, I can’t have something like that and then go on to start seeing patients just doesn’t work.
It is good for falling asleep. That’s true.
Yes. Then Thanksgiving everyone says, Oh, it’s the tryptophan. Yeah, definitely. No, it’s because ones and we get a big sugar spike, followed by the insulin spike and then we’re and we’re storing fat.
Okay, yeah, no and Thanksgiving dinner that yeah, it’s not the turkey. It’s the stuffing.
It’s the it’s the I think it’s the stuffing stuffing yourself. Yeah, exactly. We’re stuffed. So is there any other tidbits that you have for our physician audience here about what we are about a current status of nutritional science based on how we’ve evolved?
Yeah, well, I would say that to throw away any of the hard rules, there’s no there’s no need for three meals a day. There’s no need for getting enough carbs or anything like that. The key thing I say is to minimize carbs, maximize proteins and fats and then also and this is the key one is listen to your body. Try different things like for me breakfast just doesn’t work. But there are some people who who are eat a very healthy diet and breakfast as part of it. So if you can’t do away with breakfast, then just find a healthy breakfast to eat. That’s protein and fat and not carbide for me, no breakfast is works well for me. So listen to your body and follow the cues and give any diet a little bit of time to work it as you reduce carbohydrates, you’re not going to like it at first. Giving up lunch, for example is very hard for me to do but once I’ve done Now I can do it any, any day I want. I can’t usually do it two days in a row, but I
just listen to your body. That’s I would say, and I think not being dogmatic. That’s one of the issues that I have, like the Paleo diet or the keto diet is that, you know, in order to stay in ketosis, just the, the mental energy that it takes to do something like that, I mean, if you’re a high performance athlete, and you’re like trying this for a reason, but like, I don’t know, to recommend that to your to patients, that’s just completely overhauling.
Yeah, I ended up living, then that’s not evolutionarily correct, either. Because we were very opportunistic. We did sometimes feast we did sometimes eat, you know, the rare foods and we got a windfall of this, that or the other, that’s okay. It’s all okay. With that saying everything in moderation, including moderation. It’s okay. I mean, I have dessert every now and then I love pizza. You know, you just have to work it into regular routine of healthy of healthy foods.
In New York, how can you avoid pizza?
Yeah. wouldn’t wouldn’t dream of giving a pizza.
Alright, so let’s let’s move on to the different specialty sections of your of your book. So one thing that’s near and dear to my heart otolaryngology. You mentioned the recurrent laryngeal nerve. And I thought that was really entertaining because, you know, we do thyroidectomy is and so when you’re doing a thyroid, when you’re removing a thyroid, you have to find the recurrent laryngeal nerve. And, you know, you’re explaining it to a patient before surgery about how this is a risk. And it never made sense that it ended up just getting hooked under and coming back up. And, and I think of like, you know, in the book you brought up what it would look like in a draft or a Brontosaurus, right, right. Like, it’s just that nerve is gonna be so long in that animal. Yeah, but so how did it end up that way?
Well, so the nerve makes a pass from the brain to the lyrics to the voicebox and its earliest incarnation, you gotta remember that these These cranial nerves these are ancient ancient nerves, the spinal nerves and cranial nerves go back way back in our evolutionary history. And so if you go back to the earliest incarnation of this recurrent laryngeal nerve, it made a shot from the it was in fish, we’re talking about fish here. So the shot that the drive that it took to go from the brain to the gills because our larynx evolved from the gills, and that was this nice straight shot very short. And they didn’t, they didn’t, they don’t have a neck or a chest, fish don’t and so as our heart and they do have a closed circulatory system, they do have a heart. And as the heart migrated away from the brain, in the development of tetrapods, you know, infamy, reptiles, amphibians and so forth. You sort of elongated and created a true neck, a true chest that’s separate from the head, so the heart and the brain started to become separate from one another. Well, this nerve sort of meanders through the vessels of the heart, even in fish, but it makes us Rate shot. But as the heart moved backwards, or I should say downwards, if we’re talking anatomical position, in the more inferior position, it brought that nerve with it because that nerve gets tangled around the aorta, the aortic arch. And so developmentally, if you think about tweaking genes with random mutations, it was just too much of an ask to untangle that using random mutations. And so the solution that not a solution, just what happened was that the nerve just got pulled into the chest. And so this nerve goes from the brain loops around the aorta. Because it exits the vagus nerve. It’s in the Vegas nerve bundle in the spinal cord, and then it comes out in the chest and then comes back up to the neck. You know, the other nerves in our neck don’t do that. This was the only one that there was just just bad luck. And it didn’t, it didn’t sort it out. But as far as we know, every vertebra it has this problem. Every single one, every single tetrapod, every reptile, every mammal so and we’ve dissected The giraffe and you can see this, this several meters long nerve that could be measured in centimeters. It’s measured in meters in the giraffe, and so we would assume no one’s ever fossilized. We’ve never seen a fossilized version of this and the Brontosaurus and you know the other bracket. So the bracket soars the other but dinosaurs in that family, but we would have just assumed by extrapolation that they would have this several meters long at that point, probably double digit meters long, recurrent laryngeal, it doesn’t cause problems day to day. But what it does causes that as you mentioned, neck surgery, but also chest surgery. cardiothoracic surgeons have to look out for that nerve as well. Because if they accidentally cut it, while performing a bypass or anything else, the person will learn to will need to learn to talk again and potentially I’m actually not entirely sure how permanently disabled you are without that nerve. That’s something you would know I imagine.
Yes, yeah, that’s this is something this is something of a treat. So So ultimately, what happens if the nerve does get cut than half of the cord you know, that cord doesn’t move Right. And so what generally happens is it becomes fixed in a medial position, so that you bring one you can bring your other chord over to the other and then you can have a voice. But for a while you just have a very breathy voice because your vocal cords don’t close. Mm hmm. Which means you have to take a breath between almost every word that you can be at slightly higher aspiration risk, because purpose the larynx is the valve to prevent aspiration. Mm hmm. But, and then one of the surgeries that we can do, we can actually put some filler into the cord, if it’s not getting MIDI alized to in order to force it to towards the middle so that the other half so that the valve becomes competent again, and you can create a voice and you can prevent aspiration. We put like, similar to what you would use to get rid of someone’s wrinkles, like Breslin, and then you know, and then there’s more permanent surgery if you’re finding that that the paralysis because it was cut rather than just stretched and poetic. So that’s, that’s how we that’s how we manage a vocal cord process. So, so speaking of which, speaking of the valve, the larynx being a valve to prevent aspiration.
I was just gonna say that
is choking risk.
Right? Right. Really the elephant in the room when you’re talking about anything going on in the neck is that the common tube for food in the air? You know what could go wrong, the aspiration risk that humans face is actually greater than most of our relatives, especially in early childhood. I mean, choking is a is a hazard as an extreme hazard in our species. And it’s because our throat is so shallow, it’s really shallow. And so you have in a very small amount of space, you have a lot of work to do to make sure that the food gets into the right place and the water especially in the lungs, don’t take that on. And just just the fact that we have a throat where the food and air start off on the same path is really an unfortunate design. And there’s there’s a lot of downside to it. And in fact, if you look at birds, for example, whose whose nostrils make a direct shot to their lungs, bypassing the throat all together, thank you Have it so much better than we do and snakes as well. So birds and reptiles, most of them actually have a separate conveyance of air from their nostrils. So if you see a snake that’s halfway through swallowing something, you’re not like, Oh my gosh, how is he possibly breathing, he’s breathing just fine and so are the birds too. I’ve seen a bird with a fish sort of stuck in its throat. And while it needs to, it does need to get that fish up or down. It’s not going to fix he ate it while it’s figuring that out. And so in fact, I saw this one bird on the beach one time I was watching and he made about five or six tries to swallow this fish wetting it in the saltwater and trying everything each attempt took several minutes and eventually gave up he couldn’t couldn’t swallow this fish. straightaway. Yeah, very frustrating, but he wasn’t. It’s fixed at you know, he had no trouble breathing while he was trying to do that. And there was no urgency as
if I don’t swallow this. Yeah, I’m gonna die.
Yeah, right. Right. So we don’t we have that problem where we can easily get food lodged and if it gets lodged in our throat, the nasal pharynx joins, as well of course so there’s no the nostrils are Any help if you’re if you’re stuck in your throat, so that’s that in of itself is poor design. But the other apes share that design with us and as all mammals do, but the other apes have much more room to sort the flow of traffic into two lanes, so to speak. So the epiglottis has more room to do its work in covering the glottis. But we don’t so what happened was that our larynx migrated upwards over the last really, fairly recently, the last couple hundred thousand years, maybe a million years, it migrated upward. Now that migration is measured in millimeters, not maybe centimeters, but at the same time, there’s just not a lot of room back in the throat anyway. So that was precious room. And our babies, as we know are born quite incapable. And so choking is just a major hazard that really has to do with the anatomical design of the throat.
And actually when you’re born, your larynx is much higher. Mm hmm. I see. I see a lot of patients newborns come in with learning Malaysia which is this is just a floppy larynx. So their larynx makes a lot of noise when they’re breathing. And so they come in, and the parents often complain that their kid is congested. Because it sounds like it’s coming from the nose. And the reason it sounds like it’s coming from those because the larynx sits so high and the reason is because they you know, if you’ve ever tried drinking while you’re lying on your back, doesn’t work if you’re gonna aspirate, but they do they drink lying on their back all the time. And they do, and they do just fine. And I think that’s the reason that the larynx needs to be so high initially and then and then it just ends. So is the reason that it ended up elevated in us is that because it’s a more finely tuned communication apparatus, and that’s why it needed to be higher.
That’s certainly the the thinking, you know, it’s one of these things in evolution where you have an explanation that seems to fit all the data but you can’t know for sure without a time machine exactly what was going on, in terms of the selective pressure, but what we do know is that having a larynx that’s higher in our throat allows us to make a much richer variety of vowel sounds and so Certainly none of the other apes, but most of the other hominins. As we model what their throat look like, they wouldn’t have been capable of the kind of speech that we can make. So the fricatives and the other sounds that are made by the puckering of your soft palate and your throat. And certainly the click sounds of some of the earliest spoken languages are simply just not possible without that larynx being very, very high. And so and the reason why is that you shape your throat right before the air gets to the larynx. And then you have that you just have a lot more in your toolkit. And so most of Neanderthals had this fairly high throat as well. So some people infer that they must have been able to speak because we can’t think of any other advantage for that high voicebox clearly disadvantage, and otherwise, it’s a disadvantage. Yeah, we understand all the costs, but the only benefit we can, we can see is in speech. And there’s disagreements about that too, because a lot of people think that actually gestural communication probably drove language. I don’t see those as either or I think gestures were a big part of our communication toolkit. We’ve transitioned more towards vocal auditory communication in the last million or so years. And I think that was when the fossil record supports the idea of the the throat migrating upwards and upwards. Particularly the hyoid bone is, is generally the easiest way to do this because larynx doesn’t fossilize as well, really, at all. But the hyoid bone does. And so these are inferences that are drawn from the position of the high end form in the throat.
Yeah, the hyoid bones. Interesting because we, we remove it with impunity,
right? It’s one of the few bones that’s really not attached to any other bones, right? It’s the scaffold for the musculature involving the larynx as I understand it,
but but even like if someone has a third gospel duck cyst, which is you know, the third starts off in the back of the tongue and then it extends, it descends to below the larynx. It sometimes leaves a little bit of trail of what becomes a cyst behind that then needs to be removed and in removed, so we remove the hyoid bone with the cyst, and it greatly decreases the recurrence risk. It’s called the SIS trunk procedure
and can they speak more Totally fine. Totally. And I wonder, though if that if that’s because they’ve had the benefit of proper development up to that point. So if you would remove the hyoid bone at birth or in utero, probably not as much, or what do you think? Yeah,
that’s that’s an interesting question is your question that will never be answered?
Well, I mean, yeah, I mean, you could do you could think about experimental ways to do it. Not on humans. But yeah, you’re right. It wouldn’t give you quite the developmental question we’re asking.
So yeah, the, as far as we don’t know, what it’s what its value is there’s, you know, it’s interesting, we learn these things. And now talking to you, especially with your with your book, it turns out that the answers that we’re sometimes given are just based in conjecture, not based in evolutionary development. Like, you know, I learned that the hyoid bone developed and really it only seems to function in roaring in lions, and so it doesn’t, it doesn’t have a role, but but it did have a role and then maybe, maybe it doesn’t any longer. Maybe it says, in development, but not then. Once you’re developed, and the same thing with, with the sinuses, right, that’s, that’s something that you and I have been communicating about trying to try to figure out because what we learn is, well, it could be to help Rhett increase the resonance of your voice, or it could be to lighten your skull. Or it could be to a crumple zone. Like if you’re, if you’re a primate swinging from a tree, and you smash into a tree and you break your sinuses, you, you know, it functions like a crumple zone, so you don’t die. And maybe you can go on to reproduce, although, probably not likely.
Yeah, I mean, I would be skeptical of all of those explanations and not again, not that I think they’re, you know, terrible stories, but it’s just hard to see selection at work in cases like that. But what’s interesting about medicine and evolutionary biology is they both have this tendency practitioners like like, like yourself and myself, of creating stories that fit the data. And usually these are just fanciful stories, but actually, when met In an evolutionary biology come together there. And they, I think the stories that they tell together actually tend to be much more accurate than either one does separately, because evolutionary biologists think about selection. And they think about ancestral environment. And physicians think about how the body works right now. And I think when you put those two perspectives together, especially if you have a good background in anatomy, I think is when you really, really get insights in how the body works. And to me, the hero of all this is Dan Lieberman, if you know him at Harvard, he really approaches the anatomy of the human person from an evolutionary perspective, and it’s really insightful.
Yeah, it just it gives us this completely different perspective rather than having to make up a story de novo of where this why this exists. You know, if you talk to an evolutionary biologist about it, you’ll get a lot more insight and and do you want to go into the sinuses a little more we can save that for article
because I think it’s a good it’s a good example of how just because something does something for us now doesn’t mean that that’s what it was evolved. To do for example, or that it gave enough benefit to a really been considered an adaptation. So yeah, let’s talk about the science.
So as far as what they do now, it seems like they do nothing, right. What they do is they they secrete mucus, which then gets pushed in a very specific direction actually against gravity and for some of the sinuses, into the nose, it drips down the back of your throat, and then you swallow it. It’s called mucosa. ciliary flow. And, and I mean, it could be that you need that mucus in order to have enough of a mucus blanket to swallow your food to lubricate your food. So it actually goes down the esophagus, but I really I find it unlikely you could just upregulate the mucus that’s produced in your nose and your throat in order to have enough so that
was always my question was that if the chambers are just there to provide provide surface area for mucus production, that would be one thing, but it doesn’t seem to me that they’re necessary for that, but that’s where your perspective would be key here. I mean, that’s not the only place where certainly where there are mucous membranes but also where there’s mucus production, correct. Oh,
there’s mucus production. You know, all over the inside of your nose and the inside of your mouth, which should be more than enough. And if it isn’t, then you can up regulate it and you just did. And you would still need to swallow the same amount. It’s not like you would start drowning because you’re producing too much because because, you know, you’re producing the same amount of mucus just more localized. And we don’t find if someone has large sinuses or small sinuses. Some people have a trophic sinuses that they really have a deficit because of it. Some people don’t have frontal sinuses, so the forehead sinuses, they just don’t have them. And right, it’s fine. They don’t have any type of a deficit. So one thing that we used to do, and we really don’t do it anymore, is if you’d have chronic frontal sinus infections, we’d actually obliterate the sinus. So you’d scrape all the mucous membrane out of the mean, it turns out that that can turn into a disaster. So we don’t do that anymore. You’re
removing the like the sub mucosa so that it does, nothing comes back.
Exactly, exactly. You’re like scarring it, you’d pack it with fat to just fill it up. But if you left a single cell behind, then you’d end up in a mucus sealed with a mucosal in that area. And that would be problematic. So, but still, they would have complications from the surgery itself, but not because they didn’t have a sinus anymore. So it doesn’t seem like they really have a function anymore, but they can cause problems. And so something that you and I had spoken about was that, you know, in our modern society, since we live on top of each other, we get a lot of, we get more colds than we did when we were hunter gatherers out in the field in a tribe of, you know, far fewer than we’re around now. So you get a lot of colds and that can affect the sinuses and some people as a cold turns into, it starts out as a viral upper respiratory tract infection turns into a bacterial sinus infection, and that can cause all sorts, all sorts of problems that can cause brain abscesses and orbital abscesses. If only just or if you have asthma causes asthma exacerbations. Like these things can be dangerous. It rarely causes rarely causes the ABS disease, but you know, in terms of quality of life, you now you know, you’re not going to be someone that’s going to be selected for because you’ve got this foul smell coming out of your nose, lose your sense of smell. It’s very uncomfortable. So So you can live a long life with a chronic sinus infection, but you know, you’re probably gonna be, you’re gonna have a hard harder time reproducing in that setting. So these are they have a liability to them, at least our modern society. So the question is, where could they have come from and where could they their function have been previously that they still exists now?
Well, I think you you’ve, I think you’ve given us all the information to produce a pretty good working theory. First of all, I think that drawbacks to the sciences that you mentioned about infection and how how the poor design and the poor drainage can can make all of this the symptoms of restaurant frictions worse. All that’s true, but I don’t think it was a major plague on our species, until we started living in higher population density. So before farming was invented, and remember, farming was just very recently invented if you’re if you’re used to the type of timescales that I work in. So prior to that population sizes were measured in the low hundreds 150 to 250. So you just you weren’t ready ravaged by a cold virus very often. I mean, it went through if it went through the population once, and that would have been it, it doesn’t circle the globe and mutate and come back again. And all this sort of never ending onslaught of viral infection. I just don’t think that our pre historic forebears were very sickly people with infectious disease, because it just wouldn’t have been passed around. It would have, you know, like I said, Go through once. And that’s it. And with no host, and these, most of the groups were fairly isolated from one another, at least on timescales of years to decades, not not over longer timescales. But so I don’t think that we were passing around these effects, I don’t think it actually was all that much of a detriment until forming. And we have evolved very, very little since the 15,000 years ago that we started sort of being more sedentary and staying in one place and that and that’s what farming allowed. So I don’t think that we’ve even had enough time to experience the selection, pressure, and even even then, even if we do think of this as a major detriment to us, we’ve sort of escaped natural selection in that way. We don’t really live and die and succeed or not, based on how healthy we are that much anymore. cultural evolution has so outpaced biological evolution over the last 15,000 years. And that’s why you have like, no, the Hapsburgs of Europe were tremendously successful in their reproductive capacity, but because of their own poor reproductive choices, they were a very sickly group, right? I mean, they have words, their face wasn’t even formed correctly talked about the sciences. And yet, because of the way that that power leads to reproductive success in our species, it didn’t, it didn’t affect them in terms of the reproductive success. And I think that, you know, you map that phenomenon all the way back 15,000 years, I don’t think that the common cold was just very much of a selective pressure, even sinus infections would have to be very serious before they really affected your ability to reproduce,
but even a lot of sinus infections, bacterial sinus infections are self limited. So just because you have a sudden spectrum doesn’t necessitate antibiotics, but we do we do often treat them so so then where did the sinuses come from? The short answer is that
our sinuses are related to the sciences that all mammals have. But they almost all mammals have them in their snouts. Okay. And so every mammals outside of primates are snout if you think about a horse, a kangaroo, a dog, even bears, you have all of this room in the snout, and that’s where these large cavities can concentrate millions upon millions upon millions olfactory receptors. So the purpose of the smell is to really heighten the sense of smell. And that’s why they have so many more kinds of olfactory receptors as well. Every other mammal outside of priming is really driven by its sense of smell. And so the snout had enormous advantages, and they navigate their world through all the odorant receptors that they have there. Well, in primates, we represented a transition towards vision as the primary sense that we navigate the world away from smell and towards vision. And those two did end up intention. It would be great if we had kept the sense of smell while we develop vision but here’s why that wasn’t possible to really get the best view of The world you don’t put your eyes on the side, like horses and everything else. That’s great for a wide field of view, but you have very little overlap between the two fields of use of your eyes. And the overlap is what allows you good three dimensional stereoscopic vision at a distance. So if you bring the eyes forward, you have your visual field field covered by two eyes, you get good depth perception. The problem with that is if you bring your eyes forward, and you don’t reduce yours now, that’s now is right in the middle, it’s right in the middle of your field of view. So what primates did, while the eyes migrated forward, the snout regressed, and it got smushed in to our face, essentially. And that was great because it got it out of the way. And but it reduced our reliance on smell our ability to smell that well. And that was okay because we were transitioning towards vision. So there was really not not that big of a drawback. And more evidence for this, by the way is found in the fact that most of our olfactory receptors have now been lost. They’re all pseudo genes, not all of them, but we have several I forgot the number of just looking this up the other day, but I think it’s over 1000 olfactory receptors, pseudo genes. So these genes have been broken by mutation. But there was no effect because we’re not really driven by our sense of smell anymore. So as the snout regressed into the face, those sinus cavities still existed, and they just got mushed up into the bones of our face. And so if you ask me why we have sciences, it’s because our ancestors did. It’s not because they perform any important function for us. We can breathe through our mouth just fine. And in fact, anytime you do strangers exercise your most your most of the air is coming in through your mouth. And yet you don’t have any terrible effects of that. So I would, I would argue that the sinuses do seem to be these fairly vestigial in the sense that they were important to our ancestors. They’re not important to us. But they weren’t removed by evolution, because evolution doesn’t fix every mistake.
Yeah, you have to have enough pressure and without that pressure, then then it then it just
stays. The other apes did the same thing we did, but they handled it better. So for example, the orangutans ditched Some of their sinuses that some of the para nasal sinuses they just ditch them altogether. Somehow they did get lucky. And the mutation sort of eliminated those sinus cavities. So Ryan tans got the best end of this deal. chimpanzees have a very similar arrangement that we have, but yet the drainage from the maxillary sciences in particular, is wider. And it’s also higher up in the chamber so it doesn’t. So the mucus does isn’t allowed to pool at the bottom as much. So they have better drainage. They don’t suffer sinus infections like we do. They don’t live in the population densities that we do and
they don’t get colds. I mean, yeah, no, you know what they ship with the sniffles often?
Yeah, not really. And in fact, your dog also, you know, is a good example. They never really have upper respiratory issues unless you’re talking about a breed who we have smooshed their sinuses like the pugs and Pekinese and that should tell you something actually that that this mushed up side is is really our breeding ground for for infection and that’s what we have essentially where we are pugs in terms of how our assignment is we’re just sort of very quickly smushed in To our face and sub optimally designed thereafter,
I will be sure to tell that to my next patient with a sinus infection. You are a pug of the human race. Yeah, that will that will go poorly. One story and
that was Dr. Bradley Block at the physicians guide to doctoring. He can be found at physicians guide to doctoring comm or wherever you get your podcasts. If you have a question for previous guest or have an idea for a future episode, send a comment on the webpage. Also, please be sure to leave a five star review on your preferred podcast platform. We’ll see you next time on the physicians guide to doctoring.
Transcribed by https://otter.ai

Support for Physician Burnout Syndrome with Torie Sepah, MD

Torie Sepah, MD, completed her internship in family medicine at Kaiser Permanente Los Angeles Medical Center, then went on to complete a psychiatry residency at LA County + USC Medical Center. She has studied physician burnout syndrome extensively. It is a topic that is very personal to her and we discuss why. She defines the syndrome, what the major causes are, what the consequences are and what has actually been proven to help. Among them is connection.

Her Facebook group – Physician to Physician: Healing the Practice of Medicine, has become a signal in the noise surrounding burnout, providing us with a community of physicians who understand the hardships of our field and can help.  

She has worked extensively in correctional medicine, having served as the chief psychiatrist at the California Institution for Women, being the first female chief psychiatrist at that prison.

Since 2018, Dr. Sepah is a community psychiatrist once again, seeing patients with HIV in an integrated clinic and running her own interventional psychiatry clinic, which focuses on deep Transcranial Magnetic Stimulation (dTMS) as well as reproductive psychiatry, neuropsychiatric disorders, and early diagnoses or schizophrenia. 

Dr. Sepah is an assistant clinical professor, department of psychiatry, Keck School of Medicine of USC. Prior to becoming a physician, she was a journalist and assistant editor of Ms. Magazine, writing the health column which prompted her interest in medicine. Dr. Sepah can be reached at her self-titled site, Torie Sepah, MD,  and on Twitter @toriesepahmd.

Find this and all episodes on your favorite podcast platform at PhysiciansGuidetoDoctoring.com

Please be sure to leave a five-star review, a nice comment and SHARE!!!

This episode is brought to you by Orange County Bookkeepers (OCB) Healthcare Accounting: an all in one accounting firm for small healthcare businesses and private medical practices. One thing that I personally love about OCB Accountants, is that they are QuickBook professionals with over 20 years’ experience, focusing specifically on healthcare. They utilize a tailored approach individualized to your needs. They are a full-service bookkeeping firm specializing in accounting, payroll, taxes and financial planning. For our listeners, for a limited time, they are offering 25% off their services for the first 3 months. You can visit them at OCBmed.com or call 833-671-3873 or 949-215-6200.

Support for Physician Burnout Syndrome with Torie Sepah, MD

Torie Sepah, MD, completed her internship in family medicine at Kaiser Permanente Los Angeles Medical Center, then went on to complete a psychiatry residency at LA County + USC Medical Center. She has studied physician burnout syndrome extensively. It is a topic that is very personal to her and we discuss why. She defines the syndrome, what the major causes are, what the consequences are and what has actually been proven to help. Among them is connection.

Her Facebook group – Physician to Physician: Healing the Practice of Medicine, has become a signal in the noise surrounding burnout, providing us with a community of physicians who understand the hardships of our field and can help.  

She has worked extensively in correctional medicine, having served as the chief psychiatrist at the California Institution for Women, being the first female chief psychiatrist at that prison.

Since 2018, Dr. Sepah is a community psychiatrist once again, seeing patients with HIV in an integrated clinic and running her own interventional psychiatry clinic, which focuses on deep Transcranial Magnetic Stimulation (dTMS) as well as reproductive psychiatry, neuropsychiatric disorders, and early diagnoses or schizophrenia.

Dr. Sepah is an assistant clinical professor, department of psychiatry, Keck School of Medicine of USC. Prior to becoming a physician, she was a journalist and assistant editor of Ms. Magazine, writing the health column which prompted her interest in medicine. Dr. Sepah can be reached at her self-titled site, Torie Sepah, MD,  and on Twitter @toriesepahmd.

Find this and all episodes on your favorite podcast platform at PhysiciansGuidetoDoctoring.com

Please be sure to leave a five-star review, a nice comment and SHARE!!!

This episode is brought to you by Orange County Bookkeepers (OCB) Healthcare Accounting: an all in one accounting firm for small healthcare businesses and private medical practices. One thing that I personally love about OCB Accountants, is that they are QuickBook professionals with over 20 years’ experience, focusing specifically on healthcare. They utilize a tailored approach individualized to your needs. They are a full-service bookkeeping firm specializing in accounting, payroll, taxes and financial planning. For our listeners, for a limited time, they are offering 25% off their services for the first 3 months. You can visit them at OCBmed.com or call 833-671-3873 or 949-215-6200.

EPISODE TRANSCRIPT

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Teresa completed her internship in family medicine at Kaiser Permanente Los Angeles, then went on to complete a psychiatry residency at LA County USC. She has studied physician burnout syndrome extensively, and it’s a topic that is very personal to her. And she discusses why we then define the syndrome. What the major causes are, what the consequences are, and what has actually been proven to help among them, his connection. Her Facebook group physician to physician healing, the practice of medicine has become a signal in the noise surrounding burnout, providing us with a community of physicians who understand the hardships of our field and can help. She’s worked extensively in correctional medicine, having served as the chief psychiatrist at the California institution for women, being the first female chief psychiatrist at that prison since 2018. Dr. SEPA is back to being a community psychiatrist. seeing patients with HIV in an integrated clinic and running her own interventional studies. Ettrick clinic, which focuses on deep transcranial magnetic stimulation, as well as reproductive psychiatry, neuro psychiatric disorders, and early diagnosis of schizophrenia. Dr. SEPA is an assistant clinical professor at the Department of Psychiatry at the Keck School of Medicine at USC. Prior to becoming a physician, she was a journalist and assistant editor of MS magazine, writing the health column, which prompted her interest in medicine. Dr. SEPA can be reached at herself titled site Tory SEPA MD and on Twitter at Torrey SEPA MD
Welcome to the physicians guide to doctoring A Practical Guide for practicing physicians. Dr. Bradley Block interviews experts in and out of medicine to find out everything we should have been learning while we were memorizing Krebs cycle. The ideas expressed on this podcast are those of the interviewer and interviewee and do not represent those of their respective employers.
Now, here’s Dr. Bradley Block.
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Tech tutorial purpose. Thanks so much for being on the show today.
Thank you so much for having me.
So there are a lot of misconceptions out there about physician burnout and physician burnout syndrome. And I actually never heard of it referred to as a syndrome until I read one of your blog posts. So I think if you just call it physician burnout, I might qualify for that. Because in the most general sense, I’m feeling pretty burned out right now I have a three and a half year old, a two year old and a four month old and they’re all sick and nobody’s sleeping. And we’re all miserable. And I’m feeling pretty burned out. But But that’s not what burnout is. Right? That’s not what we’re talking about when you’re when you specify as physician burnout syndrome. So how do you define the syndrome?
I’m really thank you for having me. And I’m very grateful that you asked that question. The definition is not insignificant. Because we have a way of, if we have a way of defining something, then we have a much better way of perhaps utilizing interventions that might be effective. We know there is a definition of burnout syndrome. And we’ve had that definition actually, for some time. It’s based on the work of a psychologist who was in a seminal psychologist in organizational psychology, Dr. Maslak, who defined through lots and lots of research, the burnout syndrome as a three prong syndrome involving emotional exhaustion, which basically means what it is, you know, you have really nothing left to give. And then secondarily, something that I think is a little bit poorly worded depersonalization was essentially means having negative feelings towards patients. And then lastly, having a sense of low personal accomplishment. So these three indices together when they reach a certain level, define physician burnout syndrome. And we actually can measure that using historically it’s been the MBI or the mass lack burnout index in most. And it’s why it’s important is because I often see that is referred burnout, burnout, burnout is referred to so many different situations that are not necessarily physician burnout, are but our stress, for example, or physical fatigue, which everyone can have and everyone will. Those are are not the same as physician burnout syndrome. And the ramifications of those are not the same as physician burnout. And our interventions for those should not be the same.
So with regard to interventions
have the following which do you think are the most useful for treating?
burnout syndrome? physician burnout syndrome, is it? Is it meditation, yoga or vitamin injections? Which of those three do you think are the most useful? I’m just kidding. That that is that’s, that’s right. Because that’s, that’s a lot of what we’re being told now is like, I’m sorry that you’re, yes, you’re going through this, you know, you should do try meditating, or journaling, or do you know, right? Like, those are the solutions that were being given.
So that’s exactly right in there and the elephant in the room if you realize the fundamental problem with Those three solutions, what’s the what what is the problem there? What do you think it’s not that there’s anything wrong with yoga or meditation, I always say those have shown to do actually meditate mindfulness and yoga do reduce stress or a three month period, you know, in studies, we see that they can sustain or sustainable at least for right now for a three month period and reducing stress. But what is the fundamental problem, when we look at physician burnout syndrome and using those is that where they are placing the burden of the problem is on the physician. So the message is, you are lacking something either you’re too tightly wound, you’re too you’re not, you’re not relaxed enough. You’re too stressed out. All of the reasons and all of the ways in which you were selected. To really perform and excel in this profession, which is how you got this far, we now want you to actually undo that. And go learn yoga, stop checking labs on patients at night, because apparently that’s stressing you out and burning you out. We want you to now go learn how to become mindful on your weekends, by the way, and sign this form saying get it on your own time.
But we’re not going to find someone to check those labs for you. You’re still going to be responsible for checking those labs. Just make sure you do your yoga before and after you check those labs. Because if something happens, you’re still responsible for it.
Okay, so what happened with that that has been the most troubling component is that we skipped a lot of steps in not addressing physician burnout. appropriately, we went from, oh, doctors have quote, burnout. Therefore, it must mean they can’t control their own workload. They don’t have lives. They don’t know how to control their stress, something is wrong with them. So let’s start sending them to mindfulness training. And yet, we don’t really know whether that works or not. And now nobody asked. We’re just giving more putting adding more to these physicians place now we’re now we’re telling doctors, not only are you have a stress case, you’ve got to now learn how to become a mindful stress case. So you’ve got to learn mindfulness. In addition to checking your inbox and getting through the 30 tasks, you’ve got to do it in a mindful way.
My favorite is when you get the incomplete because you, you haven’t taken that hour and a half course yet on mindfulness, so we can check the box that says that we are As an organization are addressing physician burnout, that was definitely something that I had to do for one of the hospitals where I had privileges It was just something else to add onto my plate as if I didn’t have enough.
Exactly problem. Any assumption, the underlying assumption is, the problem is with the physician. The problem is you’re either too wound up or conversely, by the way, you’re not resilient enough somehow. And if you weren’t, you lost your resilience. I always say this, how, how is that possible? So somebody was resilient enough to get to medical school, residency, you know, all of that and all of a sudden, they’re not resilient enough. They need resiliency. They need to go and learn resiliency all over again. How does that happen? How do you lose your resiliency? Why don’t we step back and look at what the actual contributors to physician burnout syndrome is, I found down at a table with people who are at the executive table of companies, healthcare institutions and said, you know, their intentions are very well, they really want to help physicians. But there is this place that they start is completely wrong, which is their starting at all the way out in z where they don’t start a which is, first let’s start with what is this? What is physician burnout syndrome? What isn’t it? Then from there? Let’s go to what are ways and what are the evidence based interventions if there are any By the way, and then from there, what are the why does this matter? Why would we want to address this? What are the ramifications of this? How, why are we all invested in this not just as physicians, but As a community, why does this matter to patients, to nurses to administrators, etc, lawyers, etc through that discussion, I rarely hear in that way. Most of the time, what I hear is a company will have physician coaching mindfulness training, they’ll have a retreat for doctors, they’ll have somebody come in, give a speech, about how to increase their resiliency, and improve their balance their workload.
So it seems to me that this is similar to what the the general public thinks is wrong with doctors in that, in that when a patient comes in, we’re trying to treat their symptoms. We’re not trying to treat the underlying problem which is completely untrue. Because it’s not like when someone comes in, we don’t do we do our best to try to get them to move more and increase their physical activity. And, and eat better and is we’re not just trying to get them to quit smoking, we’re not just trying to push pills on them, we’re pushing pills in them, because we’ve tried all those other things. And, and they don’t work. So we’re just we’re just doing the best we can. So we’re trying to get at the underlying problem, not just treat the symptoms, but it sounds like in this situation, they’re just trying to treat the symptoms. They’re not trying to get at the underlying problem, although arguably, it is very hard to get like to make big system changes like this is much more costly. And it’s much harder than, you know, a yoga retreat or whatever it is. But so, so, so let’s talk about that. Right. So the symptoms of physician burnout syndrome, emotional exhaustion, depersonalization and a sense of low accomplishment. Yes, what are the causes?
Good question. So the the causes have been pretty consistent, I must say consistently identified as being the same Since we’ve been measuring them in the last decade or so, the top contributors are loss of autonomy, electronic medical record system and having feeling I I just read the new the newest study that came out by medscape, which is feeling like a cog in a wheel, which I think is also related to loss of autonomy. Those are essentially the top two have been loss of autonomy, the impact of the electronic medical record system. And the shift to the shift in healthcare system from administrative large administrative burden has been the consistently identified over the last decade as the root contributors to physician burnout.
I would say that with no expertise in this area, but I would say that You could probably lump EMR into increased administrative burden because what you’re doing the problem I don’t think is the EMR itself, right? Like I can now read someone’s chart and figure out what’s going on without having to translate, you know, someone’s horrible handwriting. So and then I can use dictation software, you can use a scribe, we can have templates. So there are a lot of ways in which the EMR is actually a good thing. It makes us more efficient. But the all of the garbage that we have to enter is, is unnecessary. And but but it’s it’s been put upon us by the powers that be. So I think that you could really lump into the administrative burdens, because it’s not the EMR itself. It’s it’s the administrative burdens that are cooked into the EMR so that the data can be collected and used by someone far away and not actually help the physician and help the patient at the time.
Yeah, overall, you know, it’s true. There’s a lot of overlap in the way the one can look at this one can interpret the studies and the way the, the wording on it is described in terms of causes. There’s quite a bit of overlap. For example, the top radiology most recently recognized is excessive charting paperwork, okay? But then there’s, again increasing computerization and practice. Well, those two are very, you know, intimately related. And then there’s loss of control and autonomy 24% say, contribute that say that is the main contributor but then 22% feeling like a cog, a cog in a wheel. Well, those two are very similar, correct. So, there seems to be overall a very consistent message. That there is a disconnect in terms of physicians feeling that they have a voice in their work in the design of their work. And also feeling a disconnect in terms of when it seems work ends and begins, which appears to have appears to be related to both the inefficiency of the electronic medical record system but also the problem with electronic medical record system continuing to be on correct. So I have an app right on my phone. It gives me messages constantly. That you know, there’s an inbox in there Hey, patient message with a refill this this inbox, lobstering you know and that is really actually disruptive. You know, I’m at my
you need to get that off your Phone. Yeah, exactly. That sounds horrible. I don’t I don’t have that on my phone, I have to log in on my laptop on my system. So when I, you know that way, you know, at least the way that my practice work, we have a doctor on call if there’s an emergency, they’ll call the code, right? There’s the they’re these things away that that they’re these barriers, which, you know, there are barriers for the patient, but ultimately, they insulate us from having to have that feeling of being on all the time.
And that it’s important that that is, you know, I talked to so many doctors and they’ll say, What do I do? I’ve been told to download this app. You know, am I supposed to check it all weekend? These are gray areas, though. So these are new gray areas. These are not we don’t what I always tell doctors and I learned this later in life. Where is it in your contract? Where is that app? Your contract?
You you’ve got to you’ve got I guess a solution to that would be sort that out. Talk to whoever’s right so you’re not you’re you’re whoever that is, whoever is getting those messages is not the owner of their practice. They’re your lawyer, because if they were the owner, it wouldn’t be such a gray area. Well find out, address it, address it, don’t be afraid find out where your responsibilities starting and and do your best to get get protected time.
That’s where we also have a problem as physicians and that’s not. And when I say problem, it’s this is probably something that I spend the most time talking to physicians, both in our group and individually is this isn’t about resiliency, but this the culture that we learn. Madison is one of stoicism. So we don’t ask whether we’re supposed to see that patient on that time, we will usually do what we’re told right at training. That’s how we are praying. I mean, I’m not proposing that that’s the healthiest way of learning medicine but that’s the culture in which we learned how to become physicians was not by placing limits or boundaries.
Yeah, if you don’t wake up at midnight to check that lab, you clearly don’t care about your patients. Right? That’s what the messages,
you’re not going to make it, you’re not going to finish residency. And so we have been, it’s hard wired in positions to grin and bear it. And we are a group that has a very difficult time, setting boundaries for ourselves and saying, Hey, you know, do I have to check this app all weekend long, or, you know, I mean, does it make you feel well, maybe I’m a bad doctor, if I take this app off my phone? Geez, you know, maybe I’m supposed to I mean, I you know, that’s what I signed up for. I mean, I’m a doctor, I, we just don’t do that because we’ve never, never done that. One of the things that I am trying to work on collectively. Lee is identifying the difference between becoming stronger as a group of physicians does mean, identifying what we are capable of doing long term and maintaining that is actually gonna have impact on our patients. So we will be better doctors, if we can say, Okay, how about how long can I sustain this? How long can I really check these, you know, this app every weekend, you know, and still love what I do and do it well and have a have a life that’s fulfilling. And in order to do that, it means having a conversation with other doctors saying hey, do you find that this is this is kind of intrusive, or what are your thoughts and as it’s much easier When you approach it as, as a group of physicians, then by yourself and having physician commodity, you know, we have a much stronger voice. When there are a few of us than just one of us.
I think that is an excellent segue into talking about your, your Facebook group. Great, right? You’re the the power of the community, the power of connection. So tell us about the Facebook group. And then you know, starting with with its origins, why, why did you start it? Why is it so personal to you?
Yes, yes. And I started it in a general sense, there is an evidence base, one of the truly, probably the most consistent and the highest level of evidence based intervention for physician burnout syndrome is peer to peer. That’s true peer to peer that means physician to physician support and Ideally, it would be one hour a week during the workweek, by the way, without any administrators or supervisors in the meeting that has been, you know, shown in randomized control trials even to reduce physician burnout and prevent it. I did a study in residency on physician burnout syndrome, when I was a third year resident in psychiatry comparing burnout between two specialties and also between residents and attendings, and we were pretty surprised that our residents did not have a reduction in resident in their burnout syndrome. As they escalated through training, meaning as their call dropped, and our attendings had higher burnout syndrome, then attendings in another specialty, despite having, you know, essentially no call right? something was amiss. That was in 2011 when I did that study, and there was a wake up call when I did that study. In it was a big program it was at us LA County USC. So the N, if you will, was large enough where, you know, the results were, were significant. And we, as a result implemented, approved a peer to peer group for one of the resident classes, which was a third year resident class and I left the group as a pilot, I found from that that was the starting point. And I did that for another three years, expanded it to ob gyn residency, etc. Fast forward years have passed and physician burnout, you know, there at USC LA County. That model actually built on itself every class now and as a group apartment actually has a peer to peer group and is, you know, self sustaining. I returned it to this concept when one of my classmates from medical school took his own life, two years ago, it was quite a surprise to me. He was, you know, somebody who was, you know, I was shocked, I have to say I felt a degree of blame because I had been in contact with with him on Facebook and you know, he hadn’t come to our reunion and I had reached out and I’ve noticed some, some things, some signs on, you know, some pose, but I had really been dismissive of them even as a psychiatrist because he was a physician. I just thought, Well, yeah, I’m just I’m reading too too far into this. She’s fine, you know, and, and I’ve deeply regretted not reaching out and not doing more to find out how he was doing. I was very troubled by his loss because it wasn’t just a loss for for me in terms of a friend but it was a loss for his community, the loss for his patients because anytime a physician takes their life, we lose 3000 Patient contacts just a year. So physicians are there’s a multiplier effect. So we lose a million patient contacts a year just due to physician suicide. And Jason was a veteran. So very unique position in that sense and his connection with patients. I just felt it was a tremendous loss. And when I went back and looked at statistics of physicians who do complete suicide, I was rather shocked at how little we know about physicians who complete suicide, but what we do know is that 85% of them do not access any psychiatric care, including not being even diagnosed with depression or anxiety, and most of them are feel lonely and isolated. If that made sense that made a lot of sense to me. He had recently moved to a new state and it seemed that a community was something that had been protective. Not just for Jason, but his protected had been protected from me when I was in medical school and residency, something that I desperately missed even as I was progressing in my career in it would be ideal to set up in person groups for physicians, I felt, if at the minimum, I could set up a virtual doctors lounge, if you will, where there’s a safe space for doctors to just say how they feel, maybe maybe we can, maybe they can reach out to me Maybe I can help get them up, you know, somebody they need to talk to you or I can they can just feel like they’re not alone in how they’re feeling. Maybe that would prevent somebody like Jason from becoming increasingly isolated, and feeling getting to the point that he did. And that’s how it started. And we now have close to 3000 position members. It’s been incredibly gratifying to have a place where doctors can go to to
say how they feel if they’re having a bad day. does appear to be that physicians will open up to other physicians more readily. Which makes sense. It makes sense, right? Human beings are tribal. And, and physicians are a tribe. We get each other right. We have this, this experience in the same way that particular to, to Jason Yeah, veterans, right? They have this is unique lived experience that only veterans get that only veterans understand absolutions. You know, I’m not comparing the two experiences, we don’t go through what they go through. But we do have this unique lived experience that only other physicians get. So it makes sense that we’d open up to each other because you know what, I know the person reading this gets it. I know, they get it because they went through what I went through, they’re going through what I go through,
and they and you important. One of the things that we worked very, very hard on into crew is for four of us now who are the administrators in the group and We work very, very hard having physicians learn how to mentor each other in the group because we treat each other sometimes worse than we treat anybody else. Interestingly, because that’s how we learned to be. It’s like how you treat family sometimes. So a lot of it is really learning and modeling. We are, you know, we go back to very interesting to see, to see physicians, and I’m certainly not perfect. And I’ve done this as well, which is we can regress back to our training days when we learn in a specific way. And when we are stressed, we’re not always the most tolerant with each other, by the way we are with patients, but we’re not with each other. And part of what we work on in the group is learning to not have an answer for each other. We’re not here to judge other physicians or I’m not here to tell physicians what to do. We’re not here to give people you know, their you know, a path to this is the thing to you should do to not do that you shouldn’t done that. Most of the time, what the group we’re we’re trying to teach physicians is building camaraderie, true camaraderie, which means listening and accepting the physicians because we need each other. In the end, not a lot of physicians anywhere actually, wherever you go, we’re always just a few of us. And that in itself is a significant goal is relearning how we relate to each other as well because we are very, we are more comfortable being not so great with each other at times. And that is something we also work through in the group. And we can’t afford to turn our backs on each other. There’s not enough physicians. So we work on that in the group as well. You know, We give people a lot of chances in the group, you know, a lot of feedback on how to combat you know, let’s let’s approach this this way let’s work together because we want we have young physicians, we have older physicians, we have male physicians, we have female physicians, we want a group that is truly diverse, and reflects the reality of the physician workforce. Right. And that takes a lot of work to sustain all of these people having conversations, right. But that’s important. That’s the other facet of it is being able to hear each other among the noise.
So you took this this issue, right, that led to the loss of your friend and colleague, the isolation and you turned it on its head, right you gave you you created this forum for connection. So that was your response to that. I think that’s incredible. And I think the fact that we have so many positions that being said, there are a million physicians in the country, right? And only 3000 of them are on this Facebook group and I’m sure, tons more are would be would be helped by this. Right? more connections because it’s just exponential right? The more physicians you have, the more positions you can connect with each other. And the more we can we can help each other and create recreate this community. Right. And I think it’s just like you said, it’s from our training in our training, right? You have to go it alone, you got to do it alone, you got to achieve and you got to beat your competitors. You got to beat. Yeah, your classmates, your ranking class needs to be better than theirs if you’re going to get the competitive spot. And now, we have to look past that and work together. And yeah, there’s a lot that we’re up against. Right?
We will not make it if we’re not going to be a solid group. So we won’t survive because we are out number in every This is the first year 2019 where there were more physicians employed and owners of practices. So And that means that in any administration, there’s never going to have a majority of physicians, right? And we’re only
headed more in that direction, right? The more complicated this gets, the more infrastructure you need for billing, the more infrastructure you need for your electronic medical records and charting, the less you’re going to be able to have a physician run practice, the more you’re going to need the infrastructure of a much larger organization. So it’s, it’s only going to get worse, it’s not going to get better.
That’s exactly right. And if we have to learn and this is something we talked about, also when the group is I think, we have some divided and subdivided and more can our little tiny into our sub sub specialties. It’s like, read diet, you know what, like, you know, not just psychiatry, but it’s like,
oh, yeah, I can. Yeah, and in, in my field, right, like, I’m not specialized enough as an ear, nose and throat doctor, we have right ologists and otologist syndrome. otologist facial plastics Yeah, yeah, yeah. Or ophthalmology. Wow, like,
retina. There. Is
there a different we had an episode of that a little while ago, where apparently they’re eight, eight subspecialties in ophthalmology. It’s it was and I’ve always an ounce and you have eight different fellowships
and everybody and here’s the thing is I can tell you right now because I’ve sat you know I had the the true privilege of having a seat at the Big Boy table and that hurts us extremely. When we are so subdivided and can’t see beyond our sets of subspecialty. We’ve got to be a fit, we’re physicians or we’re going to fit that’s how we get pay disparity. That’s how we get essentially moved into this position of not having very strong bargaining power. We are not very powerful in our you know, as a one forensic science coyotes just like in the hospital, you know, it’s just like, so what if I think, you know, I click 86 times to close, who cares? I mean, there’s like one person, right. Whereas, as a group, we actually have a voice. We, you know, we each physician creates 17 jobs 17 to spite existing. Okay, that’s quite, we also don’t know our worth. That’s the other thing we’re incredibly we’ve managed to not understand our our impact on the larger economic ball. That’s why
we direct so much of the money in healthcare, right, the healthcare is just, it’s a huge percent of the GDP and who’s deciding how that money is spent? physicians. So our impact on the system is true is tremendous, is tremendous.
And if we actually were able to see or solve as we did in medical school, as physicians, or as med students as one unit, you know, and even in residency, I can We will probably be more cohesive than we become as we kind of progress, you know, we start to fall more and more into our specialties and it does not benefit us. And we know that if we look at the bills that we’re seeing go through in terms of Medicare reimbursement, we know it’s not helping us to be seeing ourselves as such specialists and specialists know that we’re losing. We’re you know, we are not because there is no, I should say there’s the American Academy of nurse practitioners. There’s the American Academy, there’s the American Psychological Association. There’s not the AMA is then there’s a me but then there’s also then all these other subspecialties, right, there’s like the APA. There’s the AFP and we’re, you know, we’re all over the place and we have not really stood behind one strong lobby and it shows I’ll tell you that your number of residency positions that are increasing at 3% per year, as opposed to our medical student admission rate has gone up 10% which it should they adjusted their rate, but Senate has only approved a 3% increase in terms of residency position. So we have 7%, whereas this gap, so we have found more than 1000 physicians in the US we create each year. We’re standing there, unmatched. Okay. But just to end then we’re talking about a physician shortage and increasing provider status for everybody we can, and we have more than 1000 physicians standing there every year. And that partially is because we’re not quite united yet in the network. But we were still thinking about what what little subculture psychiatry to our block, right.
Well, for all its flaws. Yeah, this is one place where Facebook I think, has been a great benefit because I’m a member of the physicians on social media. Ah, that Donna Cornell’s Started, right that’s, that’s just growing exponentially. So now I have this community of doctors on social media. I’m a member of passive income physicians and the white coat investor Facebook group, because here’s another, if you can gain financial independence, then if you’re suffering from burnout, you’re financially independent. So you can go tell your employer to screw off. And you can find a job that works for you and work and work on your own terms. So they’re all you know that with regards to social media, we’re able to amplify each other’s voices. And then with your group, we’re able to find a community to help us, right, it’s physician to physician healing the practice of medicine, so we’re able to help us heal each other, heal each other through difficult times. So for all Facebook’s flaws in this one regard, it’s really helped us to coalesce in these communities, which might be disparate, but right, like I would have never interacted with you for my entire life, had these things not existed and now you know, we’re able to amplify each other’s voices and can with each
other, I completely agree Facebook has changed the way physicians organize. We have grassroots organizing we’re doing we are campaigning for, you know, patient sprites on Facebook. I mean, we finally have a voice. I think we found each other. I mean, where it sounds really cheesy maybe but you know, where we finally, I think are we are utilizing it in a way that is beneficial both in creating a community that’s helpful for us, and ultimately is going to have a larger impact on improving healthcare, because if doctors are healthy and staying alive and happy, then we know that trickles down, we know that we know that from study.
Oh, well, that’s Yeah, that’s a whole other issue is that physician burnout syndrome affects patients patient outcomes. And it makes sense, right, because one of the symptoms is depersonalization. So if you depersonalized your patients, right, that that will ultimately affect their outcomes. Well unfortune We can’t open that door right now because I know you have a patient to see and I’ve got to go pick up my kids from school. So we’ve, but it’s really been great talking to you. Where can people find you online?
Yes, I can be well on twitter at Torres SEPA and di t o r i s EP h empty. And our Facebook group, I think the best way is to just look at the link it’s for we go through a it’s not a no, it’s a closed group. So we go through a vetting process for physicians and physicians and training. It’s called physician to physician killing the practice of medicine. And my website is based. It’s linked to my practice in large part but it does have a link to the my writings on Kevin MD. So it’s www dot. Tory’s efa. md calm.
Well, Dr. Theresa, thank you so much for taking the time. It’s been great talking to you.
Likewise. Thank you again.
That was Dr. Bradley Block at the physicians guide to doctoring. He can be found at physicians guide to doctoring calm, or wherever you get your podcasts. If you have a question for previous guest or have an idea for a future episode, send a comment on the web page. Also, please be sure to leave a five star review on your preferred podcast platform. We’ll see you next time on the physicians guide to doctoring.
Transcribed by https://otter.ai

Discussing Flipping the Script on Health Disparities with Max Jordan Nguemeni Tiako

Max Jordan Nguemeni Tiako is a 4th year med student (out of 5) at the Yale School of Medicine and hosts his own podcast, Flip the Script, about healthcare disparities. He starts out discussing how some of what we learn about race being a risk factor for some diseases are a product of social constructs, not genetic predisposition. We then discuss racial disparities in substance-use disorder treatment. We then pivot from health disparities to physician training disparities. We learn about the hardships faced by minority medical students from microaggressions from students and faculty to disparities in grading and how this can affect career trajectory. He ends by discussing some pearls he has learned from his own podcast.

Mr. Tiako grew up in Yaounde, Cameroon, and moved to the US to attend Howard University, got a BS in in civil and environmental engineering and then a Masters in Bioengineering from the Georgia Institute of Technology. He is currently doing research connecting his civil/environmental engineering background to identify elements of urban design that can be leveraged to improve health outcomes and move the needle towards health equity. His research fellowship is at the Center for Emergency Care & Policy research at the University of Pennsylvania. He spends his free time writing about racism and medical education in the medical student magazine InTraining.

His Twitter handle: @MaxJordan_N

His podcast can be found here:

iTunes: https://podcasts.apple.com/us/podcast/flip-the-script/id1402777078

Soundcloud: https://soundcloud.com/yaleuniversity/sets/flip-the-script

Spotify: https://open.spotify.com/show/1judlJj8gLg8OnVJtpXv7O?si=snZWGMbaRiafUfJZajHRyw

This episode is brought to you by Orange County Bookkeepers (OCB) Healthcare Accounting: an all in one accounting firm for small healthcare businesses and private medical practices. One thing that I personally love about OCB Accountants, is that they are QuickBook professionals with over 20 years’ experience, focusing specifically on healthcare. They utilize a tailored approach individualized to your needs. They are a full-service bookkeeping firm specializing in accounting, payroll, taxes and financial planning. For our listeners, for a limited time, they are offering 25% off their services for the first 3 months. You can visit them at OCBmed.com or call 833-671-3873 or 949-215-6200.

Discussing Flipping the Script on Health Disparities with Max Jordan Nguemeni Tiako

Max Jordan Nguemeni Tiako is a 4th year med student (out of 5) at the Yale School of Medicine and hosts his own podcast, Flip the Script, about healthcare disparities. He starts out discussing how some of what we learn about race being a risk factor for some diseases are a product of social constructs, not genetic predisposition. We then discuss racial disparities in substance-use disorder treatment. We then pivot from health disparities to physician training disparities. We learn about the hardships faced by minority medical students from microaggressions from students and faculty to disparities in grading and how this can affect career trajectory. He ends by discussing some pearls he has learned from his own podcast.

Mr. Tiako grew up in Yaounde, Cameroon, and moved to the US to attend Howard University, got a BS in in civil and environmental engineering and then a Masters in Bioengineering from the Georgia Institute of Technology. He is currently doing research connecting his civil/environmental engineering background to identify elements of urban design that can be leveraged to improve health outcomes and move the needle towards health equity. His research fellowship is at the Center for Emergency Care & Policy research at the University of Pennsylvania. He spends his free time writing about racism and medical education in the medical student magazine InTraining.

His Twitter handle: @MaxJordan_N

His podcast can be found here:

iTunes: https://podcasts.apple.com/us/podcast/flip-the-script/id1402777078

Soundcloud: https://soundcloud.com/yaleuniversity/sets/flip-the-script

Spotify: https://open.spotify.com/show/1judlJj8gLg8OnVJtpXv7O?si=snZWGMbaRiafUfJZajHRyw

This episode is brought to you by Orange County Bookkeepers (OCB) Healthcare Accounting: an all in one accounting firm for small healthcare businesses and private medical practices. One thing that I personally love about OCB Accountants, is that they are QuickBook professionals with over 20 years’ experience, focusing specifically on healthcare. They utilize a tailored approach individualized to your needs. They are a full-service bookkeeping firm specializing in accounting, payroll, taxes and financial planning. For our listeners, for a limited time, they are offering 25% off their services for the first 3 months. You can visit them at OCBmed.com or call 833-671-3873 or 949-215-6200.

EPISODE TRANSCRIPT

Disclaimer: This is the transcript to the episode. This transcript was created by a talk to text application and the function of having this here is to improve the page search engine optimization. This transcript has not been proofread, so please listen to the episode and don’t read this. The information contained herein will inevitably contain inaccuracies that affect that quality of the information conveyed and the creator of this content will not be held liable for consequences of the use of the information herein.

Max Jordan, England, Jaco is a fourth year medical student out of five at the Yale School of Medicine and hosts his own podcast flip the script about healthcare disparities. He starts out discussing how some of what we learned about race, being a risk factor for some diseases are actually a product of social construct, not genetic predisposition. We then discuss racial disparities in substance use disorder treatment, and then pivot from health disparities to physician training disparities. We learn about the hardships faced by minority medical students from microaggressions from students and faculty to disparities in grading, and how this can affect career trajectory. Hands up by discussing some of the pearls he’s learned from his own podcast. Mr. Chaco grew up in yone de Cameroon and moved to the US to attend Howard University, got a BS in Civil and Environmental Engineering, and then a master’s in bioengineering from the Georgia Institute of Technology. He’s currently doing research conducting his civil environmental engineering background. To identify elements of urban design that can be leveraged to improve health outcomes and move the needle towards health equity. His research fellowship is at the center for emergency care and Policy Research at the University of Pennsylvania. He spends his free time doesn’t sound like there’s much writing about racism and medical education in the medical student magazine in training.
Welcome to the physicians guide to doctoring A Practical Guide for practicing physicians. Dr. Bradley Block interviews experts in and out of medicine to find out everything we should have been learning while we were memorizing kreb cycle. The ideas expressed on this podcast are those of the interviewer and interviewee and do not represent those of their respective employers.
And now, here’s Dr. Bradley Block.
This episode is brought to you by Orange County bookkeepers, healthcare, accounting and all in one Counting firm for small healthcare businesses and private medical practices. One thing that I personally love about OCB accountants is that they are quickbook professionals with over 20 years experience focusing specifically on healthcare. They utilize a tailored approach individualized to your needs. There are a full service bookkeeping firm specializing in accounting, payroll taxes, and financial planning. And for our listeners for limited time, they’re offering 25% off their services for the first three months. You can visit them at OCB med calm that’s OCB m Ed, or call at 833-671-3873 or 949215 6200 and check out the show notes for more information. Max Jordan go mini Tiago. Thanks so much for being on the show today.
Brad, thank you so much for having me.
So, why was it necessary to make your podcast Why do you feel compelled? You’re a busy medical student you have enough on your plate enough studying to do all the rest of the responsibilities that comes with a medical student. Yes, that you decided you were compelled to create this podcast. Why was it necessary? Why is it so important to tell this story for me I you
know, I listen to a lot of podcasts. And while in medical school, that was one of the ways I just sort of entertained myself and one of the sort of struggles in med school so far has been that the quality of our education when it comes specifically to health inequities isn’t particularly great just about anywhere across the country. And so, you know, a lot of times as a black medical students, and I am sure other minority medical students may identify with this. Now we find ourselves either engaging in conversations with our colleagues related to health disparities, especially for those instances where perhaps some of our colleagues have lesser exposure or lesser awareness. Two issues related to racism and equality in this country. And some of those compositions can be toxic depending on the type of setting. For example, in med school, where I go to school at Yale, we have a ethics and professional responsibility course. And some of those sessions health inequities come up or in our public health and Epidemiology course or even in our main lecture, you know, sometimes, you know, one of the lecturer may be giving a lecture or a sale on glaucoma and then nearing the end after we’ve talked about the pathophysiology, and the pharmacology, all the sort of like basic science and clinical aspects of a disease, a little bit of epidemiology gets presented and race as a sort of, how do you call that race as a risk factor is often presented alongside other risk factors that are not social constructs, like say, for example, for glaucoma history of diabetes. And so the sort of conflation of race as a biological factor when truly as more of a social construct and That race by itself is isolated by itself. Race isn’t so much a risk factor, but rather exposure to racism really made me want to share more of this with the world in a way that didn’t feel as taxing as, as was the case early on in med school, sort of like repeatedly engaging in this very much the same conversation over and over.
So you’re saying it’s not like say Tay Sachs, right? So right, Ashkenazi Jews, they have this mutation, where if two people with this mutation get married, they have, you know, a quarter chance of having a child that has Tay Sachs, right? So this is being a Jew right myself. We still don’t we don’t know. Like, is it a race is a religion. Is it a culture Is it fine, whatever. But that being said, right, that is genetic. So what you’re saying is when the professor is saying that, being African American puts you at higher risk for glaucoma, you what you’re saying is it’s not something inheritable. To the genetics of that individual, it is things that occur in society that put them at higher risk of glaucoma.
Well, so specific to black holes. Now what I would say is the evidence isn’t clear. And so the way it’s often presented, it’s as if it is clear, right? So for example, you’re right, like so illness like Tay Sachs disease? Well, yes, we know about the genetics. And truly those sort of genetic or things that have been shown to be linked to a specific alio are more so related to like ancestry, right? So for example, sickle cell disease is more prevalent among people from Sub Saharan ancestry. Like I grew up in Cameroon. I know so many people who had sickle cell disease and part you know, because of the sickle, the sickle cell trait, and a theory that says the sickle cell trait is supposed to be protective against malaria. So that by itself right, should not be conflated with the fact with like, with black race, in the context of being in America, and even Then Right, so the sickle cell trait is as common in some parts of the Mediterranean, you know, in some countries or regions of country of countries that are adjacent to the Mediterranean Sea. But then you have social factors like access to premarital counseling that are way more, you know, prevalent and say, most parts of like Spain and Greece that aren’t the case and say, in Cameroon, and, of course, then if you don’t have access to premarital counseling, the likelihood of two people with the sickle cell trait, you know, having children together is way higher. So it’s not as straightforward as sometimes we make it seem in the way we we teach race and genetics. And then the other thing is just about your average African American has like something like 25% Caucasian ancestry, right. And the way race is defined in the US is a self identified thing, right? Like so you have African Americans like who self identify as black like Barack Obama, who is however biracial, right, just the way we race was constructed in this country as more around how you’re perceived, and how you self identify and the history of like the one drop rule. And that by itself cannot be used to teach medical genetics, if that makes any sense.
Yeah. Because the way you perceive someone, if you’re then using it to weigh their risks of having a certain problem, might not be genuinely something that should be weighed in there.
Right? It’s not scientific. Yeah.
Yeah. Interesting. Interesting. Okay. So I can see where that would get taxing because you’re hearing it from an authority over and over. And each time you want to raise your hand and be like, yeah, and a shake them like that. It’s just it’s not that straight. Let’s not Stop saying that. I keep hearing that over and over until your best platform for communicating that information was great in your podcast. Yep. Exactly. Because there are people that want to hear and there are people that don’t write there are people that that just want to continue living the way that they’ve been living. And thinking the way that they’ve been thinking not have something changed their mind, because this is what they know. And this is what’s been working for them. And yeah, I’m sure you encounter that all the time in your where you’ll you’ll start talking about something and then you encounter resistance.
Yes, that’s also the case. But I will say right in the context of medical education, it’s important that we get taught what’s true. And this is a debate that comes up a lot, sort of like how do you change the minds of the quote, quote, unquote, Old Guard way of how medicine was taught versus how it should be taught today, as we have so much more advances, you know, when it comes to social science and medicine? So certainly, the podcast itself allows me to disseminate you know, the work of other sorts of social scientists and epidemiologists and physicians and all these people who do fantastic work related to health disparities. It also makes it such that if I ever get in a discussion about any given topic, but someone who you know may be skeptical because I know Maybe sometimes as a black medical student, there’s a perception that my position may be bias because I’m black. And thus I, you know, have a conflict, conflict of interest. So we’re like, well, there’s an anthropologist who did this very work. And I’ll send you the link because she was a guest on my podcast. And that kind of ends. If that makes any sense.
Yeah. You have a bibliography. Right. Yeah. That’s great. And, you know, something that I found an advantage of my podcast is if I have a question, I could just find an expert on it and invite them onto the show. And there you guys, I get my
answer. Right. Yeah, exactly. And I’ve gotten to learn a lot by doing this myself. So
so that’s that was gonna be one of the things that we can discuss. Excellent segue. So what are those? What are the some of the issues that that you’ve discussed that you maybe weren’t aware of before that have been particularly enlightening? So some of the things that you learned from your podcast my
first guest was Professor Colin Roberts at Yale College and history and Africana Studies, she studied the role that physicians played in the British transatlantic slave trade and as well as the sort of birth of the pharmaceutical industry way back during the slave trade, like, for example, one of the things that I learned is the pharmaceutical industry that we know today and the center of that context of mass production of medication came out of actually it was sort of born out of the out of the transatlantic slave trade where they were up. How do you call the apple tech carries? I don’t know how to pronounce that. Well. apothecaries. Yeah, there you go. Yeah. So for example, GlaxoSmithKline traces its roots all the way back to slavery, or, for example, the medical examination that physicians had to perform on those that were captured and, you know, at the cost of the African continent, and then brought on to the boats and how, you know, physician had to sort of force them to remain alive. You know, there was a lot of force feeding that happened on these boats or ships, I guess I should say, lots of force feeding, making sure that people remained as healthy as possible. And there interestingly, you know, what Professor Roberts describes because a lot of her work was archived All she knows she went to the UK and dug up letters that some of these physicians wrote back to their wives in the UK about what they were doing. And some of them were conflicted about what they were up to. But there was such a good financial incentive, while poverty may have been breaking back in the UK that they felt like well, you know, this is what I got to do. And it speaks to the eyes to me as a medical student now, right like thinking about the Hippocrates boats off, right, like, Who are we what is our allegiance to, to our pockets or to the board to people and people that were meant to serve, and society. So that’s one of the things that I’ve really liked. It really sat with me after I did that recording, another set, sort of like learning experiences for me amongst all my episodes was about this concept of a two tiered system of addiction treatment that we have in the US and the guests. The first guest I had on this was a professor Helena Hanson. She’s a psychiatrist and anthropologist and a You and this is the first time I had to like travel somewhere to interview. I guess it was really exciting. So basically, you know, the US has a history of splitting how we treat opioid addiction, right methadone versus buprenorphine, where buprenorphine is basically it, you know, the partial agonist to the new receptor versus methadone, which is a full agonist. And as it turns out, even an orphan is more accessible in areas that are richer, have more white people, less black people, as Hispanic people and people that are more more likely to be privately insured. And methadone is more, you know, accessible to black and Hispanic people and just the nature of how people access methadone versus buprenorphine. It’s really there’s a stark difference there this concept of the carceral state, but you know, but not within carceral institutions shows up in the provision of methadone, right. You have to show up to a clinic every single day and somebody has to watch you take your medication then you have to pee in a cup for a day. You and drug test. I mean, some people do eventually sort of quote unquote, in the trust of their provider and get to be able to, I don’t know, get a month a week’s worth of supply of methadone as opposed to showing up to the clinic every day. But overall, it’s a very invasive and intrusive process. And it’s almost like wonderful co wrote about the carceral state. And it’s sort of like, just uses throughout society, he thought about how methadone will be provided. Whereas with paper norson, you know, you can go to your doctor like you, you go get, I don’t know, your prescription for I don’t know, an SSRI, and then you go to the pharmacy, and then you pick it up. But, you know, it provides some level of privacy and normalcy that being a methadone patient just doesn’t and it’s a highly racialized, and that’s one of the favorite episodes in terms of just how much I learned from talking to Professor Hanson.
The interesting, you would think if there’s a method of treating something that is in an economically disadvantaged area, you’re doing it in a way that costs more Right, like because although it’s very labor intensive to have people come in, and it just it like from an economic standpoint, if it just doesn’t, it just doesn’t make sense.
You know, I have actually never thought about that until now. I mean, you know, methadone was introduced in like the 70s. And Duke wasn’t FDA approved for serious disorder until like, 2002. And before then people were sort of using it, I’m prescribing it off label. So I think part of it maybe the sort of latency with court, you know, people getting with the times, but even then, most recently, New York State just disagreed. I think maybe the governor vetoed it. I can remember the detail behind it, but basically, the state legislature, and the governor’s mansion in the state of New York got in the way of making sure that the orphan will be equally as accessible as methadone, basically cementing the the existing system that is in New York state right now, especially in New York City. Yeah, I haven’t thought much and I should take that up, like So how much does it cost you a pair operationalize. methadone clinic versus buprenorphine provision. But I also understand to an extent, right, why you have if you if you need methadone, I suppose if you need methadone, and you need to show up to a clinic every day, methadone is a full agonist, and there is a risk of overdose. And so the sorts of provision, some of it may be too much. But some of it may be like rationalize bubble, but as long as methadone and buprenorphine as are equally available, I think that this sort of notion of opportunity of choice for patients doesn’t necessarily exist for black and Hispanic patients, especially if they’re low income.
And just to be clear, so to the listeners, you’re a medical student, I’m an otolaryngologist, neither of us have expertise in the differences between these two medications. So you know, I think we will we I think we should change focus a little bit. Yeah.
Maybe I got too in the weeds.
On addiction, by the way. Oh, so you do
that okay.
Yeah, I got to have become an addiction researcher basically, after having learned so much from Dr. Hansen. Yeah. So I should have probably said that
that is something that allowed you to kind of springboard into that area. Yeah. So something that you are and also are an expert right now is being a student. And so one of your episodes was a big hit your way to success. And I just thought that that term was, was interesting, right? And really telling of, you know, standardized tests. So right, what does that mean? And what is what are some of the things that you guys talked about on that episode?
So big idea way to success? It’s kind of a joke, like an online running joke back that’s been going on for a while now. And so if you google bigger your way to success, there’s like a list of a bunch of racial stereotypes that are known to show up on the US Emily’s standardized tests both step one and step two. So, for example, you know, if you get like a question about a young, I don’t know, 35 year old black woman who’s coming in with a dry cough You don’t even need to read the whole paragraph you kind of know that oh, this is gonna be about sarcoidosis. Right? Yeah. So, there are several of those. You talked about Tay Sachs disease earlier, when you know like you just kind of them when they tell you Oh, this person is like French Canadian or like those stereotypes are very much ingrained in both in how medicals our medical curricula are designed, but also ultimately how the standardized test I don’t know whether it’s kind of like to give us freebies. But at the end of the day, it I feel sometimes it can contribute to reinforcing stereotypes such that you know, some diseases may end up being under diagnosed and subpopulations because we don’t always even have the presence of expanding our differential diagnosis just based on this kind of statistical discrimination. Oh, yeah. You
don’t know what you don’t know about this person and exactly what example my wife’s father is black and her mother is an Ashkenazi Jew. So to look at her, you know, most people look at her and think she’s black. Some people look at her and think she’s Dominican. But most people look at her and they think black. And so, you know, she could be a carrier for Tay Sachs. Right? We were tested, we have three kids. And so we she wasn’t. But like, if you were looking at that multiple choice test and looked at her, right, you would not test this person or take socks, that’s not going to be the way you’re going to answer that question. So right, you know, so you don’t know you don’t know what you don’t know about this person’s history.
And, and my advisor, my academic advisor, tells a story of a patient who had cystic fibrosis black kid, and this isn’t a day where sometimes like x rays would be printed out. And four weeks, no one would figure out what’s going on with this kid. And someone else looked at the X ray without knowing the history without knowing this patient’s history and was just like, Whoa, who’s the kid would see just by looking at the X ray, and it hadn’t crossed the medical you know, the medical teams mind at the time because it’s like, oh, you have a black kid with a lung issue is no one is thinking about cystic fibrosis because we it’s so ingrained in us Think CF is for white people a sickle cell is for black people, sarcoidosis is for black. That’s kind of those are the stereotypes of medical licensure exams. And my guests on that episode is Dr. Jenny sighs. She’s an emergency medicine resident at Yale. And I met her while she was still doing this work as a med student as well. So she’s done some studies that kind of fine comb through the curriculum of the medical school over Bronwyn where she trained and wrote some papers about the need for introduction of critical race theory and a lot of medical school curricula, right thinking about how race is constructed, racism is constructed and how it affects disease and inequality and those types of things. And I think, you know, with that kind of approach, where we embrace the social sciences and what they have to offer medical education that we ultimately gain right from being just better trained physicians, but that’s basically what that episode was about. So before we move on, are
there are there any other particular lessons that you’ve learned from your episodes that you think bear mentioning there’s so many
more one more nugget. Well, so episode specific, I think my episode so I did two episodes about reproduction, especially black, you know, related to black women. And I interviewed a professor of bridges, garbage issues and anthropologist and Professor Robert doty. Robert so she wrote killing the black body. And he our bridges wrote are reproducing race and they both talked about ways in which the medical preparedness along with the instruments of the state and state by state i mean capital and state had this element of control over reproduction, especially off black women. So kRb just work at the time I interviewed her is centered around the experience of low income black woman on Medicaid in New York City who basically felt a lot that their experience seeking prenatal care was a lot more invasive, compared to the experience of women who are not on Medicaid just because a lot of the testing and a lot of the questioning and a lot of the things that are required a pregnant woman drink Natal care of mandated whereas it’s not the case for women who are on more, you know, private insurance and Professor Roberts work, you know, killing a black body and our compensation in general was about the criminalization of black women during pregnancy. And, you know, we talked about how, you know, during the crack cocaine epidemic, you know, black men were punished really harshly for using during pregnancy. And today, in the context of the opioid epidemic, some of the laws that were put in place during the, you know, around drug use during pregnancy, are basically now sort of like reverberating and affecting pregnant women who are using opioids. In fact, Dr. Bridges just wrote a paper in the Harvard Law Review about opioid use disorder of pregnancy, and how using drugs in this new context actually can erode one’s white privilege. So just fantastic work. I’m so lucky to have just been able to sit and ask them questions. Yeah,
it’s a great medium. It’s a great medium, it really allows us to put ourselves in some In front of some incredible people and their self included, yourself included
learner, or sort of Elon,
well, we’re all learners. We’re all there. So, okay, so one thing we’re going to talk about was your experience as a learner, right? So we’re going to talk about interpersonal racism as a medical student, and institutional racism as a medical student. So what can you tell us was let’s start with interpersonal racism? How does that affect medical students specifically?
So I think their interpersonal racism and med school as kind of twofold, both like experiencing it, and also witnessing it and by experiencing it, I mean, like, sort of, in one on one encounters with classmates, residents, colleagues, even lecturers and then witnessing, it’s so being wielded against classmates or even wielded against patients directly or indirectly. And so for me in med school, I’ve had Yeah, and they haven’t necessarily been like The most egregious forms of quote unquote interpersonal racism in terms of like what’s happened to me, but at the time some you know, it can feel like, Oh my god, I can’t believe this is happening. So a good example, my first year, Terence Crutcher among many black men were killed by the police. And you know, some classmates went to a protest. I didn’t go Actually, I had to get the VA and then come back to campus and the DS not not super close. So after they went to this black lives matter, rally, you know, in their white coat, as physicians often do when they go to political demonstrations, one of our classmates called, like, how do you call it like a panel discussion around should physicians wear their white coats to protest and it felt like a very clear direct attack on those of us who did go to the rally, but in general, those of us who support Black Lives Matter, it wasn’t like a direct like, you guys. Black lives don’t matter, but it felt that way. Right. It felt that clearly my class felt that even if I think like last matter, I need to know I need to leave stuff out before I come into Medical School or into the classroom or whatever and it’s in, you know, some of us don’t have that luxury, the activism that we engage in, or the advocacy that we engage in isn’t only about our patients, it’s like also about ourselves, right? Because like, when I walk out of the hospital, I think that white coat off and I’m just another black dude that the police can pull over. And, and that was probably one of the bigger things that I felt hurt about in that school as a first year. But, you know, the worst things that I’ve seen are more so around, you know, witnessing issues related to patient care, you know, seeing patients being labeled as quote unquote, medication seeking even though how can you tell we can’t read people’s minds, you know, and it often happens around like mission was in a sickle cell crisis. Sorry, before
you move on. For that point. I just thought, you know, as, as medical providers, right, I know. That term. We’re doctors, right, but we’re under the umbrella of providers, doctors, nurses, and other other health professionals, right. Our goal is to help people people live longer, better lives, right? And so something that plays an incredibly important role in living a long healthy life is social determinants of health. Right? that determines health outcomes, much more so than the Lipitor that we’re prescribing the hydrochloride size for your blood pressure, right? So by wearing your white coat to a rally to help improve social determinants of health, it seems to me a completely appropriate thing to do. Right. What was the counter argument to that? What is it that you heard that said that someone said, why you shouldn’t be doing that? Is it because it’s political, and you should leave politics out
of medicine? Right. So that’s one of the arguments that were made. And I think, you know, race or racism kind of ruffles, you know, still still today ruffles people’s feathers in ways that Other political issues don’t nearly as much right? I have never. So as a med student, I was also part of this coalition. And that was for saving the Affordable Care Act. I did phone banking for funding for chip, you know, children’s and insurance. No one’s ever said, Oh, leave your white coat before you go outside and do as a demonstration for the Affordable Care Act. But the way insurance is decided in this country is the heavily political issue. But I think there’s just a discomfort, right with a lot of non black people when it comes to embracing the notion of racial justice that led to some people feel like Oh, we got to have a conversation about this. I don’t feel comfortable with people wearing yellow gear, or their white coats at this demonstration. And rightfully, some of us were like, Are you kidding me?
Yeah. Interesting. Interesting.
I mean, someone even suggested, well, what would you say if someone is wearing their white coat to a neo nazi rally kind of making the false equivalence between neo nazis and the Black Lives Matter movement, which is
Yeah, I don’t even know what to say about that specific comparison. But yeah,
so I think the counter argument would be, if this person did that, there would have to there would potentially be consequences, but they can find feel free to do that. However, if you are seeing doing it, then, you know, and you’re in a program, and your program director sees like, there, there are ramifications to to doing that. And I would hope at least that there wouldn’t be ramifications to doing that in something like blacklivesmatter. Right.
And I think a ton about you know, the first do no harm, which is part of our posts, right. And this debate of physicians engaging with social responsibility and politics is as old as like the 1800s right when Barca was super engaged in Germany and and like, you know, pushing the government to create a program for compulsory needs expectations, right. That’s how we found out about chicken Some may argue, oh, well, your job as a doctor is in a clinic room and not outside. But truly, it’s everywhere. It’s no, no, but here’s,
here’s, here’s what it is. If they agree with you, then it’s your job to be involved in advocacy. And if they disagree with you, then usually the white coat at home, right? It’s just that that’s just what it is whether they agree with your whatever your you know, it’s the same way when like someone in Hollywood, right says like, you know, Trump is terrible, or Trump is amazing. And then, you know, if you just if you agree, you’re like, yeah, I totally agree with this person. And if you disagree, you’re like, is singing or whatever. So I think I think the same thing applies here. Right? If they agree with you, and they think great. If you wear your white coat, then it should it gives you some more like authority and respectability of the institution that you can carry with you to this rally. And if you disagree, then you’re you know, abusing your privilege as a medical student. And yeah,
it’s
my personal take. Okay. So we’re also going to discuss studies that you’re familiar with that focus on racial climate for medical students and residents and fat and faculty. And you we’re going to we’re going to discuss that as well as disparities in grading and career advancement. So, so what can you tell us about just in general the the racial climate for, for trainees,
right. So I think in general, you know, medical students, especially those who are underrepresented in medicine, describe what seems to be a tense, often tense racial climate and medical school and that, you know, not necessarily feeling supported as minorities, you know, feeling higher burden when it comes to contributing to educating our peers on matters of health equity or health inequities, and facing kind of a barrage of microaggressions from tears faculty, residents and whatnot and
some study what what’s a microaggression? Because some of our listeners might be familiar With that term Good point, I don’t
personally like using the term microaggression. But it’s it’s, it’s
just use it for now you got it I know.
So microaggressions are, you know, considered to be slights that are typically not intentional based on a marker of difference that you may carry, but that land within negative impact and can leave like a lasting effect on the recipient of the microaggression. So for example, something that’s as commonly told to black people is like, Oh my god, you sound What is it? You sound so articulate, right, which oftentimes is rooted in the assumption that you you’re not supposed to be articulate or that you don’t, you know, that you’re not supposed to sound educated as a black person, even though you may be still like in higher education and a lot of about microaggression is basically based on prior experiences as the recipient and also just having faced them over and over and kind of what the expectation and interpretation is. And and I guess they’re called micro only if the person who is the perpetrator didn’t intended to offend it, but there’s so much right. So
so they intended to offend that it’s a macro aggression. Oh, yeah, it’s
a total aggression.
Micro is based on the intent, not how it was received, like if I bother you a little makes it a microaggression versus my value on. It’s the intention of the person making the statement.
Right. I think that’s that’s my understanding of the way that psychologists who, who coined the term described it as Yes, yeah. Oddly enough, though, you know, that there isn’t. I mean, maybe there is and I’m just not as familiar but like in the, in the, in the literature regarding medical students experiences, there’s a there’s quite some about, you know, microaggressions but I guess that’s in part because those are way more common and be sophisticated, highly educated settings, right. People don’t just call you the N word. You know, by the time they’ve reached medical school, they know better or you know, they mean like this Things that are more macro and that they happen like middle school or, you know, like, happen a little less commonly and in, in higher education and perhaps that’s why there’s more of a focus on micro aggressions. That being said, though, there are some macro aggressions that’s still happening.
And then how does that lead to? How does it affect outcomes like grading or career trajectory?
So I think microaggressions by themselves, you know, the climate in general and medical school has an effect on medical students like mental health, you know, and, you know, feeling burnt out and sort of like increasing rates or feeling socially isolated and not supported. And so you can think how that may have an impact on one’s ability to or just like one’s even will to to do as well as they may have meant to initially from that sort of like intrinsic element of the experience as a medical student, but there’s also when I think about grading, what’s been What’s out there literature wise is that they are disparities and grading. And they’re more so rooted in the perception of those who do great medical students, because a lot of these studies basically kind of control for all the other things that are more intrinsic to the students like sort of like performance, right? How did you do on step one? How did you do on those kind of like objective metrics that have nothing to do with a third party deciding whether you get honors versus high pass or pass and for example, the comments that students get in their in their evaluations oftentimes are racialized and gender. So there’s a study that was done at Yale by one of my mentors, my mentor came in a few of my interests, actually, Dr. Wright and Dr. Smith and the rest of their team, there’s a large team that looked at letters, how do you call this MSP The, the big letter that goes out when you apply to residency? I’m not there yet. And I look at comments from the from tertiary grades, and the most, the letters that are more likely to have those superlatives. Not excellent those Kind of terms are way more likely to go to white male medical students and black male medical students are more likely to be sort of just labeled as competent, maybe like hard worker, but never those superlatives that program directors tend to look for. And then women get labeled as carrying, you know, kind of this sort of kind of benevolent sexism that often shows up where the qualities of the students are highlighted based oftentimes on race and gender. And then when you think about career advancement opportunities, like la Alpha Omega alpha, right, lucky, I mean, I don’t know whether that’s lucky or not, but we don’t have a chapter on my medical school. But the same team that did this study on MSP content, looked at resident applicants that that submitted applications to Yale, so something like maybe 15,000 medical students from across the country and they found that when you control for grades, step one scores like you know, all the kind of the semi objectives, I don’t really think they’re all that objective, but the number of things Black and Asian medical students are six times less likely still to be inducted in AOA up their homes, you know, their home institutions and, you know, some program directors filter applications by a by, you know, elite status. And it’s a huge thing to think that it has six times, you know, my take on that is there are people that are eligible on AoE, typically based on their, I guess, ranking in their medical school class, like, you know, are you in the top, whatever quartile it isn’t different institution, and then there’s a body of student members that that often have to vote on, on induction membership, whatever, based on, I don’t know, some criteria set within the school. And, you know, you can imagine that some of it is basically kind of a popularity contest, and it’s kind of telling that those were way less likely to make it into a way are black and Asian students. You know, kind of like least likely to look white, I guess I’d like to present or potentially present us like, it’s kind of my read on that. If you ask me. That’s kind of racist. And the stuff
I don’t know if kinda is
in that statement. Yeah. So So what you’re saying is that it affects your grades. Right? Yeah. In that and that can be that’s been studied for, right that’s what you’re saying is, is that if you blind, you know, if you blind someone, to, to what this person looks like, as much as possible by just doing the objective multiple choice tests that we all have to take and we’re all then it really the data really seems to speak for itself and so that I think if you turn if you think of things in terms of like, I heard actually Jamie Foxx once referred to himself as the arrow and his grandma was the bow so I thought that was a great analogy for the way that my wife and I are raising our kids we just were aiming the bow and the arrow is gonna go or the I was gonna go. But if you’re if your career trajectory is like is the bow pointing in a certain direction, if you’re already starting at a lower angle, because this is good Preventing you, now you’re getting lower grades. Because you’re being described this way your letter of recommendation aren’t as compelling. You’re not, you’re less likely to get an eo, this is talking in terms of career trajectory, where you’re going to end up 2030 years from now, you’ve already attained the bow in a different direction, right? And there’s no quantify. I mean, there’s like no exact way of being able to sort of quantify that, I guess, unless we were to kind of look at things in the perspective like a prospective cohort. This I mean, there is a chord out there. I don’t know what questions they asked the participants, but the change does a lot of studies on like bias and microaggressions and whatnot. Amongst medical student It was a cohort that initially enrolled like 5000 med students across the country, and they followed them and I think they’re now 30 are residents so I’m, you know, I’m curious to see when they’ll make some of the some of the questions that they’ve asked available and, and and how far one could ask like, oh, what, how did the trajectory of some of these students change based on their experiences with with racism and whatnot in med school. And I’ll give you an anecdote in terms of both the grading and some of the, you know, the gatekeeping structures that may exist. So I had an experience where I that’s so rare, I had a black male resident in a longitudinal clinic. And I was and, you know, supervised by an attending who was white, and during that time, it was a weekly clinic, and most of the time on collections, you know, you spent a lot of your time with, with the resident and not so much with the attending, and this resident at the end, and we have great, you know, great working or poor, you know, every day at the end of clinic, would maybe spend 15 minutes sorting out the attending. At the end of the clerkship, this resident will be a super long, very good about ration. I mean, I was beaming with pride, even though he submitted it late, and they’re attending on his end, nothing in the part of the evaluation that’s supposed to go in my transcript, literally nothing. So he saw nothing that’s worth talking about me and what would end up being my MSP letter. So I email my clerkship director, because this resident had turned it has turned his evaluation late like, Hey, you know, do you think we can also add the residents evaluation just for more text in my eval? And you know, it, this is a rotation that are honored anyways. And I did really well, overall. So there was no, there was no grid issue. I just wanted those comments to also appear. And the response was, well, for that specific clinic, we really just wanted comments from the attending and not so much for the residents and needed so well anyways, that it doesn’t matter. Now, imagine if I didn’t do well, and that the structure is that we just want comments from the attending and the attending pays me no mind, but the one time that I do get a black president has evolved doesn’t even make it, you know, into my transcript that’s sort of like dwindling representation amongst who supervise us has an impact ultimately on whether what are you know, what are, how do you call that what our msps are tracking So I have are going to look like I spent an entire year on the war. I never had a black attending who was going to give me a grant. I had a few black presidents. You know what I mean?
Yeah, you know that that sums it up in terms of your experience. I don’t know. Sometimes I think it’s very telling in terms of your experience, right? One or no black attendings, a few black residents. And so this is what this is what your experience is like. And as opposed to students of other backgrounds who are able to look and see people who look like them in all sorts of specialties. So so when you when you see, let’s say, you did have one, black attending, right? And how do you think that would affect your decision with regards to specialty Do you think that would in that would alter your decision making I mean, it’s hard, because you’re, you’re, you’re it’s hard to take yourself out of the situation and look at it objectively, but, I mean, generally, if you’re on a rotation, and you’re Your attendings and residents are jerks, you’re less likely to go into that specialty, you’re not gonna have a good experience. Whereas, even if it’s maybe not the right fit for you, if you have a specialty where, where you have a great time, because you’re getting along with everybody, you’re more likely to go into that specialty. So what about your situation where there are very few people who look like you? And yet, you have one, maybe two and other specialties? How do you think that will alter your decision making in terms of what you ultimately choose?
I think for me, I probably would end because there’s like I said, there are so few and just about every specialty, right? So it’s so the bets are like almost non existent. But I think it would make the experience better in that one. As a student on that rotation, I maybe I’ll spend a little less time worrying whether the feedback or criticism that I’m getting from the attending is like from a place of assumption of inferiority that sometimes we just kinda have to wonder like, Oh, this is attending thing I’m done, right? Like, that doesn’t tend to be the case, when you have another black attending that may hold you, they may even be I have just from having conversations with other peers that sometimes a black attending or even resident may hold you to a higher standard because they want you to, there’s this link fit in making sure that you do well. And we’ve all kind of been, it’s all been ingrained in us that you have to be twice as good to have it half as half as good. That’s kind of like the saying that just about every black parent tells their child so I don’t think for me, at least it would like make me want to go into a specialty versus versus another. But I think for some people, though, it may in that being told that you are welcome in this specialty is very meaningful, right? And that is indeed perhaps more likely to happen if the time that you attended and that specialty. You had a mentor who took ownership of you as a student and like mentor to you. Yeah, there’s some specialties out here. Even if everybody was black I wouldn’t go into.
And whenever I have a student rotating with me, one thing I always tell them is, it’s the most important thing is to find out what you don’t like.
There’s a bunch of stuff out there that you’d be happy doing. Just make sure you’re not in one of the ones that you won’t be.
Yeah. So I think the impact is not so much of a, seeing a black attending is going to make somebody go into it, but guess is not having a black attending and then also not being welcomed or even not being being told that Oh, you’re never gonna make it or people not showing enthusiasm or not mentoring you the lack of black attendings as opposed to the presence of them. I don’t know if I’m making a clear argument here that can impact you know, those trajectories is my guess. I mean, there isn’t often an assumption that Oh, minority medical students are aware and more likely to budget primary care without investigating the root of it. All right, like Sure, yes, we are more likely a bunch of primary care but nobody knows. Whether when we came into med school, whoo, half of us were like, Oh, I’m gonna do plastic surgery or I’m gonna do neurosurgery or whatever, right. But as I would like for it to be studied, whether during those clerkship experiences the, you know, experiences of not feeling included, being actively or passively has made people more or less likely to say, oh, bump that I’m not going into insert specialty, because, like you said, those people were jerks, or those people didn’t include me, or those people just never saw me as fitting with them. My opposite one of my optical faculty members, like y’all, she’s a black woman, Dr. Kristen, why will, she said when she was a resident, you know, she is a tiny black woman, and everybody who walked in who was a tall white man, they would say, Oh, he’s gone. And he just looks like his daughter right now. And she said, I’m going to retina but people never ever supported the idea that she would be a retinal surgeon. But she said, I’m going to do it from an intrinsic motivation. And she did it. She’s a retinal surgeon but barrage with these assumptions on all year. You’re just you’re just going to be a generalist, although it’s obviously it’s great to be a generalist, regardless of being as in primary care or like a generalist and that surgical specialty, it almost kind of robs you of your dreams sometimes, you know, to not be told that you can do it, you can also do it. Yeah.
Well, Max This is this would be a great conversation. I really appreciate you taking a lot of time out of the busy students schedule and away from your studies to have this conversation and and to put together the podcast because it’s clearly clearly a lot of very important conversations that need to take place. And I’m, I’m so glad that you found this platform. So where can people find us? Where can people find your podcast? So the podcast is flipped a script. If you can find it on iTunes, Spotify, SoundCloud, if you search for flip the script, yell, I think there are a few things that show up as flip the script by itself. So it’s the one with the El blue yell logo. It’s the broadcast center that helps me with hosting. flip the script yell, it’s easy to find. On on Twitter, the handle is flips pod. Yeah, so check it out. So we’ll include links to all that in the show notes because I certainly had trouble finding when I just looked for flip the script and then the done popping up and it didn’t make any sense I was looking for Yeah. So now I find,
yes. Well, thank you so much for the opportunity to have this discussion. I really appreciate it.
That was Dr. Bradley Block at the physicians guide to doctoring. He can be found at physicians guide to doctoring calm, or wherever you get your podcasts. If you have a question for previous guests, or have an idea for a future episode, send a comment on the web page. Also, please be sure to leave a five star review on your preferred podcast platform. We’ll see you next time on the physicians guide to doctoring.
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