Bradley Block

Size Matters Not: Tiny Habits for Big Changes with BJ Fogg, PhD

This interview is one of my most important. If you are doing to share any of my episodes, this is one that I would implore you to share with your friends, family and colleagues. This is part 1 of 2 of my interviews with BJ Fogg, PhD, author of the book Tiny Habits: The Small Changes That Change Everything. We all struggle to change our behaviors, to develop good habits and stop bad habits. There is a lot of popular wisdom about this and most, if not all, is just wrong. This is where Dr. Fogg steps in.

Dr. Fogg discovered the keys to changing behavior through changing habits. For those of you on medical school faculty, this should be a class. This should actually be taught in high school. Until then, as physicians, this information is critical, not just for lifestyle changes that can help patients eat better, move more, and smoke less, but even applies to checking their blood pressure and taking their medication. Popular wisdom is wrong. Guilt and shame are destructive. People don’t start habits by feeling badly, they start habits by feeling successful. And we are more likely to be successful by starting a habit that is small, that we actually want to do, and the third key to this is a prompt that reminds you it is time to perform the behavior. If you are going to learn piano, you start with chopsticks. If you are going to start to exercise, you do one sit-up. The smallest increment that you can fall back on when you motivation is waning so you don’t fall off the wagon completely and you keep your habit. And you do it at a point in your day that you can associate with the new behavior, even if they are completely unrelated. You’ll have a reminder that is baked into your day.

Dr. Fogg founded the Behavior Design Lab at Stanford University. In addition to his research, Dr. Fogg teaches industry innovators how human behavior really works. He created the Tiny Habits Academy to help people around the world and interestingly, the Tiny Habits Academy long preceded the Tiny Habits book. He lives in Northern California and Maui.

This is Part 1. Part 2 will be out next week. He was kind enough to already offer another interview, so if you have any questions, please email them to me at Brad@physiciansguidetodoctoring.com

He can be found at BJFOGG.com and tinyhabits.com

Is Single Payor Really Bettor? with Dr. Kwadwo Kyeremanteng

Dr. Kwadwo Kyeremanteng is the founder of the Resource Optimization Network and a critical care and palliative care physician. He is also the host of the Solving Healthcare Podcast. He is also Canadian, so we discuss the Canadian Healthcare System, which, on its surface, looks like a comprehensive, all encompassing, federally administered single-payor system, like what some of the democrats are discussing in the US. We discuss why this is not the case, and get into some of the details about what isn’t covered, how it is more of a provincial system and what are the differences in provinces. We discuss how the money flows through the system and how private insurance can play a role in some ancillary services. And true to the name of his podcast, at the end, we solve healthcare.

Dr. Kyeremanteng was born and raised in Edmonton where he did his medical school at the University of Alberta. He and his wife then moved to Ottawa where he did his Internal Medicine residency training at the University of Ottawa followed by a two-year fellowship program in Palliative Care and Critical Care. He stayed after his training and is now an Assistant Professor in the Division of Palliative Care and Critical Care Medicine. He also has research positions with Ottawa Hospital Research Institute (OHRI) & Institut du-savoir Montfort as a Senior Clinician Investigator.

His academic interests include the integration of Palliative Care in the Intensive Care Unit as well as health services research and cost evaluations. More information regarding his current research interests and projects can be found here.

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EPISODE TRANSCRIPT

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Dr. quanto caramon Tang is the founder of the resource optimization network and are critical care and palliative care physician. He’s also the host of the solving healthcare podcast. He’s also Canadian. So we discussed the Canadian healthcare system, which on its surface looks like a comprehensive all encompassing, Federally Administered single payer system. Sound familiar, kind of like what Medicare for All is supposed to be. Which is because why this isn’t the case in Canada and get into some of the details about what isn’t covered, how it’s more of a provincial system. And what are the differences in some of the provinces we discussed how the money flows through the system, and how private insurance can actually play a role in some ancillary services, and true to the name of his podcast. At the end, we solve healthcare. Dr. Sherman Tang was born and raised in Edmonton, where he did his medical school at the University of Alberta. He and his wife then moved to Ottawa, where he did his internal medicine residency training at the University of Ottawa followed by a two year fellowship program in palliative care and critical care. He stayed after his training and is now an assistant professor in the Division of palliative care and critical Care Medicine. He also has research positions with the Ottawa Hospital Research Institute. And I apologize for the pronunciation Institute disavow your forte as a senior clinician investigator. His academic interests include the integration of palliative care in the intensive care unit, as well as health services, research and cost evaluations.
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.
Dr. Quadro Carmen Tang, thanks so much for being on the podcast.
Bradley. Thank you for having me.
So, Canadians seem to think that American ambulances are going to check your credit score before they’re willing to take you to the hospital. And on the other end, you’ve got Americans thinking that Canadians have having a heart attack need to wait in a Soviet Cold War, breadline get into the hospital, right? Clearly, neither of these things are true, but this is how we view each other systems. Yep. American we’ve got multi payer private insurance with a little bit of government assistance and Canadians you’ve got this concept of single player. That being said, it’s it’s a bit more complex or a lot more complicated than that. So we’re gonna get into it. To start, how long has Canada been on single player and how did that system end up starting?
Yeah. Great question. Bradley. It’s, so officially this all started in 1968 ish. And so it was Put about by Tommy Douglas, from sketching. So one of our Western prairie conference provinces and yeah, Canadians being Canadians wanted universal health care that was accessible, complete, publicly run. And so with those principles, they produced the universal health health care in the mid in the late 60s and basically would find the federal government would fund provinces to say, you know, this is what our principles are, and you guys decide where their money needs to go. And, but like it in the big picture has to adhere to some key principles. And so, the Canadian Health Act was produced in 1984, which kind of solidified the principles of what Canadian healthcare was all about. And so, the key elements of that was that it was publicly run. That was accessible that was comprehensive, comprehensive, was universal and portable. And so since then that’s been officially documented and so legal document and yeah, and since then we’ve been running a publicly a universal single payer system
since 1968. That that, yeah, that sounds like a really civilized place to live.
And I gotta tell you, Brad, it is a civilized place to live yet because I get a lot of it’s like you said like those worries that if you come in with a medical problem that you are going to wait forever for, for things to be addressed. And to be honest with you. There are some areas in medicine where you are waiting a long time like if you depending on what province you’re in. If you are waiting for a hip replacement, you might be waiting a long time if you were waiting for any other orthopedic, elective procedure, but if you come in with any Thing urgent. Okay, so whether that’s you’re having an EMI you’re having trouble breathing, you need urgent surgery. Like doesn’t matter where you’re from doesn’t matter what card you have in your wallet, you get treated the same and you get treated urgently you get treated with respect and, and that’s key principles for Canadians and and we abide by that
well and they’re also I would imagine ways to kind of game the system, right? If you’re an orthopedic surgeon and you’ve got a patient who you think might need a knee replacement, I’m sure there are ways to kind of put them in line so that it makes it seem like it’s a six month Wait, but in reality, it’s really not that long of a wait because they they know the patients that are likely to need it and the patients that are likely to not so you don’t ultimately waiting, you’re waiting that long.
Yeah, exactly. As you put it like that. You can adjust a priority like if you think somebody needs a procedure sooner than later you have that prerogative If and so it’s like, there aren’t, I don’t want to make it appear like there’s millions of people suffering waiting for some procedures to happen. But I think what is consistent is that if something needs to be addressed sooner than later
it’s addressed. If it’s elective, it’s elective and urgent. It’s urgent. Okay, exactly. So is it? Is it really a federal system? Or is it more of a provincial system that utilizes federal funds?
I think the latter like is a better way to put it. So literally, the federal government gives payments to each province based on population based on need, and the provinces decide how they’re going to distribute funds. So for example, in Alberta, when I was still living there, there would be about I think, eight or nine health authorities and the government would give the provincial government would give each money, each Health Authority a pocket of money, and they decide whether that’s should be more focused on outpatient impatience or whatever. Ever, like community resources, like whatever they felt was of higher need in Ontario now they’re just in the process of trying to establish a system similar to that, but every province is variable. But the principle though is that federal government gives money to the each province and the decide how its allocated.
So you mentioned it’s based on population and it’s based on need How is need assessed? Is it based on the idealization?
Yeah, so once again, it’s it depends on the province, but I could speak to Ontario because that’s where I’m at right now. Part of the funding model for each hospital is based on it used to be on based on need, like if you’re seeing more volume of hip replacements, then we’re going to fund that are going to give you a certain amount of money, certain amount of intensive care admissions will give you a certain amount of money. Now they’re using it on quality metrics, like so if you’re, if you’re meeting specific quality metrics within each sector in medicine, like within the orthopaedics within general surgery, then they will provide a certain amount. So basically, they’re rewarding hospitals that are of higher quality. But this is something that’s always changing in healthcare, like I think Ontario now is, is trying to go towards that Alberta model that I was describing earlier where there’s a health authority, we’re going to provide you with money in that health authority. And you as the Health Authority, decide where you want to put your money and how you want to put your money into your area,
but more regional control, if you know that exactly. That happens in American in Medicaid, you have these private companies, where the if the patient qualifies for Medicaid, they can get their insurance through a managed Medicaid provider. So the provider or the the insurance company will get a lump sum per patient that they take care of, and they will decide how they’re going to administer that. And that kind of takes the government out of the loop because, you know, I think government does something Well, but it’s not the most efficient, the private industry tends to be more efficient. So it’s a way to capitalize on both of those strengths. So that’s what it sounds like you give more regional control. And now the federal government doesn’t need to be involved in the minutiae of what happens in that province or even within the region of that province.
Exactly. And this is obviously just my opinion, I do feel like it’s probably a wiser approach, you know, like almost like a bottom up approach where you in your region, you know, where the needs are, like, you might be a region that has more and more elderly population, you might have a population that has, you know, more youth and having some more resources towards that specific patient population might make more sense. And so I, my bias, personally is like, this is the way to go because you get so much variability in in these approaches to how we fund healthcare and, and in my humble opinion, Brad like, the more government that gets involved, the more I find administrative positions or being involved in the more inefficient everything becomes so I love the idea of it coming from like a bottom up approach and be more regional and I think where you’re thrown down makes a lot of sense. I forgot what
it’s called. It’s it’s someone’s law based based on a some British ship captain where bureaucracy fills the space it’s given. Like you said, If you set a meeting for two hours long Parker’s meeting will let Parker’s nice I’m impressed. Yeah, by. Like, if you set a meeting for two hours long that meeting will last for two hours, even if you could get everything done in an hour. So yeah, Parkinson’s Law.
We talked a little bit of pre interview about some of our similarities. And I think one thing I must reinforce is efficiency. Like we’re both busy people. So yeah, the Parkinson’s Law is and I know you’ve been in these medical meetings too, like they are. Most people just like to hear
themselves talk. Exactly. I got stuff to do.
Yeah, go see patients got some family. Got some costs of health care. That’s right. Yeah.
Out of South Africa, or so we’re trying to do here. So so one one attempt at the American government to solve healthcare was Obamacare. Right, the Affordable Care Act and one aspect of the Affordable Care Act is that insurance needs to have these 10 essential benefits in patient care, outpatient care, medications, emergency department, maternity and newborn Mental Health and Substance disorder, physical and Rehabilitation Services, labs and imaging. I’m not sure if I’ve named them all i don’t think that was 10. But but you get the idea, right? All these different aspects of health care. If you’re going to have insurance, it needs to cover all of them. So But the Canadian healthcare system, right? It’s it’s single payer to some degree, yes. But it hasn’t covered all 10 of those things in their entirety, right? Because that would just be to expect to have all of that paid for in its entirety for every single person in your country. Just the the costs would end up skyrocketing. So that’s not how it works in Canada.
Exactly. What says
what is paid for,
it’s about 70 to 75% of healthcare related costs. So it’s essential services, actually, it’s probably easier to just say what’s not covered. So typical allied health like physiotherapy, occupational therapy, optometry is not covered drugs, unless you unless you’re elderly in most provinces aren’t aren’t covered. So there’s a good chunk of services that aren’t covered within the healthcare system and it’s as you said, like, we Pay this I would need to check a reference. But somewhere between 45 to 50%, I think of our GDP goes to goes to healthcare related expenditures. So we spend a lot. And that’s my whole area of research, to be honest with you is how we can be more efficient with our spending. But yeah, it is not complete. And so some argue do should we be covering more like one of the hot topics in Alberta, or in Canada, we just had a an election was pharmacare and having within the universal health care initiative to have drugs covered, and no party was really diving into details on how this would be approached. But it was certainly on the minds of Canadians of having more complete coverage of some of the medication. So yeah, but you nailed it, Brad, like we’re not it’s not, we’re not covering 100% of health care’s use, or their private insurance companies that come in to fill the gaps like You pay us this amount per year and you’ll get this percent of your rehabilitation services or medications or long term care or whatever it is that’s not being covered. Are there private insurance companies that are trying to fill those gaps? 100% So, the I’m in a government town capital of Canada, Ottawa here. And a lot of for example, government employees have a very complete insurance packages where, you know, a large portion of medications, a large portion of massage therapy, physiotherapy, optometry, all those have to be covered. And usually there’s limits but there’s, that is absolutely true that there’s private health care companies that supplement Yeah, so
a lot of single payer system that that makes it
illegal. I guess a single payer for essential services is the way I would look at it. Okay. But for the, you know, the non essential services like dental, for example, didn’t mention that as well. You we all have most of us have insurance, separate insurance for that.
Yeah, I’ve been in the situation I’m in. I’m an EMT. So I’ll have a patient that comes in with a neck abscess. Right? So I get called by the emergency department to assess this patient. They’ve got an abscess, where’s the next neck abscess coming from what’s coming from an infected tooth. So the tooth needs to be pulled? Well, this patient doesn’t have dental care, they have Medicaid, so their emergency department stay is going to be covered. But if we call a dentist to take out their tooth, not covered. So you know, they’re kind of stuck having to pay out of pocket even though they have you know, they’re, they’re a certain percent below or I think it’s like 135% above the poverty line qualifies for for Medicaid. Right. So they’re not coming in with much of pay for this dental care, but now they’ve got to pay for a dental extraction out of pocket. So it’s dental dentistry is I think sometimes is frequently forgotten about in these insurance plans. But it is, it’s sometimes critical. Yeah.
And I mean, we kind of touched on this earlier about some of the myths of, you know, within Canada, everyone, it’s very, you have a heart attack, you’re gonna have to wait. But, you know, one of the, like, a true common concern when we hear about some of the scenarios in the states is that if you for example, and correct me if I’m wrong, okay, because I don’t you know, this is just from what I’m hearing from my colleagues is, if you have you know, minimal insurance and you come in with a problem, say you have a cancer related a head neck, malignancy, and you need x medication to be able to, to cover or to go to chemo or to have an adjuvant therapy, you might not have, like, if you don’t have insurance, you might not be able to afford treatment. And so what we often hear about us people having to do, you know, their second mortgage on their house, just to Ford
most common cause of bankruptcy in America medical bills. Absolutely. So, so what, you know, the whole pre existing condition debate, right, that’s something that that came out in the Affordable Care Act is that if you had head neck cancer before the Affordable Care Act, you couldn’t afford insurance. So what would need to happen, you’d need to pay for it out of pocket until your funds are so depleted, that you would qualify for Medicaid, and then you’d go on Medicaid, and then the government would pay for the rest. But meanwhile, you’ve you’re, you’re just depleted. You’re just depleted your future, right? Yeah. So so but now with the Affordable Care Act, you can now apply for private insurance. However, it’s not on a rolling basis. You can’t just apply for it right now. You need to apply for it when it’s available, and I can’t remember if it’s quarterly or once a year, but you’re you know, in that interim, you’re either just gonna have to wait for your cancer to progress waiting for insurance, or you’re gonna have to pay out of pocket until until that happens and end up in that in that similar slip. scenario. So preexisting conditions doesn’t mean you can get insurance just when you need it. Oh, wait till you get pneumonia and then apply for insurance? No, you should. It just prevents you from when you make that decision to get health care. It can’t or health insurance, right? It’s not the same thing to get health insurance that they can’t stop you from getting it, which can also make premiums go up for everybody else because now you have to pay for the possibility of someone with an expensive condition that’s going to end up on your plan. And that’s what insurance does, it spreads out the risk. That risk needs to be spread up beforehand, but you’re totally right. It can. You can you can end up bankrupt from a condition but you did have the ability to pay for insurance. The problem is that some people end up with plans frequently that they don’t understand. Meaning like yeah, I have a high deductible. And so I have low premiums but I have a high deductible which means that my monthly payments if I don’t go to the doctor are low but If I do go to the doctor, then it’s I’m gonna have to pay out of pocket, probably 100% until I meet my deductible. So it seems like I don’t have health insurance, because people think that it’s going to cover everything. But really, it’s, it’s in a lot of ways just for those disasters that you’re referring to where, if you didn’t have it, you would end up bankrupt. Yeah, those are some plans or you end up with a high premium plan and the low deductible it just, you know, but you’re when you’re choosing it, you it’s hard to understand all the nuances of it.
Yeah, cuz it sounds like there’s a lot of nuance. You know, just to contrast that with us. It’s, you know, there’s some provinces that have you pay a small premium for your insurance from like your provincial health care insurance, usually somewhere between than what’s and forgive me if this is mildly wrong, but it’s usually between 50 to $400 a year kind of thing. But regardless whether you if you didn’t pay it, you still get treated. You might get a bill for the government versus you had to pay for your insurance premium, but you’re still getting treatment. And I, I think, when we hear stories like that, like, I could speak for almost all Canadians, when we hear, you know, someone’s has to bankrupt their house in a time of need, when, you know, they just need optimal care. It just breaks your heart, especially, you know, we’re talking to clinicians here we got in this game because we want to help people, not break people. You know what I’m saying? So it’s, it’s it’s tough to hear
scenario scenarios like that.
But it doesn’t mean that you Yeah, the American system is just, it’s preposterous. Yeah. I had an interview a little while ago with an evolutionary biologist. And one thing that we the whole theme was, the human body just doesn’t make sense. It’s kind of cobbled together over time. And things are built on other things like the fact that our hand has is like a bunch of rocks, like Put together and then our fingers extend out of these like eight different buttons. It doesn’t make sense. And that’s kind of what the American system is. It’s not like it was built from the ground up. It started kind of with in World War Two there because there was no workforce, there was caps on salaries. And so they they started offering other benefits like pensions and health insurance. And that was the start of the American system. So it’s based on it’s an employer based system, which just if you’re going to build it from the ground up doesn’t make sense. It doesn’t mean that single payer is the way and the only way. But I think you and I are on the same page and that we believe in universal coverage. So you know, so everyone has something so that stuff like this doesn’t happen. And I think most Americans are on the same page with that, that like health care is a right. You know, I’m of the belief that there is a role for the private sector and for individual payers, you know, for individual people, if you want to pay for more care, then and you want to pay for foster care and you want to pay for that, you know, great have a way to get private money. For those that can afford it, to just inject more money into the system, rather than just having it be single payer, everybody gets the same because it’s just, it’s just not going to be as as efficient. But that’s my personal. That’s actually what happens in I think, Germany. If you make less than 30% above the poverty line, you get health insurance, you just you just have it. You don’t don’t, I don’t think you have to apply for it. You just have it. And above that, yeah, you have to pay for private insurance. And there are a bunch of different systems out there and you choose which one that works for you and in fine. So that’s, that’s my, that’s my soapbox.
And Brad like, honestly, it’s a hot topic in Canada to like privatization, you know, cuz you bring up a lot of good points. Like it’s not, it’s not the most efficient system in the world. And like, like I said earlier, there are people that have long wait times for some elective procedures and there’s people out there that want to be more functional and not wait 18 months or are a year for their hip to be done.
And also you’re spending a ton you’re spending a ton there’s more efficient ways to spend the money. I mean, it’s great that, that you have the system but, you know, American is America is much more efficient with the spending, but but Canada, also you got the person that you said, I think it was 50% of GDP. Like, that’s
just a tremendous, it’s like,
it’s high. And like, and once again, this is my personal belief, too. I actually legit feel like there’s a role of privatization in healthcare, even in Canada. And the worry is that, you know, one of the common words that you hear mentioned in debates is having that read, like resource drain where, you know, the best surgeons, the best EMT surgeon is now just going to work in the private sector and, and you know, not not, so it’s going to be kind of like a two tier system. Well, yeah, the rich get a better service. But you know, there’s like everything else like you just got to be a little bit nuanced about it, like Say, if that EMT surgeon is only allowed to work 25% of their time or 50% of their time in the private sector, that will offset some of that, you know, concern that the, like the quality drain is is happening. And so I just think we got to be, we just got to think through it a little bit more. And use util because we have the capacity we have, like I can speak for the our orthopedic surgeons, like we have guys that are on their third, the third fellowship, they got some of them even got PhDs because there’s no work. Right. And if you think about what’s happening in North America, throughout the world, we have an aging population, baby boomers are getting into the height of resource utilization. There’s tons of people that need work like that need to have treatment, and it’s just we don’t have enough money to fund a wars for 24 hours or for you overtime and so on. But if there was a private element to that, where, you know, people that could afford it are willing to pay there were 20 to 25 K to get their hip done earlier. Yeah,
wait times go down, and that money is going to be used to offset the cost for those who don’t have that type of
exactly. Yes, exactly. So I think there’s, I think resolving
right now, right, we’ll get right.
But yeah, no, I do. My bias is there’s a there’s a role.
So we got a little off the rails and that both you and I, we know how to self healthcare if someone would just listen to us. Yeah. So but there are some things that are done well in some promises, and maybe a little more poorly in another. How do the promises differ in how they administer health care and which province is your favorite? It’s
gonna give me a trouble
So, in terms of different provinces will have a more regional approach. So bottom up where, you know, they fund the region and region decides where the resources go, some are not regionalised. And, you know, the provincial government decides how much money a hospital is going to get based on either a volume based on quality. I got to go back to Alberta, like I really, they went away for a while from the regionalize approach, and I think it in some ways, made care worse. The function functionality of the province worse, they’ve been not totally adverse to privatization so you could get your an MRI CT scan, you can get that done and pay for it privately in a bat doc did that quite early. The reimbursement for their physician services is is I would Say, more than appropriate. So if you if I had to say one, I would, I would, I would, I would lean on Alberta. And sorry for my Ontario folks that are listening. But like I said, they’re they’re moving towards a more regionalized approach as well. And I’m optimistic that things will start to be more efficient and, and, and care will improve. But we also one of the things that I don’t know if it’s fair to talk about, but I’ll do it anyway, one of the things that really irked me about how things were handled in Ontario was from physician pay perspective, they made some unilateral cuts. So some specialties For example, some cardiologist based on if there were heavy diagnostic practice, they they could have lost up to like 20% of their income from these unilateral cuts. And I I gotta tell you, I was not happy with this approach because, you know, we this is a clinic, a physician audience, but you We hustle, we do what we need to do for our patients. We take the brunt of, you know, Dr. Google, of administrators of unhappy patients, we do our best to try and serve. And then for the organization to just unilaterally, you know, take the wheels out and make these cuts. It was it was upsetting for, to say the least. And so that left the sour spot and a lot of clinicians for sure, and things have gotten better in terms of now there’s arbitration between our Ontario Medical Association and, and the government. So the process is better. But when you do that, you know, I guess just, it’s just a big slap in the face, like our specialty lost about about 5%. And, and I’m all about, you know, if there’s areas where it needs to be tweaked, because yeah, there was some specialties that Some opinions would say is overpaid and or the fee schedule is outdated. And, you know, I think that’s fair. But it’s got to be discussion. It’s got to be a by, like both parties to decide what, what’s the best approach. But so that left of real. Ah, that was upsetting.
Yeah. And that happens that happens in the states too, where an insurance company can just make this unilateral decision. And, you know, if you’re a big hospital system, then maybe you have some leverage, but then then you’re leaving a lot of patients out in the lurch if you just decide, you know, what, we’re not taking your insurance anymore. So you know, it gives the insurance company a lot of leverage, just make these heavy handed decisions. And, and there’s very little recourse other than just not taking that insurance and ultimately, in that situation, it’s the patients who suffer. So how does the money flow? Like, how is it that doctors get paid to that you said, you know, in a lot of provinces, it’s Regional, it’s a bottom up, you’re given a lump sum. So So is it? Is it your a salary? Is it fee for service? Is it come some combination
of the two? I’m glad you brought this up. So most provinces, it’s a combination, it’s a combination. So most provinces regardless of whether it’s mostly regional or not, it’s actually going to be the province that decides a fee schedule. And it’s agreed upon that every physician in the province is going to be paid that same within that specialty the same further based on the fee schedule. So most specialists, our our our bill, essentially the Ministry of Health or the government, the provincial government, and would be reimbursed based on the services they provide some province. Some specialties also have like an academic plan which is mostly salary based So basically incentive to be able to teach residents because there’s also a cost to that, right? Like, if you’re teaching residents, you’re not as efficient, you’re not as fast. So compared to the dogs that are in the community that would be able to see more patients in a shorter period of time. So there’s a lot of provinces and a lot of specialties have that option to go towards a more salaried approach. And some also have a hybrid where they get a salary but for example, if you all their night calls or weekend calls might be billable. And so there is some flexibility in terms of how it’s how it’s how physicians are paid, certainly in our in my situation in critical care, we are paid a fee for service. And then my I also do Pyatt of care which that is being paid a salary. And so I get both sides of the equation.
Interesting. What about the hospitals? How do they How do they give you? Or is it the money flows from the region to the hospital in the hospital is the one that pays the doctor. One thing
I guess that’s quite unique in Canada, like, I am not a hospital employee, you know, the hospital, hospital doesn’t pay me, jack, it’s I build the government and the government pays me based on services are provided based on this fee schedule. Okay. And then the hospital does the same thing. And so the hospital, so they will either get paid by like, the most updated one that I know is our hospital will be paid based on quality metrics on the ability to minimize, for example, part of the equation, not the whole equation be the volume of patients they see but also are you meeting your quality metrics, less, you know, surgical infections, less ventilators, associated pneumonias, and so that enhances their their budget as well. So, yeah, so basically physicians get paid by the government. directly, hospitals get paid by the government or region. And but certainly the docs are being paid by the hospital. Okay. Okay.
Is there anything right now that’s being debated in the government any any hot topics? Or is it something that they’re trying to stay away from? Because because it’s too much too
sensitive to touch all man, there’s a lot of like hot topics in general like, or no healthcare sorry,
healthcare related. Yeah, being
debated in the government. Ya know, there’s lots so there’s where to start. So we mentioned pharmacare. There’s the privatization that’s still being debated, like having some level of privatization. There’s medical assistance in dying, like, you know, having more clear legislation in terms of who’s eligible. What else is there, all the cannabis legalization like, Ah, you know, in terms of, you know, right now, you could legally purchase Cannabis, but how safe is it? Are we doing effective monitoring? Well, what what if you’re if you if you consume and you drive like what’s the level? That is okay and what’s not okay?
They recently maybe figuring that out before legalizing I gotta
tell you a bunch of it in the wind and seeing what happens.
I gotta tell you this. There’s been a bit of a shotgun approach with a couple of things, but one of them was the candidates who were eager to to get the my personal opinion they’re eager to get the revenue because it’s obviously heavily lucrative if adopted appropriately and then medical assistance and dying. I don’t know what drove that one. But we, I would say we weren’t 100% ready for that when it came out as well. But, um, but yeah, there is a bit of a, hey, we’ll figure this out as we go approach in some of these. Some of these tissues.
It was popular so the politicians decided to pass it and just figured they would kick the can down the road for figuring out all the nuance that really makes it or breaks it.
Yeah. That’s what it feels like. Interesting. Okay.
Just like America. Yeah. So tell us about your podcast solving healthcare. My main question for you is, have you solved healthcare yet? And if not, What’s taking so long?
I love it. I love that question. So, so Brett, what’s it stem from is like I mentioned earlier that we have a research group resource optimization network. And we’ve been pretty productive over the last few years. And our area of interest is how to make healthcare more sustainable. How do we save money? How do we improve care? And honestly, we were doing these what I would say pretty great studies and nothing was changing at all. And it was totally myself like what are we like, what are we doing? Like, what’s the purpose of this if nothing’s gonna change? So then, you know, podcasts and fuzziest. And so I was like, you know, maybe if we increase awareness, and maybe maybe this could start drumming up some noise. And so, we decided to develop solving healthcare. And, you know, we’re about at the time of recording about five months deep into it, and I gotta tell you, Bradley like I’ve, I’ve never outside of like moments in medicine, but a this is truly been a humbling experience because like, I do feel like we are solving healthcare and things are changing and things are improving. I’ll give some examples. Like we did an episode on overparenting and, and the lack of support for kids with anxiety, depression and other mental health disorders and Like, for example, in Canada, we’re talking about what’s covered what’s not, if you wanted to see a child psychologist for services, that’s about a $3,000 bill for a proper assessment, and a lot of people can’t afford that. And so we brought this issue up. And now one of the clinics in Ottawa is going to be providing free care for, for kids that can’t afford it, essentially. And so I
feel like that’s such a great investment. Right? Like you provide child childhood mental health services, and you’re gonna save yourself a ton, right decades down the road, but you’re gonna save yourself a ton down the road that and that seems like they could. It’s so it just intuitive. But you’re right, you got to find the money somewhere to do that. And someone’s got to have the political will to say, you know what, we’re going to take money away from this and put it towards that.
Exactly. And so by increasing the awareness, bringing it up and like I’m married to a psychologist, and I had no idea what some of some of these issues, you know, I didn’t Know About the $3,000 bill that these families got to sort out or, or maybe just not go to see a psychologist because of and that discussion with Adrian, it was Dr. Adrian Matheson. And talking about as you put, if you invest in this in these kids early, it could have such upstream positive impacts on their lives. And that you wouldn’t believe it, you know, avoid long term mental illness, avoid them being incarcerated, avoid them and having drug addictions. And and it just hits such a. I mean, you and I, we both have three boys. And like, it’s like if we can’t step up for a kids, but can we step off for you know what I’m saying? And so like, when, like, when I heard about this initiative of having free care for the kids, I was like, This is what it’s all about. This is why we’re doing this. This is a small step. This is a little thing, but this i’m a i’m one person. I have a team now helping out with the podcast, so shout out to the team. Love you guys. But this is me five months in and already having a footprint. And this is to me, this is how we’re solving. And this is just the beginning to Bradley like, we, because of this similar episode, we did one on marginalized patient populations, like people that are on the streets in the care that they need. You know, there’s one of our intensivists approached me saying, Can we not start funding some kind of program to get, you know, these kids that are vulnerable into some program to try and, you know, give them some hope. And so, like, nothing has materialized yet. But we’re having that discussion. We’re having that dialogue, and that’s how it starts, and it’s how it started.
I can’t happen without that dialogue.
And I believe in my loins, I believe, like, things are gonna get better.
Well, where can people find where can people find your podcasts? Yeah, so
solving healthcare. We’re on or everywhere. We’re, we’re on. We’re on Apple. We’re on Spotify, Stitcher, everywhere you find your podcasts cost box, wherever you are Google Play, you can follow us at Quantcast on Twitter, Facebook, Instagram, YouTube, and I really appreciate the listenership and those that are listening already.
And I think there’s also a link to it on your web page resource optimization network comm it’s a good place to find it too.
And can I say one more thing, Bretton Woods, I, I want to make sure that your listeners realize how beautiful of a thing what you’re doing is okay. We as clinicians, and and medical trainees, we don’t get some of these finer skills in medical school. It’s very mentorship dependent and if you don’t have that kind of access to good mentors and like, some of the stuff the content you’re creating, we people don’t get that exposure. So I think Just want to commend you for the value of the show. I’ve been a recent subscriber and the content that you’ve been throwing down. It’s been beautiful and i think it’s it’s a way that we can become stronger we could become more connected with our patients and their families. So like, Good on you, my friend.
I appreciate that. That really means a lot that really warms warms the cockles. Should buddy
should
so I really appreciate you taking the time to be on the show. You’re you got a lot of hats, the podcasts resource optimization network, palliative care, the ICU three boys. Yeah, you got a lot going on. So I really appreciate it and it’s been a lot of fun, a great conversation, and I appreciate the compliment there on the
absolutely means a lot. Thanks for reaching out boyfriend.
I take care.
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 a 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

Do No Harm, a film by Robyn Symon on Physician Suicide

Robyn Symon is a two-time Emmy Award-winner, and an accomplished writer,

producer/director, and editor. She is the producer and director of the documentary film, Do No Harm, about the healthcare system that drives us to take our lives.

We discuss how prevalent physician suicide is and how the real numbers and demographics are so difficult to track. We talk about the difference between paying lip service to change and what changes may actually help. We also talk about how the current coronavirus epidemic will make more apparent how overtaxed and overburdened many physicians really are. There will be an upcoming virtual screening on April 19 (see below).

 

Ms. Symon began as a television news reporter in Texas, then joined PBS in Miami where she hosted and produced documentaries, public affairs programs and the TV series Florida! (6 seasons; Travel Channel). She wrote and produced the docu-series “Voices of Vision,” which focused on the work of non-profit organizations worldwide. She has produced hundreds of hours of TV series for major cable networks including Discovery, CNBC, HGTV and currently produces a series on the Reelz Channel.

DoNoHarmFilm.com

Virtual Screening

WHEN: Sunday, April 19th at 8 PM EST/7 PM CT/5 PM PST

WHERE: FOR TICKETS: ZOOM WEBINAR LINK https://zoom.us/webinar/register/8715849795868/WN_x–X68dnR_i6_kTXvCyVFA

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.

Robert diamond is a two time Emmy Award winner and an accomplished Writer, producer, director and editor. She’s the producer and director of the documentary film do no harm about the healthcare system that drives us physicians to take our lives. We discuss how prevalent physician suicide is, and how the real numbers and demographics are so difficult to track. We talk about the differences between paying lip service to change and what changes may actually help. We also talk about how the current Coronavirus epidemic will make more apparent how overtaxed and overburdened many physicians already were. There’ll be an upcoming virtual screening of her film on April 19, and see her website do no harm film calm for details. Miss Simon began as a television news reporter in Texas then joined PBS in Miami, or she hosted and produced documentaries public affairs programs in the TV series, Florida. She wrote and produced the docu series voices of vision, which focused on the work of nonprofit organizations worldwide. She has produced hundreds of hours of TV for major cable networks including discovery, CNBC, HDTV and currently produces series on the real channel.
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.
Robin Simon, thanks so much for being on the podcast.
It’s my pleasure to be here. Thanks, Fred.
So let’s start with the hard numbers. how frequent is it that a physician dies by suicide?
The numbers that are used by suicide experts is about 300 to 400 a year but it’s really underestimates because many of these suicides are listed as accidental and planned as extra as accidental overdoses or car accidents. And so the families of the physicians and the hospitals, and you know, the medical community are not eager to say this was a suicide. So we don’t really know it could be three or four times that we just we don’t know. But that’s what the experts are saying three to 400. And, and they say that mid career physicians have the highest rate and women attempt more than men but male physicians are more successful if you use that word. Yeah, at suicide, but mid career. We see when there are a lot of factors that come into play. It could be, you know, a malpractice food that threatens your financial security, your inability to pay off alone, ruins your reputation, your job to be at risk, and you have a family. And it just, you know, leads physicians to make what they feel is a logical choice, a logical solution to the problem.
Yeah, that actually doesn’t surprise me that it doesn’t surprise me that it’s an underestimate because, as physicians, right, we also recognize that if you die by suicide, your family can’t collect your life insurance. And so if you are going to do it, you do it in such a way that it does not appear to be a suicide so that they are able to collect I can see that being a very calculating thing for you know, a physician just the way that’s that’s the way we think we’re very pragmatic. Yes. So where does that put us compared to other professions?
Well, you know, near the top is not the top when I was working on the Film Editing, which was about a year and a half ago, because we’ve been on the film tour for about a year and a half positions had the highest rate of suicide among all professionals, and almost twice the rate of the general population. So it fluctuates, you know, from year to year. And because we don’t really know the true numbers because of the stigma of suicide and mental health in general. We don’t really know but let’s just say it’s
towards the top if not at the top. That’s interesting. Yeah, I do. I do not when I was a medical student, when I was applying to medical school. I do not remember that being on the brochure I you know, they put those shredding. They put those short white coats on us and say welcome to the club, and something that they neglect to tell us is that That, you know, here’s this short white coat. Every patient you see from now on could be something a diagnosis that you could miss and get wrong that ruins your life and could be something that haunts you for the rest of your life and affect them for the rest of their life. And by the way, we have one of the highest if not the highest suicide rate of all professions. Here’s your white coat. Right? Yeah, I do not remember that being something now. Gustin medical school. That being said, it has been a while, since I since I graduated. So you know, I know this. The schools have evolved. And they’re including more,
they’re still around. They’re still not saying that. No, that’s still not part of the tech talk. Yeah. for new students. Yeah. Because another big issue is statistics. You know, we’ve been trying to find out statistics on the rates of depression and anxiety among medical students. You We know that when they go into medical school, they’re normal or above normal. And when it comes to mental health, and within a year, they have a 25% increase in severe depression and anxiety. So, medical schools don’t want to do these anonymous surveys, because if they have to show their statistics and other schools don’t, would it leave them at a competitive disadvantage? So in the film, there are parents who, you know, were blindsided by what happened to their perfect son. And when he died by suicide, they turned their grief into action, and worked to try to get legislation passed that would force medical schools in Missouri to reveal their Or surveys for depression and anxiety. And at first, all the medical schools killed the legislation. And then they tried again. And finally, you can see in the film after much effort with the help of a very brave state representative who also have position, they finally were able to get it passed. But no, it’s the transparency is not, not the top of the list for medical schools and hospitals. Quite frankly,
that’s interesting that you say you said that they start that we that physicians or rather medical students start out with with mental health that is either consistent with the national average, let’s call it or even better than the national average. But I would think that dying by suicide would be there’d be a higher incidence among high achievers So how do you I don’t know how to juxtapose those two ideas. Right?
Right, you would think so, but their emotional state and they are perfectionist, yes, there, there may be some emotional aspect of, you know, them being perfectionist, OCD, or whatever. But this isn’t a generality. This is a survey of them being above normal. So that’s what we know. But there are ways to mitigate those rates. And it’s St. Louis University in the film, they did a pilot program, and we’re able to reduce pression and anxiety by like 20%. So it was down to 4%. And it wasn’t that difficult to do. It didn’t cost that much. But the most important thing is these young med students, this is the foundation for their career positions. So the whole premise of the film is that, you know, if you don’t have a doctor who’s mentally invested Physically functioning? Well, you can’t provide good quality care. So this is something that affects, you know, all of us. What was
it that St. Louis University did? What were the changes?
Uh, it was a combination of small things. So, for example, they went to pass fail, which, you know, step one,
and I would say that’s a big deal. I don’t think that’s a small step.
That’s a big step. Now, they’re all doing it. But at that point, there were only like 20 schools that did it. They provided they got rid of classes that were too difficult. And they gave their students time off. They extended holidays like thanksgiving for the students to go home. And they and they provided them an opportunity to do charitable work in the community. So they felt fulfilled. Not just you know, with their heads in the book. And they also did, you know, a small resiliency program. But it was the combination of these things. And of course, you know, anonymous counseling, a combination of all these things that really work. So you have a lot of hospitals now that are doing what I call bandaid approaches to improving wellness among physicians going online and do this model. So in the AMA website,
you know, the the irony of having to do medical having to do additional model modules additional work. Yeah, it’s incredible.
More, it’s incredible. And so when there’s
a lot of it’s mindless clicking Yeah,
mine was and what does it do if you don’t complete it? It makes you feel worse. Well, Wow, I can’t even do these modules, you know, for resiliency and burnout. So that’s not the solution. The solution is looking at systemic changes. That should be made to allow physicians to perform at their best, whether that means providing more support people, whether it means, you know, dealing with the EMR system that, you know, nobody seems to, like, time off, you know, dealing with a sleep deprivation, whether it’s dealing with the stigma of mental health, providing anonymous counseling, there’s so many systemic things that should be done, but not these meditation and yoga classes. And certainly, when you have bad outcomes with a patient, you know, they should be providing regular support, like support groups, every two weeks for physicians, and you could you should drop in and if you’ve had a bad outcome, lost a patient, you drop in, and it should just be part of the program. Not like, Oh, well next Wednesday at 230 The Chapel if you want to talk, we’ll have a psychologist there for you. That’s basically what’s happening in many programs. It’s like lip service to wellness programs. And it’s just not good enough. And that’s why we don’t see the change that we should be seeing because it’s very meager attempt to support physicians. So when when you can be establishment when you confront the establishment about this, right,
who is the establishment who’s
who’s in charge here?
Like who do we? Who do we even go to?
Well, really, you know, it’s a hospital system, you know, if you work at a hospital, but there there are a lot of groups involved. So for example, the medical board the medical licensing board, the questions in many states, not in New York, they changed it, but in in many states, the questions that they asked on that licensing board exam to get relicense or license in the first place. about mental health needs to change. They asked you just filled out that form. It’s still there. There was a question that was asked, Do you remember?
i? Honestly, I don’t remember. I don’t remember exactly how it was phrased. But I definitely had to check some box about make you feel uncomfortable. No, but just given that I have this podcast, I am more aware of that question than I otherwise would have been. You know, like I, as someone, you know, I don’t have any diagnosed mental health issues. So in the past, I would have just checked that off. But, you know, this this, one of the benefits of hosting this podcast is it’s made me a little more attuned to issues like this. And so yeah, when I had to fill it out at it, I understood why people would not come from forward with their mental health issues because now they’re having to check this box and you know what checking that box means Yeah, right. There’s gonna be a whole lot more that comes down the road that’s gonna make it harder for your license renewed. If you if you check yes on that box so I just you know, I just I don’t remember specifically how it was phrased but I’m definitely more to that
needs to change because this positions you don’t have the right and should be encouraged to seek mental health counseling there there on the front lines and we see that now more than ever people are finally starting to see how important positions are you know, there’s so much anger and anger towards positions you know, between the patient and condition relationship has deteriorated so much, but,
and everyone right now who’s on the front lines dealing with the Coronavirus, right the the ICU doctors, the hospitalists, the palliative care physicians, the ER doctors, the anesthesiologist, the pulmonary physicians that all of these doctors that are like neck deep in Coronavirus right now are should, should all have easy access to counseling because of what they’re going to leave they’re getting there really
is these these now we’re getting the respect that they have deserved all along. But I really fear that when this who’s done or when this was passed that day, those on the front lines are not going to have access to mental health counseling. I mean, this is like a war. And they will be suffering from PTSD. Many of them already have PTSD from losing patients. But you know, But I fear that it’s just going to be business as usual. And no mind is going to be paid to what they’ve gone through emotionally. And it’s going to be a big problem. And I just fear, you know, look suicide is, you know, what the end result gets a lot of attention. But there are just a lot of people, a lot of physicians suffering deeply with depression and anxiety. And there’s a lot as you know, self medicating. And, you know, I come from a family of physicians, but as a patient, you know, I want my doctor to feel great, and be at the top of his or her game. So we need as a as a society to wake up and understand that physicians are human and that they deserve emotional support because they’re human, just like firefighters and police officers. They’re on the front lines. They they have they have a sense of camaraderie that physicians don’t have. It’s not encouraged for them to get together. They fight fires together. We treat patients fire sensing. Exactly. So yeah, I have a big fear about what’s going to happen after this is over. So, yeah, we’re going to talk about it. Never that never a discussion that we’re going to have after the virtual screening on April 19. I know that a
virtual screening right now. Well, it’ll be in the show notes. But let’s plug the virtual screen.
Well, here’s how this happened. Because we were planning a we’ve been on a film tour for almost two years since September 2018. And we’ve had about 170 screenings at hospitals, medical schools, medical countries. foods like ASAP, and APA and many, many others. So we had a host spring, you know, live events at hospitals and conferences. And of course, with COVID-19, everything was just cancelled. But I people really wanted to see this film. So I said, you know, let’s have a virtual screening with a panel discussion. And so the film is heavy, like it’s about suicide and burnout. And it’s like, why do we need, you know, to talk about this, we’re already you know, barely surviving here. But the panel discussion is really going to focus on how this pandemic has impacted not only the healthcare worker, not only the physician but their family to what they’re going through emotionally, and what needs to happen. So we’re advocating for let’s not forget when this is over We need pork for physicians. It shouldn’t be business as usual. So that’s what I hope the focus of the panel discussion will be. First of all, what trends we’re seeing with Dr. Pamela Wible, who you know, is the physician advocate. She runs a hotline for physicians and medical students, a doctor called Puri, who does like Chi trust at UCLA. And he’s also a writer on the Chicago Med series. And parents who are featured in the film who lost their son Kevin to suicide. So we’re going to talk about what kind of numbers and calls the Pamela’s getting on her hotline. And, Paul, for us, it’s like high interest. We’ll talk about the impact on physicians families, and how they can cope best I mean, there’s a lot going on with separation of families because the physicians don’t want to infect their family. So you’ve seen the stories they’re sweeping into And in basements or not even at home where they’re sending their families away. So they’re coming home to empty homes. It’s just, you know, it’s a very scary time. So we need to, you know, deal with the fallout afterwards.
Yeah. And I think it’s, it’s important for the physicians that are going through it to realize that I’m sure as they’re going through it, recognizing that, that they’re, they’re not the only ones that are feeling this way. Right. They’re not the only ones that are having these thoughts. You know, we are we’re a community and we’re a tribe, as physicians,
that’s, that’s really the message of the film, you know, you are not alone. You’re not weak, because you’re feeling depressed or anxious or afraid. Even you know, before this crisis. You’re not alone. You’re You’re not a weak link, as the professional would like you to think because you know, there’s cutthroat competition starting in medical school, so the the message of the film is you our community, and we have to support each other. And it’s not you. It’s the system. And we need to change that
when you show this movie to physician audiences, what tends to surprise us because I think we understand, right? That we’re under a lot of pressure, right? We have to see a ton of patients, we have to chart correctly. Every patient could be a landmine of a possible, you know, an error that you can make sure you do everything perfectly, and yet they still come back and sue you, and then you’re staying late to finish your charts, financial pressures to pay back your loans. You know, you get home and then your family needs you and you feel like you’ve given everything at the office. Right? I feel like physicians, we we understand this. I’m not saying that I mean don’t misconstrue what I’m saying like as as that like validating the act, but like just the the crushing pressure that we’re under, I think you’d be, you’d be it would be hard to find a physician that wouldn’t understand that, that feeling of being under this crushing pressure, at least at some point in the career, maybe just in residency, maybe afterwards. But what do you find surprises physician surprises, the physician audiences when you show this to them? What, what really surprises us?
Well, first of all, you know, physicians are born overachievers. And then of course, you’re told, you know, now you need to build resilience. So which is kind of crazy. But I’ll tell you when when physicians see the film, because majority of the audience is made up of the blue ocean, they’re shocked at how repressed they are. about the experiences they had in medical school and residency, because they’re just, you know, trying to keep keep on that treadmill, and you don’t want to look back because you’re going to fall. So when they see with film and they see the hazing, the pimping, the bullying the, you know, sleep deprivation, in residency that we follow, they afterwards they say, wow, I had repressed so much of what happened to me. And I think being able to recognize that, even though it’s difficult is healing it’s part of the healing process because repression is not good. So it’s, it’s really good for them and it’s good for them to share their weaknesses and their fears. with each other, they normally would never do that. And I’m really surprised at how many people share their suicidal ideations, their attempt stories, their, you know, even mistakes that they’ve made their frustrations with administrators. I mean, they’ve been very vocal. So the dialogue that we see is really incredible. After the event,
it’s almost like the movie is a key that unlocks something that then just pours forth from us. Right. It’s almost like permission to start talking about the things that we weren’t, didn’t feel like we were able to talk about before.
That’s exactly what it feels like. And my uncle was a colorectal surgeon in New Jersey for 30 years, and I say was because we lost them a couple years ago, but I showed him 20 minutes of the film when I was working on it, and he said, this is going to open up Pandora’s box, because physicians are just not used to talking to each other about their struggles. It’s just not done. You know, in fact, like people would describe to me, you know, they would avoid each other in the hallways, other than like a little nod because, you know, you don’t want to ask how someone’s doing because, you know, they don’t want to show their weakness. And then you don’t want to get involved because then you might wind up holding their pager if they need help. So down the line, so there’s such little discussion about what’s really going on. So you have these relationships, but they’re very superficial. And what the film has done is really got people talking on a much deeper level and some administrators are supportive of this because they understand that to improve morale to improve wellness, you need dialogue. And you need support. So you can’t just have the film and say, okay, you have a film and you know, you got to air your feelings. Now let’s get that to work. You really need to take this and move the ball forward. What can we really do? How can we be proactive to make changes that will see real results in morale? And after the event I talked about, you know, because I’ve traveled to a lot of events. I talk about solutions that I’ve learned along the way at different hospital systems and I share them with other physicians and maybe it could work at your hospital or your medical school. So it’s been interesting to see that sharing going on. Could we do that? can we implement this? And so it’s, it’s the way I used when I do documentary films. It’s for change. And I hope that change is happening. But I just hope that it’s embraced more by the powers that the administrators at hospitals, medical societies have been very supportive. But the AMA is not supportive of the film, The acgme. Well, they don’t come off looking at well in the film, not supportive. So, you know, it’s too bad. We can all work together, but we’ll push forward for what really counts, which is systemic change to improve the wellness of physicians, and also quality of care patients. Is this an issue in other countries? Is this or is this a product of American culture where you’re worth really hinges on your status whether status is defined as academic excellence or financial Success is that is this? Is this a purely American phenomenon? Or is this happening in other countries? That’s what’s fascinating in the film, we have a section on what’s happening internationally. And what we found out is that this is truly a pandemic, because what we realized is that it doesn’t matter. Whether you have a managed care system, the pay system doesn’t matter if it’s socialized medicine. What it really comes down to is sleep deprivation and the stigma of mental health, the inability of physicians to get mental health, the stigma that they face, in their communities, for needing counseling. So if you have those two elements, the stigma of being depressed and needing help or just wanting mental health treatment or just appearing weak Feeling the stigma and sleep deprivation? together? You have this problem. And we hear from people all over the world. huge problem in Asia. We hear from Australia, big problem. South Africa, now in India, but it’s hidden, except in India in the film. You see, they read the suicide notes on the evening news. So they talk about it, but it’s a huge problem. So
still a problem even though it’s out in the open.
Yeah, exactly. Because the stigma still exist. And the sleep deprivation still exists. So especially for residents, you know, in the film, Dr. Charles Sizemore from Harvard, he and Dr. Chris Landrigan both from Brigham and Women’s and Harvard who run the sleep Center at Harvard, and they you know, they sent to me and I put it in the film like speak about it. You’re a resident, I knew Resident you’re an intern, you just got out of medical school, you’ve just had all this training. And now you’re about to see patients on your own. You know, you have clinicals, your third and fourth year of medical school, but I’m talking about really caring for patients on your own as an intern, and that they’re really you’re set up to fail, because you’re forced to work 28 hour shifts, when it’s been proven that after 16 hours, you’re not really learning your brain because you are human, doesn’t have the capacity after 16 hours. And they’ve done many studies in the lab about sleep deprivation and medical errors. So you’re a resident and you’re now forced to work these slave shifts. You get into your car, get into a car accident, sent out by the hospital, go home for come back in a few hours and then you live with a fear of hurting someone or worse killing a patient in the beginning of your career, so you’re set up to sale right from the beginning, that might hurt or kill someone. I mean this what kind of profession is this?
So well, that really begs the question, what is a resident? Right? What is an intern? Are they a student? Are they an apprentice? Are they an indentured servant? Like what? What are the what is their role? Is their role just to learn? Are we trying to optimize their learning? Or are they there to work? Like, you know, like a physician extender. Why? And I think if we really to sit down and define, we’d have to define it first before we could decide what they are. Right? And then you could decide whether those work hours are because they’re, you know, clearly they’re unreasonable. But are we going to be Are we going to accept it? Are we going to accept it They’re an apprentice. They’re not a student anymore. They’re an apprentice. So I think we need to define that. I mean, personally, I think the whole the system needs to be built from the ground up. Because Yeah, we know so much more about effective learning and effective teaching than we did. And this this system, the system has evolved. And just like we covered in episodes on the podcast about evolution with Nathan lense, who’s an evolutionary biologist, you know, evolution creates just a cobbles things together one thing on top of another, so something that used to be an arm now becomes a wing, because that was the limb that happened to be there was it? You know, if you built it from the ground up? Would you have that arm turned into a wing? Probably not. You probably have a separate set of wings and arms, but that’s not how it works. And that’s how the medical system has evolved, right? It’s just cobbled together over time. It hasn’t been built from the ground up and if we could build it from the ground up, then I think we we’d win Have an effective system because of how much research is out there. So if we’re really scientists, then we really do need to take what is what data is out there about the most effective learning and then institute that.
You’re talking about a one, nobody’s really asking me, no one asked you. And you’re talking about a century old system that no one wants to bother changing. And what you say is, that’s in medical school, and even in hospitals. Dr. ciphered said to me, Imagine that you’re using medicine has changed so much just even in the last 10 to 20 years. But yet, we’re using the same model that we did years ago, decades ago. It doesn’t work. So you can’t use the same system you have to resolve. But the system has not evolved in medical training, and it hasn’t evolved for practicing physicians. It’s a big problem because evolution could cost money and it could take time. And it seems that the people in charge, the administrators don’t want to spend the time and the money to evolve with what’s happening in our society and the demands on health care. So, for example,
because you’re going to take a financial hit, right, you’re gonna see fewer pay, it’s gonna end up with either residents who are attendings, or both see your patients, and that’s going to be a financial hit. Ultimately, it may lead to fewer medical errors and fewer lawsuits, but that front end investment that you got to make and that’s a that’s a tough thing to do. We got away from something that I want to come back to because I’m just really curious about what the answer is. You know, you mentioned that women attempt suicide more often, men die by suicide, because those their attempts are more right for lack of a better word successful but aside from the male female split, what are the other demographics is this is this more common in minorities, this is more common in people from a higher or a lower socioeconomic status. Is this, like who is this affecting the most? I’m
curious. Statistics are so cooler. Because until recently, I think since 2014, when in New York, I don’t know if you remember these two young doctors within a week of each other, jumped from the roofs of their hospitals. And it really woke everybody up once again, because I guess we went to sleep for a while to to the problem of suicide and burnout. And you know, there was renewed interest, because remember these tough topics on mental health and about suicide and depression, nobody would go. So it wasn’t just, you know, the leaders of the conferences of these big organizations. Physicians themselves, didn’t want to talk about this because they were You know, brought up just to say, this is not a problem for me because I’m supposed to be perfect. This statistics are very shaky for me. There there isn’t. There aren’t statistically say, you know, minorities are more effective. It’s it’s not. It’s not a minority thing. It’s not a socio economic crisis. You don’t really know and I don’t really because we don’t know because so many suicides are really coded as accidents. We don’t really have a good grasp. We’ve been using this 300 to 400 number for so long. Because we don’t really know I do know that Dr. Pamela Waibel when I started working on the film and she showed me this book, she said she had a die of suicide diary, and she was compiling for herself because there were no real statistics. suicides male female Now hot method of suicide. And when I shot that scene with her that you see in the film, she had about 200 names. Now she’s got over 1600 names in this diary, because I shot that scene with her in 2015, let’s say. So that’s what she’s added to her diary in just that space of time. And those are just the ones that she knows about. Those aren’t the ones that are coded as accidents, she can verify those. So we don’t really know, Brad, it’s just so that’s part of the frustration. That is not a real interest to find the numbers. The real numbers. Yeah,
yeah. I mean, you know, that was gonna make the segue into the current pandemic, same issue, the numbers, how many cases are out there? We don’t you know, we’re not tracking it. We’re not we’re not our testing is Limited, that the numbers that they’re putting out there are, you know, pale in comparison to the, to the real numbers. And it’s hard to code, you know, who actually dies as a consequence of COVID-19 versus, you know, some secondary cause. And then, you know, those statistics are just are just challenging. So, in the face of this pandemic, let’s say you, you were in the process of creating your documentary. Hmm, right. You had done it a couple years later. So that this was occurring in the midst of you creating your documentary.
What would you have done differently? In the wake of the current pandemic, what would you have either included or tracked or covered? If you had included this, what we’re going through right now in your documentary, first of all, Brett, I think it would have been easier because when I started working on excel in 2014, no One wanted to talk about it. It was so challenging to get physicians and medical students, or part of the establishment to talk about this topic, it was still very much hidden. And, you know, people just have this vision that physicians had this cushy life. And you know, they were playing golf, it just, there wasn’t a lot of motivation to talk about it. So I think now if it had happened now, there would be a lot more interest to talk about the pressures, and a lot more acknowledgments, a lot more transparency, because we see it, we see them getting suited up and getting sick and losing their allies to help patients. So of course, this would be a fascinating example of how important positions are. But when I started working on the film, position, suicide and Look, you know, suicide is a problem in society in general, why should we care about physician suicide? And I, you know, was trying to draw the link Look, if if physicians are taking their lives, what kind of care do you think you’re going to get? as a patient? Think about it, think about it. So now it’s, it’s easier to see how important positions are now, you know, men don’t realize these are ER and ICU, you know, these are hospitals that are really on the front lines, physicians like you that have private practices that are hurting and other ways you know, financially. You know, no one’s having elective surgery and people are reluctant to go out of their house forget about, let alone go to an empty appointment to get their deviated septum
earwax clean. Yeah.
physicians in private practice are hurting in other ways, but it just would have man made it easier to get along. empathy for positions that what I experienced back in 2014 1516 of all it took me four years in between shooting for a year and a half, two years and then editing for another 18 months. So in in that space of time, you know, there was just starting to see, you know, more dialogue and more programs, but there was still a lot of resistance to talk about this. So it would have been actually easier.
Yeah, I can see that right now. They’re just so overburdened and overtaxed and if they were already even a bit burned out beforehand you know, they they have no guard left. So you ask them a question and they will be more than happy to go into great detail about what is what challenges they’re facing or and have been facing.
I’m holding posted a cold COVID-19 we can still use this film as a means To get the community together and have a dialogue about what has happened, you know, how can we use this spotlight this national spotlight, this global spotlight on physicians and all healthcare workers to demand change to improve wellness and safety. So
tell us one more time about the virtual screening for do no harm.
The screening is on April 19, which is a Sunday evening. It’s 8pm on the east coast. 7pm Central and 5pm on the east coast. The easiest way to register is if they go to the do no harm film website, and on the homepage, there’s a button right there to click to learn more about the panel and the event. And then you can register
and that’s do no harm film calm, correct. Okay. Robin Simon, thank you so much for creating this Extremely important documentary and for taking this time to do the podcast.
Thank you, Brad. It was a pleasure. Thanks for having me.
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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Introduction to Meditation for Physicians with Jill Wener, MD

While this episode was recorded before the COVID-19 pandemic, it is all the more relevant. Meditation is an arrow we should all have in our quivers.

After over 10 years practicing Internal Medicine at Rush University Medical Center, Dr. Jill Wener knows firsthand what severe stress and burnout feel like. In the midst of her own burnout, she was introduced to Conscious Health Meditation, and it had a profound effect on her resilience and reactivity. After 2 years of coursework, Dr. Wener completed her 3-month teacher training in Rishikesh, India in April, 2016 and now teaches meditation, among other stress reduction techniques, full-time, primarily to physicians.

This is an introduction to meditation. She starts by defining meditation and then delve into the different types, and why she has chosen to teach Conscious Health Medication over the others. She is a skeptic turned believer and helps us to start heading in that direction. In addition to meditation, she also teaches tapping, similar to exposure therapy, and we briefly discuss this as well.

Dr. Wener’s 8+ years of practicing and teaching stress-reduction modalities such as meditation and tapping, combined with the teaching and mentoring skills developed during her academic medical career, her personal experience with burnout, and her intimate understanding of the healthcare system, make her uniquely suited to teach meditation and other stress-reduction techniques to healthcare professionals from all fields.

theresttechnique.com/

jillwener.com/

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

This and all episodes can be found at PhysiciansGuidetoDoctoring.com

 

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.

After over 10 years practicing Internal Medicine at Rush University Medical Center, Dr. Jill Wiener knows firsthand what severe stress and burnout feel like. In the midst of her own burnout. She was introduced to conscious health meditation, and it had a profound effect on her resilience and reactivity. After two years of coursework, Dr. Wiener completed her three month teacher training in Rishikesh, India in April 2016. And now teaches meditation among other stress reduction techniques, full time primarily to physicians, something we could all use a bit more of right now. This is an introduction to meditation. For the uninitiated. She starts by defining meditation and then delves into the different types and why she has chosen to teach conscious health meditation over all of the others. She’s a skeptic turn believer and helps us to start heading in that direction. In addition to meditation, she also teaches tapping, similar to exposure therapy, and we briefly discussed this as well. Dr. wieder is eight plus years of practicing and teaching Stress Reduction modalities such as meditation and tapping, combined with the teaching and mentoring skills developed during her academic medical career. Her personal experience with burnout and her intimate understanding of the healthcare system, make her uniquely suited to teach meditation and other stress reduction techniques to healthcare professionals like us from all fields.
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.
Dr. Joel Wiener. Thanks so much for being on the podcast.
Thanks for having me.
So let’s start off with your origin story. How did someone start out being a hospital Put a list internist and then become the internist Yogi.
Oh, such a lovely story. For me it started with burnout. And in 2011, they changed the residency work hours. And I don’t know where when you started when you did training, but a lot of the work ended up falling on the attendings. And that was my five year mark into being an attending and so I think it was a perfect storm, a bunch of other stuff that happened leading up to that, so I got really burnout, like it hit me like a Mack truck. It was pretty intense. And I was crying every day, one little bad thing would happen. And I would just get up and leave our office where we’d all be writing our notes and doing our documentation and go home. I just had no I had the shortest fuse and I had no ability to adapt to anything that happened to me. I wasn’t yelling at people I was just more like defeated and sad and crying and
and So,
around that time I met someone who told me they meditated twice a day. And Previous to that point, I had been the most skeptical unspiritual type a doctor, I had done some yoga before, but nothing, nothing crazy. And but something in me said, Sure, I’ll go hear your teacher speak. And when I went to go hear the teacher speak, he’s his yoga teacher from LA who was in town yoga teacher turned into a meditation teacher. And I everything he said was just like speaking to my soul. I don’t know how to describe it any other way. And I showed up. Like, I didn’t Google him, I had no idea what I was getting myself into. But I just was wearing my skeptical doctor pants and I was like, whatever, I’m smarter than everyone I know all the things about all the things and I’m gonna go there and I’ll just walk out and not have to do anything because I know better. And he started talking about stress and the way it affects our physiology and the way it affects our behavior. And that feeling of constantly being almost out of gas, that feeling of constantly being running on fumes. And he just spoke about that in a way that helped me understand how I why and how I had been feeling for the last couple of months before that. His course started the next day I had evening plans four nights in a row or four days in a row, about two hour one and a half to two hours each session. But I was like start me yesterday, I’m signing up, it was a week salary. So I was also very, very panicked about having to spend a lot of money on something that I didn’t know anything about no one I knew meditator This was we’ve come a long way. And in nine years, there was no one I knew, at least in my community that was meditating. And I signed up for this class and took it so that for me, and what I noticed was, oh, my god, these meditations are easy to do. It’s not mindfulness. It’s almost the complete opposite of that in terms of the actual practice. So it’s easy to do. You’re sitting comfortably with your back supported you’re not trying to control your mind at all. not fighting with what your mind does naturally. And I was having meditation experiences on the second day of class. So I was getting this like carrot approach rather than a stick approach that made me realize I’m actually doing something real and holy smokes. I cannot believe this was something that’s been in the world this whole time that I was just too skeptical or closed to realize. And I was able to fit it into my day. We carry pagers on us 24 hours a day, in my hospitalist job, depending on what we what service we’re on, but I was able to fit it into my day and make it work and I actually look forward to meditating and then my burnout went away. I mean, I started having benefits really quickly. I lost my road rage in three weeks, and
after a couple months, I just I wasn’t crying anymore. I wasn’t sad. I was
living in Chicago at the time, right?
Yeah, I was working at rush in Chicago and right,
downtown Chicago. Road Rage is probably different from rural Alabama. Road Rage right?
Well yeah, it’s not it’s not this is no fun. I wasn’t like a psychopath. I wasn’t like plowing into people and stuff, but I just didn’t get that like, panic anymore. And then I started to be like, Oh, actually the reason why I’m panicking right now is because I’m late because I left the house late so this is kind of my fault so me getting all freaked out about it isn’t going to help the situation I should have left earlier. And then usually when you get there and you’re late, the other person is even later and it all works out. So I I just kind of stopped mostly unconsciously stop sweating the small stuff but also was able to keep my head in moments where I would have been losing it and sometimes also doing additional talking myself down. So I felt great. You know, I burnout was great. I wasn’t at all thinking about anything else other than meditating is 20 minutes twice a day. All I was like thinking was I’ll meditate 20 minutes twice a day for the rest of my life because I’m never going back to how I felt before and then went on a retreat in India with my teacher. had some pretty incredible experiences there. And, like, you know, kind of, oh my god, even more amazing beyond what I had already been experiencing. And at that moment I was the, the stress, you know, compared to the rest of the group on the retreat, I was the closed minded doctor still, I was still very much like in my doctor world. And he said, Have you ever thought about becoming a teacher? And I was like, No, I’m a doctor, what do you mean I’m gonna be a hospitalist forever. And, but then I thought about it and I thought, Okay, well, like practice medicine and teach meditation and the teacher training is three months in India. So it’s a very intense training process Plus, it’s a couple years of prep work advanced coursework beforehand. So this is a pretty major undertaking. And so that was going to be my plan. hospitalist, you know, maybe point six FTP and then and then teach meditation the rest of the time. Then I had a really cool opportunity, opportunity to move overseas to China, and I had started to go Get some sort of itch of like, Hmm, maybe I’m going to be 65 one day and have been happy enough, but was starting to think that there was something else for me. And I’d be happy enough practicing medicine forever. But something else is out there and I had the opportunity to to China and that’s actually why I left my hospital, his job, moved to China for a few months, then went to India for my teacher training. And then that once I had been out of medicine for about six months, and did my teacher training and realized I had had a skill. That’s something other than medicine that I could do, that I was so so passionate about that I had personally experienced how life changing it could be. That’s when I realized I don’t think I want to go back to practicing medicine. I don’t see myself living that life anymore. I see myself doing things to help healthcare professionals to prevent them from getting to the point where I got where I was crying every day and losing it and to make everybody happier and higher performing and less stressed in at work. And at home as well. And so that’s that’s the answer.
That is quite the origin story.
Yeah.
So how do you define meditation, what makes meditation, meditation and not just sitting with your back straight in your eyes closed.
So meditation, meditation and mindfulness and yoga all kind of like tie in together. Yoga is typically thought of as physical poses that people do in order either to get exercise but but but traditionally, it’s physical poses that you would do to prepare yourself to sit in meditation. There’s all sorts of different types of meditation meditation in the Buddhist tradition. So what I what I teach them when I practice isn’t part of a religion. It comes from the Vedas, which is a body of knowledge that predates religion. Yoga comes from the Vedas. Ir VEDA, which is a holistic health practice that comes from India comes from the Vedas. There’s also Vedic warfare in Vedic architecture
the neti pot comes from and we use that all the time to learn
ology. Exactly, exactly. So, there’s a ton of really, really practical knowledge that comes from the Vedas, Buddhism and Hinduism. Both also came from the VEDA. So Buddhism, those types of meditation practices tend to be more contemplative meaning like you’re sitting and you’re focusing on something, you’re concentrating either on a word like a mantra, or your breath, or a physical sensation in your body, or what someone is guiding you through those, you tend to be sitting more upright. And those tend to be more what had been adapted to mindfulness practices. Now, they are also mindfulness practices that what we think of now as mindfulness is more adapted from the Buddhist lineage. Mine is more of more related to Hindu but it’s again, not at all religious, and it’s not Hinduism. But we are the difference is we are shifting our physiologic state rather than maintaining alertness and maintaining focus. Which is mindfulness, we are shifting our physiologic state when we meditate with my technique. The tradition is called Vedic meditation. I call it conscious health meditation for many reasons. But if you’re listening to this and wanting to look up more about it, Vedic meditation is where you would go. It’s also very similar to Transcendental Meditation. But I am not at all part of the TM, corporation or company or organization in any way. So I’m an independent teacher.
Why did you just have to clarify that?
I didn’t clarify that because tm is like an A Corp. It’s a corporation. And they teach people to meditate the same way I teach people to meditate, but they are their bigger cultural phenomenon. Some Some people love it. Some people get a little bit turned off by it because it’s a little bit. Some people find it maybe a little bit aggressive or a little bit culty. I’ve actually never been to any of their specific meetings. So I can’t speak for that. I’m just speaking for what people what people have reported back to me, but I tried to take any question. to try things out as hard as I can to take any of the trappings out of this practice because for me getting back to your question of like, what is meditation? It’s its physiology. It’s really so beautiful. I think one of the things that attracted to me attracted me to it so much is it made sense scientifically and medically to me, I didn’t have to stretch my brain to understand why it was working. It just was like, oh, okay, cool. That makes sense. So when we’re meditating, rather than sitting with our backstraight, and focusing and trying to cultivate present moment, awareness, which is awesome, and I think present moment, awareness, present moment, awareness is very important. That’s mindfulness. That’s not what I’m doing. When I’m meditating. When I’m teaching people to meditate. We’re using a mantra is the one that we use as a Sanskrit sound, and it has, there are many of them. I choose which one to give to my students, but there’s many different mantras that when you use them with the technique that I teach, they allow your your brain and body to settle into a distinct physiologic state. That is separate from sleeping, waking and dreaming, that is two to five times more restful than sleep based on the SPO. Two. So you’re actually more efficient, your body becomes more efficient. the metabolism of oxygen from your from hemoglobin is more efficient than sleep when you get to this physiologic state. And it’s super easy to get to and everybody can do it. I’ve never had a student that can’t get to it. So and you’re
seeing them that’s for conscious health meditation or for all forms of meditation
for what I teach. So people often will say that meditation mindfulness are the same thing. They’re like, Oh, I’m doing I’m on a meditation app. I’m doing a guided meditation. You could consider that but I think of those as more mindfulness and meditation is the actual transcending waking state consciousness and going to a different physiologic state, which then allows your body to it’s like defragging a computer. I also sort of think about it like a cooling protocol in the ICU, if you have cardiac arrest, and then you go, you know, you get the cooling blankets and everything to do Increase inflammation and free radicals so that the body is able to kind of cool off and then recover more quickly and have less damage from the cardiac arrest.
So that’s interesting. So you’re saying mindfulness meditation. For those who practice mindfulness meditation, you’re saying Actually, that’s not meditation? That’s something different. We’re using the same word. But actually, these are two different things.
Yes, I believe so. And there would be people who would be like, absolutely not what I’m doing is meditation. And I’m not gonna argue with them, I don’t care at all. It’s just a different you know, it’s on some level, it’s semantics. But it’s important to recognize that not all meditation is the same not all meditation requires sitting comfortably and maintaining alertness and fighting with your brain to make a do something that it’s not built to do because the brain just like the heartbeats, and it’s gonna beat all day long. The mind has thoughts all day long. And so to try to control those or, or or force the mind to do something other than is very uncomfortable and challenging. And that’s why you hear people being like, yeah, I meditated for three minutes today. And after, you know, four weeks, I moved up to five minutes. And then I stopped doing it because it was so hard. And I, you know, like, it’s not, it’s much more difficult to stay with it when it feels so challenging. And so this is so restful, and it feels so good that you come out of it feeling like you took the most amazing catnap ever.
So before we go take the deeper dive into the type of meditation that you practice, we just break down the other forms first, just so we know what’s out there and what the differences are.
Sure, sure. Do you have specific ones or you want me to
join? Well, I mean, you can, why don’t you start and then if there are any others that you don’t mention, then I’ll ask.
So mindfulness already talked about and mindfulness is a is a big umbrella. That’s gonna cover a lot of other types of meditation. So and again, I’m calling it meditation now, so I don’t, it doesn’t really matter to me, I just everyone always says At what I do is mindfulness and I just like to help educate people that there is a type of meditation out there that’s very different. So mindfulness meditation requires involves, you know, generally sitting comfortably, but with your back unsupported often with your legs crossed, but often not. And there’s a, an attempt to focus and cultivate your attention on something specific mantra breath, your body. The idea is becoming more aware in the present moment of what’s going on so that when you get into your real life, you are able to feel emotions coming up inside of you, and you’re not just completely a victim of the emotions as they come up and you can be more aware and maybe change the way you’re behaving a little bit. I’ve taken the Mindfulness Based Stress Reduction course I took that a few years after I learned Vedic meditation, and I loved it and I thought it was great. And it required a lot of homework and it required a lot of time to practice it. And I was just felt like, Okay, if I have to pick between one of the two, I’m going to stick with VEDA because I’ve got And such amazing results from it. And I can’t meditate all day I do want to do one to actually live my life. guided meditation or guided visualization is also a type of mindfulness because you’re, for the most part, you’re listening to what someone is saying and trying to put your attention on that and follow their instructions as they’re talking you through the sound of a waterfall or how you feel when you’re, you know, at the ocean and you hear the waves or imagining light coming through your head or you know, out of your head, whatever that is. That’s also cultivating awareness and attention. There’s chakra meditations. So chakras are energy centers throughout the body that are very much a huge central integral part of yoga practice, which we don’t always know when we go to a practice and get really sweaty. The yoga practice is all about opening and balancing these energy centers. I don’t really get into chakras much, if any at all when I teach my meditation, but that is a type of meditation where you go through There’s one at the top of your head, the corner the like your forehead and between your eyebrows, your throat, your, your chest, your heart chakra. There’s a few other ones. You can do a chakra meditation where you’re focusing on those energy centers and trying to open them or balance them. So that’s another thing. And chakras are really cool. They’re just not I’m not, I don’t have a expertise in them. And a lot of people will say, Oh, that’s too. That’s too woowoo. For me, I don’t want to get into that. But it’s actually pretty, pretty interesting. And there’s a lot of science behind it as well. So for anyone interested in taking it further, I do highly recommend that. Although studying with me isn’t, is not going to get you that what else there’s mantra meditation. So mantras. There’s tons of different types of mantras, there’s English ones, and Sanskrit ones, and German, let you know whatever language you speak, you can speak it in your own language or you can have it be some other ancient language, the ones that we use and you can say them out loud. You can say them silently. You can try to focus on them and concentrate on them in In the type of meditation I teach, you’re not focusing and concentrating on the mantra, it’s actually designed to be forgotten. Which maybe sounds a little confusing, but it’s not. You’re not trying to focus on that mantra for 20 minutes, as you’re meditating. So mantra meditation is a huge umbrella that can include mindfulness type practices that conclude what I do, which is more of a transcendental type of meditation. And that’s a umbrella term that can be there’s not just one type of that. Are there other ones that I’m
not? So that sort of sorry, the mantra meditation, you use a mantra in transcendental meditation, so as mantra meditation, the same as Transcendental Meditation.
So there’s Transcendental Meditation with like a capital T. That’s like the transcendental meditation brand. And then there is lowercase t transcendental which is just like a meditation that you do that’s going to shift your level of calm consciousness to a transcendental stage, kind of like, oh god, I’m trying to think of an example of that, you know, like Catholic, there was a lowercase E. And then there was a capital C, but I don’t remember I was a religion major in college.
I feel what they’re saying about Transcendental Meditation reminds me of like, when Bruce Lee came to America, and was teaching martial arts to Americans, and it was something that was supposed to be just within the Chinese community. And it was a problem that he was teaching it to, to non Chinese people. And I feel like that’s what you’re saying about Transcendental Meditation. It’s like, it’s this pre determined community. And if you you have to, you have to follow their rules and go within their rules and their scope and use their brand and sell their t shirts and coffee mugs.
Yes, to some extent, and bear in mind, some people who take the courses have no awareness of that and they just like learn to meditate and love it and it’s fine and some people do get much more involved. And in either way, they’re teaching people to meditate really well, and people love to practice. So. But yeah, it is a little bit more it’s like a more of a cultural community type, lifestyle kind of thing. Maybe there are types of meditation that allow you to shift to this other level of consciousness is transcendental consciousness. They’re not all capital transcendental tea, you know, capital T transcendental capital M meditation. mantras can be used for a meditation that might help you transcend waking state. mantras can also be used for mindfulness. If you think of you know people only as a mantra people sometimes meditate chanting a bunch so and and it also if you said, you know, I’m a, I’m a strong doctor, and I’m gonna kick ass at my job today. And you know, if you repeat that to yourself six times in the morning before that can also be considered a mantra and that’s English and that’s out loud. So, so there that that spectrum is very, very wide and and not very specific.
And so how did you arrive at conscious health Meditation of all of them. And I think you’ve, you’ve really covered it. But you know if you could take a deeper dive into, into, I mean, had you tried others it sounds like you tried others after you had already been a conscious health meditator and even a conscious health meditation. How did that? How did you arrive at that?
Sure when I learned that I was Vedic, so the community is Vedic meditation. So I was like zero to 60. I had no, I had done some, like, you know, very little mindfulness stuff at spas or at yoga. But I had never really been I wasn’t like looking for meditation. I was just desperate. And I was broken down enough that my consciousness cracked open just enough that I was receptive to something like this because I would not have been otherwise. Absolutely not would have, you know, if anyone listening to this is like, what is this crap? She’s just woowoo whatever. I was there, that was me. You know, I never would have been in anything like this. So. So I was I’ve met the person who told me they meditate and I went to go get the teacher. Speak. I honestly didn’t research. Not only did I not research, other types of meditation, I didn’t even research, Vedic meditation. I just signed up for the course. And it was awesome. So that that’s how I like to say it found me because it was sort of that moment in my life or something needed to change majorly. I call it conscious health meditation for a variety of reasons. I had a physical space, like a meditation, I usually teach from my home, but I when I first moved back to Atlanta, I grew up here. And so this is where I moved after my teacher training. I didn’t end up going back to China. So since 2016, I’ve been here in Atlanta, and I had the opportunity to open up like a commercial space of a meditation studio. And it wasn’t anything I expected to do. But I did and I decided the name of that was conscious health, meditation and wellness. It was not, but I was still teaching Vedic meditation. That’s what I was still calling it and then it sort of evolved over time because I teach positions. There’s also you people listening here have probably heard all sorts of horror stories about You know, the crumb crumb and Yogi Bhajan, and lots of other different guru types who have founded big movements who have done some not so good things to the people in their community. And there are some issues about that in my community as well. And I didn’t know that that happened directly to me. So I didn’t have this like big story to share. But I wanted to remove myself from any of that influence or connection. So that’s another reason why I call it conscious health meditation. So I like to be pretty forth. You know, honest about that. When asked about it, but so, for me, it’s a natural progression, but also an intentional thing as well to keep it my own community and my own brand,
so to speak to the skeptics out there, hmm. For those of us because because I’ve actually tried meditating before with my wife, we did the we did an app. We did it right before bed, because that’s really the only time that we were settled enough to do it. Yeah, man, I can’t even remember the name of the app. At this point, it’s one of the it’s one of the Uber popular ones. Yes, yes, it was headspace. And now we’re back to just scrolling our phones back right before bed. It’s you know, it didn’t, it didn’t stick. So, you know, convinced me that I should be doing it, but from a more, you know, physician skeptic kind of tilt.
Yeah, absolutely. And I love that you asked about this, because I have people telling me I’m like, it sounds too good to be true. And I agree it does. But it’s awesome. I think the only it doesn’t one thing I will say it does not fix everything. And I I was sort of sold that bill of goods a little bit when I learned so I was like, oh, if I just meditate enough, like everything in my life is gonna be perfect. And that’s not the way it works. But what I tell people and anyone that’s going to tell you that what they’re doing specifically is going to fix every problem in your life. You need to run away from them very quickly, because that’s there’s nothing that does that. There’s always going to be a side of Fact or a downside or, or an incompleteness to something you’re doing, I usually tell people 70 to 80% of things in your life, we’re going to get 70 80% better. This is if you practice consistently, this is not just taking the course, but actually doing it, taking the course and then actually doing the practice, some things in your life are going to get 50% better, some things in your life are going to get 100% better, and some things are going to be like the positive and negative symptoms of schizophrenia, but in a good way. It’s not just that the bad things are going to get better. But there’s going to be also these wonderful enrichments to your life that you didn’t necessarily know you could have or that would that you were missing, but just kind of got worse. What’s going to get worse.
You don’t have to take that question seriously.
No, I the only thing that would get worse, I think is when you start down the path of like, it can feel a little rough. Sometimes if you start down the path, this technique, as you’re going to this two to five times more restful state than sleep. It’s unwinding stresses from your entire lifetime. stresses that stress scars that we carry around with us. If you think about a song you hear on a radio that might remind you of a breakup or a particularly painful time in your life and yours, your friend is rocking out to the song and you’re like, oh, turn softball, and your heart’s pounding, and you’re sweating and you’re crying a little bit. You can’t bear to hear but someone else is having a completely different experience. It’s something in you that has this stress scar that is that you’re carrying with you. Or maybe you smell something that reminds you of your grandmother’s kitchen from when you were eight years old. And you’re like, Oh, this smells just like I could I’m right there with her God, you know, we carry these stress scars around with us, and they build up this wall around us, kind of like layers of an onion, I guess. And so you get kind of tough, and you feel like maybe you’re a little numb to the world, but it’s a survival mechanism. So it’s sometimes easier to go through life not feeling things, but also you don’t usually feel the good stuff, either when you’re that shutdown. And I think for physicians, in particular, with all the stuff that we see that just gets like layered upon layers upon layers upon us that we’re expected to just interact Realize that can happen. So as you start to peel back those layers, that’s another difference between mindfulness and this. What I’m calling metta. I’m just differentiating mindfulness and meditation. Mindfulness is great and burning off the stress, right then mindfulness will help get you out of your stressed out brain, right in that moment, and and calm the stress down. But what this technique is doing it’s it’s shifting your your nervous system from sympathetic, overdrive survival mode to parasympathetic activity. And that’s a healing mode, it’s rest and digest and, and healing. And so we’re actually able to reverse damage that’s that we’ve been stressed damage that we’ve been carrying around with us for days, weeks, months, years, decades. So this stuff as it comes out. Usually in meditation, sometimes you’ll be meditating and you’ll be like, Ooh, I’m anxious. Or I’m feeling annoyed or why is my you know, spouse making that weird noise when I’m trying to meditate or whatever it is. That’s just stress coming. Have you. And also as you start to become as that stress starts to peel to come out of you, you start it’s like peeling back the layers of the onion again, it can sometimes feel more raw and more vulnerable in there. But it’s a beautiful, it’s a beautiful space. But it’s it’s something that’s happening gradually. But I always tell my students, it’s not like you’re going to stop having emotions. I’m not, you’re not going to forget that these bad things happen. You might feel more, you might feel you might cry more commercials, if you’re watching if you’re ever watched commercials anymore, more emotionally affected by beautiful things around you as well. Because you no longer have that wall of stress around you. So for the most part is beautiful. But for some people, at times it can feel a little sensitive. But that’s why you have me when you take my my live course with me, you have me as your teacher for life. So you can email me and text me with questions at any time. And hey, I’m feeling this and I’ll explain why. So it’s not like the apps don’t do that. You know, you can’t write into the app and say hey, I had this experience while I was meditating Any thoughts? Because it isn’t a human being with expertise. So I would say that would be the only or the only downside as a long winded answer to that question, but I think it’s an important one. Absolutely. What’s some
of the science behind conscious self meditation?
Did I answer your skeptic question, by the way?
Well, I think that’s going to be more in the science aspect. Okay.
The other thing I will say is that it’s experiential. No one, no one quite understands where they’re about to get their songs get themselves into unless they know somebody who did it. And even so you still don’t know how awesome it’s going to be. Because no one believes that they’re actually gonna be able to meditate and that they’re actually going to do it and that they’ll everyone says, Oh, my mind is the only one I am the only one with monkey mind. I’m the only one who has thoughts all day long. That get louder and crazier. When I sit down to meditate. I’m the only broken one you know, I’m too my brains too active. Everybody says that. So so I don’t have to, you know, learn the techniques. Do the class and you will experience what it’s like rather than me having to convince you. So it’s kind of nice people, you know, definitely by the fourth part of the course, but generally well before that, or meditating very easily and successfully. So the question you had said the science behind it. I mean, there’s they’ve done studies on mindfulness, a lot of that that’s one of the great things about mindfulness is when it’s been adapted and secularized from the more Buddhist religious type practices to a more secular version. There’s been a lot of studies on benefits, pain control, and depression and anxiety. The Transcendental Meditation organization has a lot of money and they have done a lot of scientific studies as well on this practice. So what I teach again, is pretty much identical because my my teacher trained in that organization for 30 years and then and then he left so that organization has a bunch of studies they have but like anything you know, if you remember there’s one study about Rifaximin. Preventing hip hop encephalopathy and it was this like, oh my god is amazing results. But it was sponsored by the drug company. So you always want to be a little careful when the study is sponsored by the organization that is profiting from from the intervention. But so there’s great data there. And so there’s data on on improve school performance for kids improved depression, anxiety, pain, and and I’m talking specifically for the type that I teach, but there’s, there’s not a lot in the meditation can’t help. It makes you it’s they’ve done studies where it prevents secondary events for coronary artery disease and people who have already had events it can lower blood pressure, Gazprom so yeah, yeah, I mean, it’s, it’s you have the more benefits, the more consistent you are with the practice, but so there’s some pretty cool data and I think overall, the the body of the data suggests that it has a lot of really great impacts, but I think that studying meditations really hard because I I know that like when my students are coming to me, when they’re coming in, they’re choosing to learn to meditate because they really want to learn to meditate. They don’t like, that’s the choice that they’ve made for themselves. They’re going to be much more open and excited about it and committed to it, then if it’s something that like work is paying for, for example, that they’re like, Sure, why not some bias there? Yeah, yeah, exactly. So So and I, you know, I think that met it, it’s like a little slippery. It’s I think it’s a little bit hard to pin down and it can be frustrating. But when you do the practice, you feel the benefits. It almost stops mattering about the data, because it’s like, well, I’m doing it. I have this practice. I’m doing it I feel amazing. Data is great data helps make things more particularly something like meditation, it makes it more accepted by the mainstream scientific community, but it’s ancient knowledge that’s been around for thousands of years, if not longer. It’s it’s science. It’s science but in a difference presented differently. You know,
I wonder if there’s a minimally effective Right, like, at some point, if you don’t do it for long enough, you’re really not going to see benefits. And if you do it for longer it starts to be diminishing returns. I wonder if there’s an inflection point?
Sure, sure. Well, in my, in my technique from what I’ve been taught, at least, so that the man who started the transcendental meditation movement, who brought this technique over from people who were mostly like, monks and people who meditated all day long, he, he adapted this technique to people like you and me who have jobs and families and eat pizza and live in the world and drive cars and stuff. And so he, from what I’ve been told, tested it out. So right now it’s 20 minutes twice a day, but like, will it work with an hour once a day or two hours you know, and 20 minutes twice a day. In this in this type of meditation and and other types of meditation seems to be what people come out with as the sweet spot. I teach my course live. And in my live course, I do a ceremony on the first day and sounds good. Beautiful, but it’s you know, definitely for me it was outside the box for what I was used to, but I was I didn’t care. I thought it was lovely. I give a mantra to each person. And I’m teaching a practice, it’s 20 minutes twice a day, and my students are getting there are not 6 billion mantras. So not every student gets a different one. But it’s individualized to each student. I also teach an online course and both of my courses are CME accredited get CME for taking my courses. My, and I’m getting somewhere with this, I promise my online course. I use a this everyone gets the same mantra. And it’s 15 minutes twice a day, instead of 20 minutes twice a day, the type of mantra I use in the online courses just slightly less powerful because the students who take that don’t have that full access to me for a lifetime. And it’s important to have that ongoing contact with the teacher. But even with a different mantra, different, slightly different type of mantra that’s used in the same way. And the 15 minutes twice a day. My students are having incredible results who are taking it online, so you don’t necessarily need to go above 20 minutes twice a day. It’s like your receptors, your bliss, receptors are already full and there’s no need to stay in. Once you’re wet, you’re wet. And if you think about like dunking yourself in a swimming pool, you don’t need to dunk longer to get more wet, you’re already wet. But the 15 minutes also has been quite effective. So I think you can go a little bit less to that less than that. The 20 minutes, but generally I say less than 13 minutes is not going to be as effective.
Interesting. So where can people find those courses? My website,
I have a website meditation in medicine calm, and that’s going to have all the information about my online courses, my retreats that I do so I have a retreat for women and healthcare that I do in October at mirrorball spa. It’s the most amazing spot ever, and that’s all types of women in healthcare. But we’re not we’re it’s basically meditation and enjoying the spa and I do a little PowerPoint free little group lecture on Vedic knowledge and how it relates to life as a woman in health. Healthcare. So that’s really focused on the meditation and the stress reduction, I do another event called transformed with with my colleague, Marjorie Stiegler, who that’s more of a professional development, life transformational event. And we do that in January in Mexico. So registration for both of those are open for October this year in January of next year, and then the online courses as well. And I do another technique called tapping, which we haven’t really gotten into here. But that’s something else I do. That’s another really cool technique that helps people more with like specifics. If you want to global global life overhaul, you want to get more efficient at your job, you want to be happier, you want to be less reactive, meditations, what you want to do, but if you have a specific thing you’re trying to get over, you’re having specifically anxiety or a difficult decision to make or a phobia or trauma, difficult relationships, that’s, you can use this thing called tapping. So I have tapping question As well on that website,
what exactly is tapping.
So tapping is also called the Emotional Freedom Technique or EFT. And it is a technique that I first learned about when I was teaching my meditation course at a medical conference, the psychiatrists and psychologists came and they talked about using tapping and a few others similar modalities, with their veteran patients at the VA who had PTSD and the incredible results that they were getting. So I heard about it from a very, maybe a sanction inside the box source. And then I’ve heard about it more outside of that and people it’s it’s similar to maybe energy work, but you use the same meridians as an acupuncture or traditional Chinese medicine. But instead of using needles, you tap on them. And most of the meridians we use are on the face in the chest and you are basically tapped in and it works really really the the most effectively if you work one on one with a coach but you can also find free tapping videos on YouTube if you want to, you say negative things, whatever it is. bother you, let’s say you have a phobia of flying. As you tap through the meridians, you’re going to be saying out loud, I have this fear of flying, I’m afraid that we’re going to crash, I’m afraid that I’m gonna, you know, lose my life. I’m afraid that whatever it is you’re afraid of you say it over and over again, as you’re tapping, it actually sends Calming Signals to the hippocampus, as you’re saying it so it decouples that trigger from stress. And so the hippocampus is then not sending that stress message to the amygdala. And the amygdala is not going off into fight or flight. So you basically are changing the way your brain is reacting in the face of things that used to be very stressful, and it works very quickly. It’s very powerful. It’s incredible. I love it so much. And the results, if done right. are, they’re permanent, like you don’t have to keep tapping to get rid of the phobia. Once the phobia is gone, the phobia is gone. So I do that as well. I have an online course about using tapping for physician burnout. And I do a lot of tapping workshops at my retreats as well because people love it and you can do it very, you don’t have to get a full training in it to be able to tap on your own. That’s pretty much everything I do and teach people is to be a self sufficient practitioner at that. So I’m not guiding people through meditation, I’m teaching people specific techniques that they can do on their own without any apps, or they put their phone away. They meditate on their own same thing. Tapping, yes, you can work with me in person. But once you’ve done enough, a few sessions, then you are familiar with what to do. And you can just kind of keep it simple and treat yourself with it. It’s interesting.
It sounds familiar. It sounds similar to exposure therapy, for phobias, where you just started thinking about it and you look at pictures of it, and then you get a little closer to it and then eventually you just become habituated to it.
Yes. And the only difference is that as you were doing those sequential exposures, you will tap as you’re saying out loud, what emotion you’re having about it, what the fear is or what you’re afraid is going to happen and so what happens like, even faster and even more, it’s very streamlined. Right? So you don’t have to you can just think about it and tap on it you don’t actually have to like do it when you’re on an airplane in order to benefit from it. So you can do it sequentially like you were just suggesting as well. All right,
well, I really appreciate you taking the time to talk to us today and your website that’s where you can find all the courses Gil Wiener calm, correct. Spelling I have
comm w e n er that’s my like website for everything but I meditation in medicine calm is my website that’s more geared towards doctors to the programs that I do for doctors. So if you want to see more doctor specific programs and meditation in medicine, calm and then I’m on social media as well. Instagram and Twitter are at Gil Wiener MD. Remember it’s w e n er, and then Facebook. I have way too many professional Facebook pages and it’s Instagram and Twitter are much better if you’re like actually wanting to follow me And see what I put out into the world more streamlined, more streamlined. Yeah. And I tend to post there more often
will include all that in the show notes. Again, thank you very much for your time.
You’re welcome. Thanks for having me. This was fun.
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 a 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

Compassion Fatigue and Assertiveness with Nathalie Martinek, PhD

Nathalie Martinek, PhD is a recovering developmental and cancer biologist who transitioned out of the controlled environment of the laboratory into the messy world of human behavior and relationships. She continues to apply her critical and objective lens honed as a scientist to understanding drivers of human behavior in the various relationships that exist in healthcare contexts to discover what prevents and promotes wellbeing and professional satisfaction.

Dr. Martinek is a speaker, listener, coach and consultant who facilitates training programs and workshops worldwide for diverse health professional audiences to enhance their capacity for human connection, abuse prevention and healing through cultivation of psychologically safe and stable therapeutic partnerships. She recently published her first book, The Little Book of Assertiveness, to provide scripts for shifting power dynamics in professional relationships to embody the qualities of a respectful and compassionate healthcare culture that enables everyone to thrive.

We discuss how to be assertive in a hierarchical environment like medicine without offending your superiors – and it starts with being curious. We then pivot into discussing compassion fatigue, first by defining it and then by exploring ways to interact with patients in a way that doesn’t end with us unnecessarily burdening ourselves with no benefit to the patients. We then end with some self-care practices that allow us to process those burdens.

Find her at drnathaliemartinek.com

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

This and all episodes can be found at PhysiciansGuidetoDoctoring.com

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.

Dr. Natalie Martin Nick is a recovering developmental and cancer biologist who transitioned out of the controlled environment to the lab and into the messy world of human behavior and relationships. She continues to apply her critical and objective lens honed as a scientist to understanding drivers of human behavior in the various relationships that exists in health care contexts to discover what prevents and promotes well being and professional satisfaction. Dr. Martin Nick is a speaker, listener, coach and consultant who facilitates training programs and workshops worldwide for diverse health professional audiences to enhance their capacity for human connection, abuse prevention, and healing through cultivation of psychologically safe and stable therapeutic partnerships. She recently published her first book, The Little Book of assertiveness to provide scripts for shifting power dynamics and professional relationships to embody the qualities of respectful and compassionate healthcare culture that enables everyone to thrive. We discuss how to be assertive in the hierarchical industry. That is medicine without offending your superiors. And it starts with being curious. We then pivot into discussing compassion fatigue, first by defining it. And then by exploring ways to interact with patients in a way that doesn’t end with us unnecessarily burdening ourselves with no benefit to the patients. We then end with some self care practices that allow us to process those burdens.
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.
Dr. Natalie martynuk. Thanks so much for being on the podcast.
Thanks for having me, Bradley.
So let’s start with your origin story. What what’s your PhD and And what was your thesis?
My thesis so this is a really awesome title. It’s spark is required for basal lamina stability by mediating type for collagen deposition during embryonic development of just soft lemme Lana gastric.
Oh, Monica master mind my favorite my old friend. Yeah, that sounds that sounds really interesting and really that tends to be the theme of this podcast is everything that can be learned about the basal lamina of a I’m not even sure if that’s what you said of the dressage. That’s right. So what what does that make your PhD in? You are a developmental biologist,
development biologist, so I was really interested in understanding the unsexiest the least sexiest part of a body, which is the connective tissue, the extracellular matrix, all the environment outside of a cell. So while everyone’s studying inside, what’s going on inside the cell, I was looking at what’s going on outside of the cell that is eating influencing how cells behave, how they move, how they invade. And that led into my postdoc in cancer research. And the reason I was interested in that is because it’s a less controlled environment, you know, whereas you’re working in a cell, you can kind of manipulate the proteins being made, or you know, the enzymes, and you can see its effect of what’s going on inside the cell. Whereas what I’m interested in what I was interested in is looking at what the cell is producing how it influences its behavior, as well as the development of the organism. Yeah, so that’s basically where I started and I was looking at the cells, the macrophages of the of the fruit fly, which are involved in surveillance and removing pathogens and other things that invade that you don’t want in your body.
So is that what you’re working on right now?
I guess yes and no, biologically No. So where that led to was trying to understand how to relate this the cells that normally move around the body play a role in the music system monitoring surveillance protection against, you know, my microbes and pathogens into still using your software to study tumorigenesis. And so is looking at what how do cells move from an original location and invade into tissues and start to migrate and take over the body basically co OPT the defense system of a body of an organism for its own means of survival. And so while that was occurring, during my postdoc years, I started to become very interested in the conditions within a workplace environment that would enable certain behaviors to start to manifest as bullying or to, you know, spread around an environment and create a sort of toxic culture. So what I’m studying biologically was mirrored mirroring or mirrored in my external workplace environment, and that became more of an interest to me.
Oh, I was hoping that that was the direction you’re We’re gonna take this in, because I was hoping this wasn’t gonna be an entire podcast about Drosophila. And knowing you and what you’re doing now, I was like, man, I hope. I hope she ties this in. Oops, didn’t go back to the lab, and she’s gonna be talking to us about pipetting. Again,
no. Okay, looking at the conditions that exist that promote or prevent certain behaviors from existing and amplifying what what made you make that transition suddenly different things? burnout is one of them. You know, and the way my experience of the way I experienced burnout is that when you’re working in an environment or in a, in a in any place where you believe that it’s the right direction for you based on your training and education, what’s expected but yet it doesn’t speak to your heart. It doesn’t address some of your major interests. And what else you could be doing, the longer you stay in that situation, the less I guess the more energy is required in order to make maintain that, that makes sense. So you’re not actually living a fulfilling, at least not your work life. And it’s and it seems to spread into all your other parts of your life.
Well, sometimes it seems like it’s, you’re like a hamster on a wheel, and you’re kind of that idea of publish or perish, that you’re almost doing it for someone else, not for yourself, not for your own interests, not for not for the research, but more like you have to produce something, just in order to keep your job and keep your grant. Even if it’s just kind of like paying lip service, not not what you’re, you know, not not that you’re trying to answer a question.
Yeah. And when I start exactly so when I started to think about well, why what’s not right, what’s not going well here for me why, you know, on the surface, this should be what I’ve always wanted, interrogating the mysteries of life using fruit fly and biology. And then I was looking at the culture around me and seeing, you know, the effect of being an environment like that. on me, I was turning into someone I didn’t like in order to survive. And that that type of pressure and environment, looking at the way we address illness and try to get a better idea about the mechanisms behind disease. And we’re using a lot of data or theories or beliefs that are quite biased and, you know, got to the point where I’d be listening to someone’s talk or reading a paper and I’d be able to spot the unconscious bias very early on, and would poke too many holes within their story that I couldn’t listen to anymore. And after a while, I’m like, if this is my, if this is my experience, why am I still here? The other thing is we’re looking at human disease, you know, cancer, which doesn’t happen in a fruit fly naturally, or quite rarely, but doesn’t have the same impact. And we’re trying to understand the mechanisms of this disease in the fruit fly, but we’re using almost assumptions that by understanding the mechanisms in a fruit fly, we can apply it into the human experience, which we can’t because only humans are the only organisms on the planet who can make meaning about their life experience who, you know, we’re not looking at the impact of trauma, intergenerational trauma, community healing, we’re not eight emotions, we’re not able to study that in the controlled environment of a lab or in a tissue culture. So I started to become disillusioned with what we’re trying to achieve and whether or not what I’m doing in the lab applies to that patient that was in the floor underneath me, you know, in the in the floor down with their chemotherapy treatment, is this what they want? Is this the kind of research that they’re wanting us to do? Is this really what’s helping them? And the answer kept coming back to me No. So after a while, it was just I recognize that this is not ethical or within my integrity to continue in this way. And I had to make that tough decision to hang up my lab coat for good, at least in that setting.
So it sounds like you were so distanced from the intervention itself, like, you know, the research that you were doing was so far down the road from the eventual intervention which was then you know, distance very far from the patient itself. Then it was hard to, to continue doing that work. And it was almost like you were in the academic rat race.
Totally. No. And, and it felt a bit exploitative because we’re, we’re getting public funds, we’re using public funds. We’re justifying our, you know, the rationale for our research by saying this can potentially have some sort of direction towards a cure. But we don’t know when we’re kind of building up hope. And I, you know, I recognize the importance of that, but it’s like, it didn’t feel authentic, that we’re actually caring about the patients that were in the same hospitals or Research Institute. We weren’t actually talking them to find out what’s meaningful for you, what is it that you need us to be studying in order to support your experience? So it just felt so removed?
So then you pivoted and one you wrote a book on assertiveness, which I would imagine a lot was taken from your experience in academia and in that lab setting and then you also To speak on compassion fatigue. So, first, with regards to the shortness tell us just tell us a bit about the book and your workshops.
So assertiveness, you know is this topic that I didn’t anticipate would be this common thread running through my life since I was a kid. I noticed over the years, especially as a Canadian having moved to Australia, you know, there’s so many similarities between these two countries. So there’s quite some massive differences. And I noticed the one difference is that people were not as upfront with the feelings or their truth being honest. So you wouldn’t know where you stand with everyone. Everyone’s working hard to make sure everyone you know, looks good. Feels good. In which country? Australia In Australia, okay. Yes, sorry. And no one would really raise issues. It’s only that you know, you only discover that there’s an issue when it just becomes conflict, like boom, out of nowhere, and then it would make me think about why why that is. Why are people so afraid to speak honestly about their thoughts and feelings or ideas. What are we so afraid of, and it wasn’t quite my experience in Canada, people would be upfront with where things stood. And you’d be able to, I don’t know, work together. And maybe it was the environments that I were that I was in. But I found among really educated people, and this is not just in Australia, this is widespread. And this comes from doing lots of coaching and training work with physicians and other health professionals among health professionals. The common theme is that people are too afraid to challenge ideas, especially the ideas that come from someone who’s perceived as an authority figure, or someone who’s more knowledgeable than that than they are about a topic or an area of expertise. And so they’re more likely to be compliant and listen, or be combative in order to push their, their viewpoint across instead of challenging. And then when I started to, you know, go deeper into it, the skill involved in challenging an idea and learning more about it or getting to shift perspective is assertiveness, it became clear that we need some more information about what assertiveness could look like that is not combative, aggressive, trying to control a situation to get the outcome that you want. It’s looking at what are our values? What do we really want? And what is best for the US, not just me to see you, but we
Yeah, medicines very hierarchical, right? Like, you’ve got your medical students, your residents, your fellows, your attendings, you have the nurses and the nursing assistants, you have, you know, this is a complex system but with a very clear hierarchy. So, it can be challenging to assert yourself without being disrespectful or, you know, without fear of the repercussions of at least being viewed as disrespectful. So what recommendations do you have for within within that hierarchy for asserting ourselves, right? If we See, if we have a quiet if you’re a resident, we have a question for attending. If we think that a patient’s we should be paying more attention to lab value, or we think that the surgery may not be the best thing for this patient. You know, what, what recommendations do you have for asserting ourselves without being disrespectful?
Hmm, it’s a good question because I think there’s this assumption that assertiveness comes with disrespect that we can’t be assertive and respectful at the same time. Whereas my version as I described in the book is extremely respectful. It’s acknowledging the role that we each play among in a team that we each have an important role, and they’re all required in order to fulfill a purpose or to achieve You know, this desired outcome for all of us, including the patient, so as best as we can, so assertiveness, the way I use, it is about applying inquiry or curiosity. So we all have different assumptions. We all have different beliefs, we all are, view our roles differently and each other’s roles differently. So how do we know what we’re thinking? Unless we ask the question, tell me more. Tell me more about what you understand about the situation, or you help me understand what you mean by that. So I’m on the same page as you. So we have to recognize everyone’s role is important. Therefore, we should be respectful that we don’t each know everything. There’s something that I can learn from someone else. And I want to learn from you in this moment. So please help me understand. So I see that just the asking, asking questions instead of expecting to know all the answers, because that’s part of the culture as well that you just should know. And that’s a sign of weakness. If you ask questions, assertiveness kind of breaks through that and goes, I don’t have all the information. I don’t know everything. I’d like to know what you know, please teach me please show me I want to, you know, you have some wisdom that could benefit me and us I’d like to know it.
So it sounds like you would maybe rephrase the question as if you’re acknowledging that you may be wrong. So like, if you’re questioning the way a surgeries, the plan for the way the surgery is going to be done, it should be you think it should be done. B. And the plan is to do it a, you would more ask it assuming that A is the correct way to do it, but you think it’s B. Right? So like, yeah, the assumption is that the person who is asserting themselves doesn’t, is actually incorrect. But they want to know why. You know, why? Why answer a is actually correct. So that’s one way that you’re being deferential within the hierarchy. But at the same time, maybe, you know, that’s the way that you’re questioning the authority.
Yes, you’re not coming across as I know better than you and you must be wrong. And I’m also not coming across as I’m wrong. I’m not making any assumptions. I’m just saying I’m, I’m wondering about your plans, please describe them to me because I want to make sure I understood them because I may have missed something. And that way I can ask questions as to, you know, explaining why you’re doing it that way, not because I think you’re doing the wrong thing, or I don’t trust your judgment. I’d like to know. I’m curious because it’s part of my learning. It’s coming from this place of humility, curiosity. I want to learn more. I want to learn more from you.
So that if this patient were to walk through my door, I don’t know if I would have made the same decision. How did you arrive at that decision?
Yes. Okay. So share your thinking process behind it. Because I’m, I want to, I’m curious about how you approach a problem or you approach a situation and it’s, I’m curious to know if it’s the same as an as a how I would do it. It’s like, it’s like that just the idea about learning. I’m here to learn.
Are there any and those individuals, right, that’s what their primary role is, right? They’re apprentices so they’re, they’re likely to learn Yes. Are there particular phrases that you found useful? Or the opposite and any phrases that that are particularly toxic that we should avoid,
or anything to do with feelings where you’re trying to describe someone’s feelings. So when you say, you know, when someone’s expressing something and they’re coming across as little agitated, I see you’re really agitated. Or don’t do that, because you’re just gonna tap into their agitation and amplify it. It’s also kind of suggesting you understand their experience better than they are, when you’re pointing out their feelings. You know, the other way of doing that is I can see that there’s something that’s there’s an outcome here or there’s something that happened, that wasn’t what you expected. Can you tell me what’s going on? You know, what’s happening right now. So that’s what I call a safer way less emotive, potentially less condescending sounding, even if that’s not your intention. Another thing is, I’m sorry, you feel that way. You know, if you said something or did something that was the right thing in that situation with that other person. You’re not taking responsibility when you say I’m sorry, you feel that way. I’m sorry. That what I said was hurtful or I’m sorry, that what I said, didn’t land? Well, that wasn’t my intention. Let me try this again. You know, that’s taking responsibility for the impact you have on someone else rather than I’m sorry, you feel that way. Which is pretty much saying, Yeah, it’s like, your problems, you know, your feelings, your problems. I had nothing to do with it. Like, that’s not.
That’s sorry, Your reaction wasn’t what I expected. Yeah, yeah. Okay. Yeah. But with regards to the the assertiveness, are there particular phrases that that would be useful?
I guess it depends on the context, because in the book, it’s talking about different situations and barriers to assertiveness, what kind of power dynamics are occurring, that makes it hard to speak up. Because, you know, like what you mentioned, there’s a hierarchy. But there’s also other inequalities that are present within any, any environment. We don’t all have the same starting line in life. So we can’t just go I’m going to stand up for myself because you could be making your situation a lot worse. If you don’t Understand the unwritten rules of the place. So it’s always about understanding what are the values that we each share here and communicating that I see that you want this best outcome. So what do we each need to do in order to achieve that? very proactive?
Alright, let’s pivot now to your other area of interest, the compassion fatigue, right, something that a lot of us in medicine are experiencing. We had a speaker on the podcast a little while ago, Dr. Tory SEPA, she’s a psychiatrist, and something that she’s written about is the fact that we give so much to our patients that when we get home at the end of the day, we really have nothing left for our family. So first, let’s define what is compassion fatigue?
Hmm, yeah, I’m interested in what you said. It’s like we give so much to our patients that there’s nothing left for us. That’s exactly it. We are giving too much and we’re not able to monitor the level of which we give and whether When it when it’s enough, you know when is our level of giving sufficient to get the job done or within the realm of our role and responsibility with that patient, which will differ slightly with every other patient, the definition of compassion fatigue. So there’s, there’s a few definitions out there, because it was coined in 1995. By figley. And from my own study of doctors and other health professionals over the year, I’ve come to a different definition, which is less about compassion and more about empathic overload. So compassion fatigue is not because we are being too compassionate, it’s because we’re not being compassionate. That’s the problem. So there’s empathic overload that resulting from an imbalanced emotional investment in helping another who we perceive to be in a more vulnerable or disempowered position coupled with an absence of self care practices. So we are dealing with this sort of power imbalance or this perception that this person is so needy that I need to get Give them more than I can then I have the reserves for and I’m not doing enough practices within myself to recharge my supply of energy. So that’s how I see compassion fatigue.
Alright, let’s unpack that. Let’s go to the to the first part. So the fact that we’re we’re feel like we’re giving so much to the patient that we have nothing left. It sounds like you’re saying the assumption of that means that they require so much of us, and often it is the case that they do not. Mm hmm.
Yes. So do you have an example of when you’ve given too much to a patient? What that looks like?
Well, I would think, let’s say I just I have to give some bad news, right? So the bad news could be, we’ve been monitoring somewhere to cancer and their cancer came back or if I have someone that, you know, we’re gonna have to do a biopsy on you because there’s a possibility that you’re right. That’s the big concern. That’s the elephant in the room is his cancer, right? So let’s just use that as the example. So right. So I see up to that 30 patients in a day. And so what might happen is I have someone in whom I have to give that type of bad news. And now I’ve got someone across the hall with a completely unrelated problem. And now I need to somehow reset, forget the patient whose room I just left because now their hand right there, I give them the news, they have a plan, they have a strategy, but I’ve explained everything to them, but, but that can be really emotionally fatiguing. So now I’ve got to be able to go and completely refreshed to this next patient who has a completely different problem from you know, starting from zero. So, you know, doing that over and over and over and over, is just, it’s really taxing. So, you know, that that that’s really the, the scenario that I that I think our listeners need to be able to work with.
Okay, so let’s let’s do this in a stepwise fashion because as you’re as you’re sharing the situation with the other contexts, you know, my mind is going off of like, oh, you’re doing it this way. And then you’re doing that way. And of course, it’s going to be texting, let’s go back here with the patient, you have the results of a test, and it’s not positive, you’re sharing the news with them. And they have, you know, an emotional reaction to it, I imagine some sort of reaction. And at the same time, you also want to make sure that they they’re informed about their follow up actions, their options, etc. And so you’re working hard, you’re working really hard to try to help this person. equip this person with what you think they need in order to feel a bit more in control. After having received this news.
They’re overwhelmed. They’re shocked. They don’t know what questions to ask. Yeah, they’re asking more logistical questions than anything else. like where do I go next? What’s the phone number? Is there parking there? Because they’re just so shell shocked about their diagnosis.
That’s right. So you’re already working. You’re already doing too much work there because what you have what is required, which Just the compassion thing. So it’s not saying any other ways not compassionate, but it’s like the right action that’s needed in that moment is giving them space to process that a little bit. And so what can happen is because we’re feeling really uncomfortable with their, the first of all that the information you have to give, how it’s going to be received by them, and then their emotional response to it. We tend to go into this, give information, I need to do something to appease my discomfort at saying something that upset someone else, but you’re just the messenger, you’re not the cause of their upset. There’s a situation that is happening for them, you’re reporting to them, what the tests have shown. And what is needed is to allow space for them to just receive that information and process it in that time and space you have with them in the way they need to. That might mean that they ask you questions, but when you start giving information, they have no room and capacity to do anything with it. It’s just more energy that you’re You know, putting out in order to somehow fulfill this kind of role or obligation you feel to make them feel better. But you’re working hard to do that you’re trying to force them from the state that they’re in, which is deeply uncomfortable for you into a different state that might feel more comfortable for you, even though it’s not wonderful overall. Does that make sense?
Yes. But, you know, if they’re, if they’re asking these questions, I don’t see. You know what I mean? Like, like, realistically, a lot of times they can’t they’re so overwhelmed with this new diagnosis with this new complete change in their world, right. It’s hard for them to process any information, totally. But they’re still asking you the questions. So I don’t see a situation in which I would redirect them and tell them listen, this is not the time for you to be asking those, you know, I, I’m not sure how to pivot from there.
Yeah. So it’s almost like you know, this is big news. And this may not be what you expected or might be what you expected. But we don’t know how we’re going to you know how how we’re going to feel about it in the moment? Do you need some time to process this? Do you need time and space? You know, I’m here to answer any questions you have. But I want to make sure you’re in a headspace where you can actually do something with this information. So you’re giving them permission to take space. The problem is you have, you know, I can only imagine that there’s short appointment times, or maybe there’s a longer appointment time if there’s test results to disclose, and that everyone is trying to the patient is trying to get as much as they can from you in that time. But like what you said, they’re not in any position to be able to process any event. So sometimes it’s a good thing to go, Hey, this is big, you might need some space. And I can answer questions after before you know, so that you can be in a different headspace where you can look at all your options and look at the next move you need to make and I’m here to support you with that. Would that be okay? Or do you have questions you want to ask now? So you’re giving them choices, and it’s less laborious for You know, and then you won’t walk away feeling like you had to do all this stuff in a certain ritual within a short period of time, and then have to move on to the next patient, you gave space you allowed, you allow the space for them to decide what they need next, which is I’m not saying that that’s not what’s done. It’s just a different way of doing it.
Yeah, that is more than I want to know, just acknowledging out loud, that this is gonna, this is a very overwhelming thing. And they might have difficulty processing it all at once. And so if you know, if they need just a little bit of time before we regroup and decide what happens next, then when they can do that, you know, at least in my practice, I could very easily just go, I could go see the next patient and give them at least a few minutes to kind of, you know, maybe they want to call a family member if they came close, or something like that.
Yeah, that’s right. So there’s ways you can manage the time. Definitely. So you see those options now. And it gives you room to breathe. It’s the you probably holding your breath for a whole day. Sure. If you’re going back to bed, Patience gives you the space to breathe with them.
So you, you know, we talked about compassion, fatigue and empathic. I apologize. It was
empathic overload. empathic overload.
So what’s the difference between compassion and empathy? Or, I guess empathy is?
Yeah, compassionate empathy.
So again, there’s so many different ways that I see people describing it. Empathy to me, is emotionally neutral. It’s the ability to basically attune to what someone else is feeling. It’s not about being in someone else’s shoes. We can never ever, ever be in someone else’s shoes. We have our own experiences, our own ways of perceiving the world. We can’t actually enter into someone’s shoes, but we can imagine what it might be like for them to to experience the bad news or, you know, experience living with cancer experienced an illness. We can imagine it and we can also be, we can also appreciate how they’re using their resourcefulness to live with With it, to deal with it to manage it. That’s empathy. It’s not about feeling what other people feel. But because we are emotional beings as well as you know cognitive beings, we can actually feel in our bodies, what people are feeling. I know for me personally, the more time I’ve spent working with people I can feel in my body where they have pain. So I already know where their pain is, before they even disclose it to me that we could start to believe that’s our pain. If we didn’t know better, we didn’t know differently. So empathy is what connects us. We need that in order to build a rapport and trust in a therapeutic relationship with a patient or client. But what can happen is we can feel people’s feelings so extensively, and we can just dive into the their story of their suffering, that we fail to see all the other positive things that are also occurring in their life at the same time, we can fail to appreciate their strength in their capacity to overcome challenges that we all have and we can just see We’re the we’re the one that ruin their day because we gave them bad news, we put that on ourselves. And so we become overloaded by all those feelings, those negative feelings and we become, it can feel quite heavy. And if you’re doing this daily with so many different patients day in, day out, and not going through any sort of internal process or debriefing process or any sort of self care process where we can make sense of it and unload it from ourselves, we become quite exhausted very quickly. So let’s talk about the debriefing process. Oh, what I didn’t act that I didn’t mention was compassion. What is the difference? So compassion is recognizing that we all suffer and we all have joy. Just because you’re in the doctor patient doesn’t mean we’re so different in that way. We all have these feelings. We all have, you know, our experiences, so I can, I can appreciate that you’re in suffering right now. But you know, there are other areas of your life that are also joyful or pleasurable, that it’s not only about the suffering, and my job is not to make you suffer less than this moment or feel differently. I’m here to recognize that we all suffer, we all feel joy, and I can see them both with equanimity. And my role is to do what? To do the right action in this moment. So how, what do I need to do with this person who’s just received news that upsets them? That is compassion. Compassion is not making them trying to make them feel something different. Like what I mentioned before it’s holding it’s it’s holding space for them to experience whatever they need to experience right now. That to me is compassion. So that’s the difference between empathy and compassion. Compassion is like what I call love with action, check. It’s empathy plus action, his compassion, and empathy is just being tuned into their experience, whatever they’re what they’re feeling and thinking. And it requires some listening skills, some inquiry skills, so asking certain questions to get a better understanding of what’s going on for them and just being curious about that rather than feeling what they’re feeling and trying to make them feel something else.
So it sounds like the theme here is really giving the patient space either really giving them space or verbally acknowledging the fact that they may need to take some space and that’s gonna unburden us at least just a little bit. Definitely. What about the that debriefing that you were talking about? Can you elaborate on that?
Yeah. So I don’t mean the debriefing that occurs, if that can occur after an adverse event. I’m talking about just the everyday the stuff that weighs on us the things that we encounter on a day to day basis, you’re as a physician, you’re seeing suffering, pain, joys, everything on a day to day basis, who are you talking to about this because it can be burdening especially if something that you’re experiencing doesn’t make sense to you or you haven’t, you know, resolve it within yourself. We have all these unresolved stuff that we carry every day, unless we give a voice to it and, you know, debrief it, disclose it, offload it, it just stays inside us and it becomes again, quite heavy. So it’s having a trusted person in your life. Whether it’s a therapist, a counselor, appear, a colleague, a manager supervisor, doesn’t matter as long as you feel safe with them, and you trust them. And they’re not trying to give you advice, and try to make you solve the problem. It’s about holding space for you, to giving you space to disclose the things that are weighing on you. And through that process, you might develop your own aha moments. So it’s just again, give allowing yourself to have the space the same way you’ve just given for your patient.
Is there a role for journaling in there, you know, there, there might be some issues with legality and HIPAA, at least in the United States, just being able to talk to people about what’s happening with your patients, although it’s easy to make these fairly anonymous. You know, if you’re speaking to a spouse, or a colleague about a patient, it’s really important that you leave out any identifying information because the legal issue Yeah, so here’s the thing. So your lawyer before you Yeah, before you Again,
well, it’s not about your patient. In the end, we can say it’s about our patient, but really is it’s about us where there’s something that we experienced with the patient that’s bothering us. So it’s you don’t even have to talk about the patient. It’s about what’s bothering you what’s unresolved in you, that working with a certain patient has brought up, but it’s not about the patient at all. It’s about your experience of that. So it’s working with someone, again, trusted, confidential space where there’s no risk that they will expose that information. And you can, again, de identify everyone involved in the situation, but really is about an opportunity to talk about yourself and learn about yourself. And journaling is definitely part of it. But it requires a structure like, you know, we could do a stream of consciousness where you’re just writing whatever’s on your mind and just offloading it. There definitely can be therapeutic. You can use a self reflection practice that is helping you get clarity about a problem or, you know, again, something that’s weighing on you. By the way, what I find the most powerful is when you’re doing it in the presence of someone else. Someone else is witnessing you. They’re not trying to solve your problem because they can’t, it’s not them. They don’t have more expertise in your problem than you do. It’s your problem. It’s them just being open and holding space and allowing whatever that’s lying underneath to reveal itself. So, so is the
listener, an empathic listener, or a compassionate listener?
I think the both of you need both. You can’t have compassion without empathy. It’s like I say, empathy is the doorway to compassion because you don’t know compassion is the action. You don’t know what to do unless you are able to attune to what’s needed by that person. What’s needed or what’s needed in that situation. And what’s needed is not dictated by you. It’s dictated by the moment you know, like I said, some Breaking Bad news. You think you have to kind of appease them and make them feel better before you know you send them on their way. That’s not necessarily compassionate because you didn’t give them space to actually grieve and maybe they’re not really great at grieving or, you know, expressing emotion You allow that you enable that to happen, which is a really good thing. So compassion is the enabling the allowing the permission, the non compassion is the pushing the for things that are trying to control.
Are there any other self care practices that you recommend? And
I’m all about talking as you can tell some of the talking and
debriefing with again, a trusted person who knows how you how they can support you, you’ve told them or you’ve trained them on how to support you. Big one is reflective practice. So, you know, one form of that or shorts rounds where you know, that’s a way of getting together with other physicians or your team and talking about things that occur in the workplace and, you know, holding space for these conversations to happen, which are often held secret and buried in shame because somehow we’re supposed to believe we know everything, and that we could do everything perfectly and that that’s not possible. So the short surrounds is One format reflective practice is a more structured format that also allows you to figure out what next step to take or how to do something differently. Because you would have reviewed the impact of your actions with a patient with a colleague, whatever the situation is, and then learn from it, and learn and think about how you could take a different step forward next time. And it’s really, again, non judgmental, very open, and about Problem Management. So those are two very powerful ways that can prevent compassion, fatigue, and they all involve talking about everyone’s favorite subject themselves themselves, right? But what we also learn from everyone in the group, what you learn about from someone in the group also applies to you. So one person shares their issue and it becomes a group kind of learning opportunity, because we all experience these things.
Is there anything that we didn’t talk about today that you’d like to mention to our physician audience, either about assertive Or compassion fatigue?
Yeah, cuz. Yeah, I think overall it’s learning I guess overall, it’s learning how to be okay with the myriad of emotions that we get exposed to and the emotions that we feel. And the more we allow ourselves to be uncomfortable, the easier it becomes to be with someone when they’re going through their toughest day, and not trying to make them have any other experience and the one they have, and it’s less and less energetically taxing on us. And it’s actually more supportive for the for the patient. So everyone benefits from that kind of interaction.
I think I heard Tim Ferriss once say, a successful life is judged by the number of uncomfortable conversations you have. I think there’s something to that,
that and that’s assertiveness, exactly. It’s it’s naming the elephant. So in my book, I talk about ways I provide scripts on naming the elephant and it breaks the tension in the room and again, it brings some relief to everyone in there.
So we’re getting People find the book and where can people find you online?
Well, I’m on Twitter a lot. And it’s where I found you. That’s very family. So I’m at NATS for number four docks. And the book can be found on Amazon. And it’s called a little book of assertiveness. And don’t let the name fool you,
Dr. Natalie martynuk. Thanks so much for being on the show today.
Thank you so much, Dr. Brad for having me.
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 a 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.
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What Can Victorian Literature Teach Us About Coronavirus/ COVID-19?

What can an English professor with expertise in Victorian Literature teach us about the coronavirus? Germ theory became popularized during that era, so this is when people realized that we were the vectors of our own illnesses. One would think that this would cause us to isolate ourselves from one another, like we are doing now, but the literature of the time, which reflects the thinking of the time, shows us that it brought us closer together. A message of hope in these dire times.

Dr. Kari Nixon is an assistant professor of English at Whitworth University. She teaches medical humanities, Victorian literature, and is forever interested in death, disease, risk, and why we fear them. Dr. Nixon’s work has been shared on Huffington Post, March for Science, and more.

Her first book, “Kept from All Contagion:” Germ Theory, Disease, and the Dilemma of Human Contact will be in print Spring 2020.

She got her PhD at Southern Methodist University in Dallas, TX, with a dissertation in Victorian Bioethics, which she turned into the aforementioned book. She teaches both Victorian literature and contemporary medical humanities. She can be found at MKNixon.com

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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.

What can an English professor with expertise in Victorian literature teach us about the Coronavirus? Well, germ theory became popularized during that error. So this is when people realize that we were the vectors of our own illnesses, that one would think that this would cause us to isolate ourselves from one another, like we’re doing now. But the literature at the time, which reflects the thinking at the time shows us that it actually brought us closer together. So a message of hope in these dire times. Dr. Karen Nixon is an assistant professor of English at Whitworth University, and she teaches medical humanities Victorian literature, and is forever interested in death, disease risk, and why we fear them. Dr. Nixon’s work has been shared on the Huffington Post march for science and more. Her first book kept from all contagion, germ theory disease, and the dilemma of human contact will be in print in spring 2020. She got her PhD at Southern Methodist University in Dallas, Texas, with a dissertation in Victorian bioethics, which she turned into the affer mentioned book. She teaches Both Victorian literature and contemporary medical humanities, and can be found at MK Nixon 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 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.
Professor Carr Nixon, thanks so much for being on the podcast.
Thank you so much for having me. I’ve been really looking forward to it.
So how is it that you wrote a book about epidemics that’s set to come out in April of 2020. And, and it was the topic of your dissertation. So this was done years ago. Mm hmm. And it’s being released in the midst of The worst pandemic The world has seen in 100 years. So where is your time machine? What stocks have you been buying Now that everything’s down? So clearly, I can’t ask you about sports betting since the NBA and the NFL have been canceled. So right, how do you? How does it happen?
Uh, you know, the funny thing is that I think, I mean, I guess there’s not too many of us disease scholars, but I would venture to bet and apparently I’m good at betting, you would say, I would venture to bet that most disease scholars would just simply say that diseases always relevant, unless that seem just any professor who is of course going to say that there are esoteric specialty in research is always relevant, which I think is a sort of professorial thing to say, for me, the idea I mean, of course, it is oddly coincidental that my book is coming out in the middle of this pandemic book For me, the reason I wrote the book and the reason I’m fascinated with what society does in the face of disease is because it’s always just a matter of time. It is an inevitability. And that’s sort of a crux of my book on an individual level. I argue that disease is an inevitability we will all get sick. People say death and taxes, but I say death, taxes and disease are the three things you can depend on in life. And so if you think about any other catastrophe, I don’t know, war, maybe I can visualize a way in which we could theoretically avoid war, because we’re talking about diplomacy and people may be negotiating. We don’t get to negotiate with diseases. There’s diseases and disease outbreaks, which are essentially one form of, I guess, a natural disaster. So for me, it’s not that surprising that it happens to come out in this really Relevant time because Have you seen that meme? It goes around a lot of Kermit sipping tea?
What is he saying? Well, he’s sipping tea and what kind of tea is it?
I think it’s Lipton tea tea, okay, he’s always it’s usually captioned with, but that’s none of my business. But he has this kind of look on his face, like he could have told you this was gonna happen. And I just keep visualizing myself that way. Like, the coincidence doesn’t seem coincidental to me, because I feel like the very nature of my book has been kind of screaming into a void, that disease is coming for all of us. And we ought to think about that, when we’re not in that moment of crisis, to understand what we will feel like in the moment of crisis and do better at that point. So,
yeah, so if you can use that time machine again, right, your your book is arranged by disease, each disease, you cover, get to chapter right. So So, you’ve now written a Coronavirus chapter. What are some of the highlights? Or are there no, is there no Coronavirus chapter since people are now mostly buying into germ theory? I’m sure there are some fringe people out there. But really, it’s not. I guess it’s not germ theory anymore. So is that even a chapter?
Right? It’s not really a theory anymore, is it? It’s just germs. You know, I actually think there’s a really great parallel between the things I cover in my book, the diseases I cover, and the emerging Corona virus disease right now. The reason I cover the specific diseases I do and the time period I do is because in the 1880s to the 1818 9597, this 15 year period is this really interesting slice of history in which most people are buying into germ theory at that time, although they are still calling it germ theory. Most people pretty much believe it. They’ve started using Robert Cook’s theories to identify certain bacteria under a microscope. And I’m sure anybody who’s done laboratory science in undergrad or post grad is familiar with Cook’s postulates of how we culture a bacteria in a petri dish and then correlated with the causal pathogen that we see creating clinical manifestations in a patient. So people were believing in bacteria at this time as disease causing vectors. But they had they couldn’t do anything about it. Anything. We don’t even have penicillin till 1928. So there’s this really interesting time period and this little 15 year segment that I studied, in which there’s sort of just this existential horror, and I know that sounds sort of like an unscientific term, but I just love when the sort of cerebral realm of science and history meets up with what are the undeniable Least human components of our existence such as fear and hope and a desire to live. So there’s this existential horror that I noticed in this time period where they suddenly see and identify everything that’s killing them. And they have zero tools against it, except maybe they had started to understand antiseptics. At that time, they had a few they did understand that hand washing and sanitation helped. And isn’t that exactly where we find ourselves today at 6:15pm Pacific central time on March 16 2020. When we have a disease that is an emerging infectious disease, an ID that we don’t fully understand, we are back in the Victorians footsteps where we see something and we definitely see the epidemiological data that proves that it is killing people and all we really know to do is our basic sanitation practices. Just it’s so for me it is exactly that human and societal reaction that I wanted to isolate culture, if you will to use cooks words and Petris words, in this book that I’m seeing, again here with this infection, it’s like you’ve got all the same ingredients, the same media in that petri dish. I’m going to stick with that metaphor until it gets rolled. And and what I’m seeing are the same social reactions on all ends of the spectrum that I identified in my book happening to the Victorians. What do you mean, what are some examples? Well, the thing that I talked about in my book, and sort of the crux of it is that germ theory as it really took hold, and as people sort of looked up, I sort of imagine a married couple looking at each other over their morning coffee with the slow, cold realization that that’s the person that probably gave you tuberculosis. I always see it very cinematically, in my mind. My thesis is that That moment in history, catalyze this sort of individualistic, neoliberal idea that we should just isolate ourselves and protect ourselves. That’s the only way to survive these things that we don’t know how to control called germs. And yet, what I identify in my chapters and as you note, I do it disease by disease because I highlight the different specific social questions coming out of each disease. I identify these really beautiful moments in history where people are saying, No, I will look out for the greater good. I’m not just going to try to hermetically seal myself away in my house to preserve what I call bare biological life, a beating heart, but I’m going to help my community members engage in rich, fulfilling intrapreneurs relationships that are what make life worth living.
Okay, but if you’re listening to this, and the Coronavirus epidemic is still hot pandemic is still happening. Don’t do that. Right. Your house?
Well, no, no.
Listen right now this comes later.
Right now double down. I’m gonna double down. It’s what I do. Here we go. So yes, we are isolating and staying in our home and social distancing, which I would actually love to talk a bit more about this because my first chapter goes way before the Victorian era and talks about Daniel Defoe writing about plague in 1722. Way before germ theory and he my whole chapter is about how he promotes social distancing. Before I became apprised of that term with Coronavirus, but no, I mean, of course, I don’t mean ignore public health mandates and that would never be the goal of medical humanities. The first thing I would say is of course, my book is a literary criticism books. I am able to identify the ways that authors promote the communal good in the imaginative space of literature, right, where people are actually dying from this. But secondly, I actually think that we have much greater opportunities to live this out real in reality than the Victorians did because we have social media. I mean, I’m sitting here right now having a really fulfilling, Enriching conversation with you, in spite of the fact that we can’t leave our house
and then never would have taken place had we not gotten in touch over social media. Exactly the toxicity that occurs in there.
Yeah. And I mean, I haven’t seen so many people saying, you know, people with people that are extreme extroverts people with really high anxiety right now people with substance abuse disorders that can’t get to their a meetings right now. Reach out to me, I’m seeing that on Twitter. I’m seeing people develop groups Hangouts and FaceTime and acknowledging what I, again, sort of as an academic feel like I just kind of scream into the void of my office so often, that these social relationships are why we’re trying to keep staying alive. It’s not just the functional existence of a beating heart. It’s because we like other people, and others,
right? Yes, yes. And you’ve seen the great videos coming out of Italy, I’m sure that have gone viral. Haha, pun intended, intended of the Italians singing together from their balconies, and enjoying the communal space of song across a busy street and a balcony. So they’re safe, but they’re together. I mean, I just, I actually think we absolutely are doing these things because we’re lucky enough to have this technology. Now.
Another thing that I’m seeing is crowdsourcing of information I’m a member of a bunch of physician communities, and just the exchange of ideas globally, and I’m just floored by how smart people are like, like, you know, yet we don’t have a vaccine for this. We don’t have a medical treatment for this. But what worked into your IC? What’s been working for you? Have you tried this? Have you tried, we tried this, like, just, you know, clearly not disclosing patient information, but like, just the back and forth and the exchange of ideas is, you know, across the globe, it’s a testament, you know, how social media just shows the rawness of how horrible we can be to each other, and how creative and wonderful we can be.
Yes, I always say it’s becoming more and more of my mantra, as I think these things become, I think, as you say, more more raw and exposed in times of crisis, which again, is why I think diseases is interesting space to study. I’ve been seeing more and more humans are my Least favorite and most favorite part of humanity? Um, yeah, I’ve been seeing it in my profit sorial communities, because so many of us are now having to suddenly teach online. And just the way people have come together to make sure that we all are focused on the most ethical way to handle this with our students. I mean, initially, I was thinking, we’re talking on a zoom meeting right now You and I, I was like, Well, great. Like, we’ll just zoom all our classes, it’ll be fine. And I start seeing people posting and making Google Docs that are open access, saying, you really can’t assume that your students have internet reliably at home, if they can’t live in the dorms anymore. For many of them being on a college campus was a vital point of access to resources. Please don’t do synchronous learning. You’ve got to do asynchronous learning where they can get on when they can. And I’ve just been so grateful that as much as I try to do my best as well that we can crowdsource these things and Think about things that we may not have thought of. Or, for instance, I was home insecure as an undergrad, I didn’t have reliable housing outside of my dorms. So my students that might have been displaced into an unsafe non existence or unhealthy home when the doors closed, it was at the forefront of my mind. And I emailed all the professors in my department and I said, What do we do like we could probably offer students a place to stay. But I don’t want to offer students that are currently taking my courses a place to stay because that gets kind of thorny when I’m still in greeting authority. And we sort of develop this elaborate system by which we would house one another students to make sure that nobody was housing a student they were grading but that all the students have housing turned out to be unnecessary because my university opted to keep limited dorms open because they weren’t thinking about students, housing security, but like you I’ve seen my communities coming together and I also say, you know, academics can, they can sometimes not be the most pleasant people. But I’ve seen like the best and my most, my favorite sides of academia and why I became an academic coming out of this crisis, one of
the questions that I had was gonna lead to, can you please restore my faith in humanity with all of the horribleness that’s about to ensue? And you did. So we will not be able to skip that question. Thank you for restoring my faith in humanity. So, during our first season of my first season of doing this podcast, I had an episode called bad words. The title was longer than that. But the idea is words. While we think that our ideas help us choose our words, and they do, words can shape our ideas so that the interview was in the terms of patients with weight issues. But you say that our words can shape our ideas with regards to Even a pandemic, so and can ultimately influence the pandemic. So given that this is a largely physician audience, how can we as physicians utilize language that we use with our patients to convey the appropriate amount of gravity, right and help to help to shape that outbreak narrative that you talked about? Right?
Well, I think what you’re referring to is something that I started calling it this in my teaching, just kind of, because it’s what made sense to me and my students have found it really helpful. So I’ve, I’ve kind of developed it further, I believe it was in my cnn article, and it’s a huge part of my my second book, I call what you’re discussing this dynamic, this socio scientific discursive cycle, meaning that of course, as you say, the way we talk about things can affect the way we frame scientific questions and inquiry. One really concrete way to think about that as it may frame the grant money that people ask For and what they’re asking to study with certain grant monies, but that also, of course, the way we develop that science then filters into the way we speak, generally. So the fact that we just mentioned something a meme going viral Porsche that comes out of the original notion of biology developed in the 1940s or so. Yeah. So, initially, what I was focusing on with this pin, well, before it was a pandemic, or recognized as one was really talking about Origin Points of viruses, that has been something kind of a soapbox of mine, I suppose you would say that when, when we try to identify a patient zero. And this is where you’ll have to let me know if you if if I’ve lost you, because people sometimes bristle at this idea. I’m not saying that epidemiology is incorrect when they identify a patient zero, but what a medical humanism General would ask is when we frame the question that way to pinpoint a single source of an infection. What are we implying by that? And what are we looking for? And what might we be not thinking about? When we ask that question? The answer to that I would suggest is, I mean, we essentially are wanting someone to blame. I would think right now, there may be broader scientific reasons why we just need to know an origin point and I cannot speak to those nor do I intend to. But I do think it’s very, very stunningly human that we would like to figure out what started at all, and I think, therefore, that easily slides all too easily into blame. One of my favorite scholars ever from whom I learned everything I know about patient zero and healthy carriers and outbreak narratives. That’s her term. Her name is Priscilla Wald. She’s at Duke and one thing I love about her book. In her intro, it’s called contagious cultures, carriers and the outbreak narrative. she identifies the way that over and over and over again in history, we tend to say that diseases come from the east. We being Of course, Western culture. And what’s great about the way she does this intro is she does not at all address, whether she’s saying the epidemiology is accurate or inaccurate. It’s not a point of her argument. That’s not her field. She’s a literature scholar like me. She simply presents it as the narrative that we’ve said about h one n one and SARS and MERS. And she just lets the that speak for itself, so that you can leave her book in my opinion as a reader without thinking that’s just a little too convenient for us over in America and it makes you want to know more About if there might be some myopia in the way we’ve constructed these epidemiological questions that perhaps keep leading us to the same answer at the exclusion of other possible answers. I hope that didn’t sound too much. Like I’m trying to debunk the entire field of epidemiology. I’ve, as I was editing my cnn piece over and over, I kept getting that criticism, and it’s certainly not my or any medical humanists. I know. It’s not our intention,
know that the pattern is definitely there. Is it coincidence? Or is there actually something there? I’m certainly under qualified or completely unqualified to answer a question like that. But But I would think identifying a patient zero identifying where this came from, you know, we need things like that in order to find order in the chaos. Right? And just that’s, that’s a very human it’s a scientific need. Right? Where did it come from can help us hopefully prevent another one but it can also inform us as to What might help in terms of treatment? Now? I’m just I’m just guessing there, do we need to know patient zero in order to in order to accurately track the spread? Clearly, that didn’t help us here? Because it was being community spread before we realized it. So, yeah, I don’t know. Those are definitely interesting concepts that bear some evaluation, right. always seem to come from the quote, other.
Right, I think and something you said and the way you said that back to me, maybe it kind of clarified for me a better way to say it, but what we would say in the medical humanities is not that it’s necessarily wrong or not wrong, but that if we as a society aren’t seeing that there might be a potential bias there. If we’re incapable of possibly identifying possible biases, then you’re just absolutely certain to get some biases, right. So we’re always just trying to get people to like, think in different frameworks all the time to make sure that we do better science to make sure that we’re not missing something.
Yeah, we’re always bringing in our biases, we need to recognize that in order to account for it in order to make sure we’re being as objective as possible.
Exactly, exactly. I think I might have answered your question in a really circuitous way, the xenophobia was on my mind. First of all, as the disease has developed, what I’ve been more concerned with is ablest language, people saying, you know, well, it’s only gonna affect the infirm and the elderly. And there were great disability scholars coming out on on Twitter and Social Media and saying, you know, that’s unacceptable to phrase that as though the rest of you know people without those conditions can stop worrying because that treats that population as disposable. I I feel like the medical community has done really great with this. I would not suspect generally that doctors would have been perpetuating any of those problematic stereotypes. But I do think that risk is really hard to convey accurately to patients who are almost certainly not medically as medically literate as their doctor, right, by definition. Well, and
that also has been a problem in our past, as you mentioned in the that same cnn article, right. So syphilis was seen as a disease of sex workers, not a disease of the husbands that were then taking it home, their wives who were then giving it to their children, you know, their their unborn children, or HIV being a disease of homosexuals. So thinking that it was only affecting homosexuals while it was rapidly spreading in the heterosexual community as well. So by thinking it was a disease of the other, right, that helped it to continue spreading, and that’s happening right now with the Coronavirus, right like I’m sure we all have seen pictures of millennials out at bars, carousing and spreading them. Guess that shows that I’m not a millennial prior to them as carousing, and potentially spreading the virus among themselves, and then spreading it to others beyond that, right, so they’re disregarding it because it’s a disease that primarily affects the older population and those with comorbidities.
Right, exactly. I mean, we’ve talked about seeing the the most beautiful parts of human nature, and that would be the part that has disturbed me the most is that again, that I identify in my book, that sort of individualism of well, if I’m gonna be okay, then who cares about anything else. And the American concept
it is It is I, the older I get, maybe I’m showing my age here, but the older I get, the more I’m convinced that that’s the root of all our problems in America. But I think
also the root of our solutions, like, I can figure this out. Whereas in America, you feel more empowered to be able to innovate. Whereas other countries, if you’re the member of a cast, I mean, we do really poor this poorly with this in terms of socio economic status and race, right? Where you might not feel as empowered as you otherwise would be if you were a white male, who feel like caught as a white male, you know, you feel a constant sense of empowerment. But but in America, like you do have more social and mobility than in other places, and more of an opportunity to innovate. And that’s why we see all these, you know, innovation happening, certainly happening other places in the world. But, you know, America is definitely a popular place where that for that to take place. So the individualism is horrible, when you’re being horrible to each other and ignoring other people’s needs. But at the same time, you know, I have an idea. I think I can do this in vain,
that American gumption
like that, yeah, yeah. And do attitude.
No, but you’re absolutely right. I mean, I think that’s the sort of problematic attitude that, in fact, is allowing it. I mean, we see it epidemiologically It’s a fact that that is how it spread, because people weren’t worrying early enough about the most vulnerable among them.
Yeah, unknowingly putting themselves at risk because, right some of the data that we’ve seen said there’s the mortality from this is point 2%. in I think it was like 10 to 40 year olds and and point 4% in 40 to 50 year olds. So right point 2% seems like it’s not going to happen to you, but if you’re if you’re in a high school of man, am I going to do this math correctly? Let’s say 500 people, right, your high school class then that means that I’m gonna get this wrong, you know, one or two people are gonna dive It doesn’t mean the middle but you know, that’s what this is. So, so like, right, well, that you know, like, and yet you’re out and passing into among each other thinking that you are invincible, right.
And one of my students told me about Coronavirus parties Where people earlier on were using it for the masks and stuff for costumes. And again, that speaks to this sort of privileged flipping, see that it’s not going to happen to you. And yeah, I think one of the ironies I tried to highlight in my cnn piece is that you get really rude awakenings when you behave that way. One of the texts that I discussed in my chapter on syphilis, actually is by Henrik Ibsen. It’s a play called ghosts. And it is literally about the the way that his mother tried the main character his mother tried to hide from the main character, the fact that he had syphilis. She tried to stay with this philandering husband to have this perfect seeming home, that that in fact delayed him getting this imaginary treatment in the realm of the play and causes his death doodoo syphilis and He was writing that in direct response to exactly what you said, these sort of, quote unquote good Victorian middle class women who are giving birth to babies with the sniffles. You kind of only learn about this in medical school anymore because you don’t typically see congenital syphilis these days, but the sniffles and the notched teeth and all these very physical signs that a mother could see the second she held her baby just as easily as a doctor could that this was not what she had imagined. And it was striking visual evidence of the epidemiological fact that these were, as Epson called it. The ghosts of their behaviors and prejudices coming back to haunt them.
And it’s happening now. Well, history repeats itself, so that’s why we need It’s why we need more historians out there. I’m sure you’ve been shouting from the rooftops for a while from the very beginning here.
Yeah. Well, I mentioned the Kermit tea thing. That’s kind of how I keep thinking, you know, a zombie class this January. And we use that to talk about access to health care ableism cognitive alterity so many different things. And one of the movies of course we watched was contagion even though that’s not a zombie movie zombies have become sort of synonymous with contagious disease these days. And it’s been funny to watch people online now watching contagion because now it seems relevant to them. And, and as I said in the beginning of this interview, for me, it’s always it’s always been relevant. It’s always been about to happen to us. And now just finally have
your classes next semester are going to suddenly get a whole lot more popular.
I know my poor kids in my zombie class thought it was all theoretical. And
then I Oh, and the CDC years ago played on the popularity of the zombie theme by having a page for what to do during the zombie apocalypse, but it was just a way for them to publicize disaster preparedness. For any disaster, there are a few things you’re going to need. And they just, that was just the same list they had for every disaster.
And then the required text in that class a stroke of genius. Yeah, they have to read that and analyze it and kind of tell me what they think it means about our society.
So, do you have any any parting words for the physician audience in the age of Coronavirus? What we should be looking for what should be prepared, how we should be talking about it, how we should be addressing it to to patients or we happen to have the media in front of us?
Ah, well, I mean, I think I would just circle back to sort of the theme of this whole interview that times like this give us the ability to really live our values, whatever those may be. And that applies to doctors of course to right now. I feel like doctors just by you know, being on the front lines of this even in private you know, non hospitalist practice are doing that but I think just kind of realizing teach my medical ethics students all the time, my my sort of mantra, I hope I don’t get in trouble for this. My mantra to these, these pre med kids is Kaiser Permanente is coming for you. You think that you want to help people, that’s why you want to be a doctor and because you’re smart, and nobody’s going to warn you until they throw you into the trenches that you’re going to have a 15 minute appointment slot per patient. seven of those minutes need to be writing up orders and notes. So you get eight minutes for a patient who is a human with a history and needs and worries that are uniquely theirs. And I mostly spend my entire medical ethics class teaching my students about the lack of ethics in the pressures that are put on doctors today, and just trying to give get their heads wrapped around that so they can prepare now for how to make maintain their humanity and the good heart that got them into doctoring. When those pressures arrive, and I guess I would just say that this is a great time to try to, if you can like be in the moment and just be the human talking to another human. That is the reason you got into medicine because at the end of the day, nobody really knows perfectly what to do. And so I think more than anything, what we’ll call them patients down is that human connection that so many people crave from their doctors, and I say all that background to say that I completely recognize the pressures that are on doctors to do that to stop for a minute and say, Okay, I’m a person, I’m talking to a worried person. Let’s start from there. But I think you know, in modern society, we all unfortunately are under those very frustrating economic Productivity pressures. And it behooves all of us even myself as well to stop sometimes and just remind myself why I’m doing this to begin with and as doctors, and for me, too, as a disease scholar, this is that moment where I think we are called to do that as part of our calling.
I don’t think we can hear that enough. No, we do. We do hear that. But certainly, we could hear it more. So I appreciate that. Professor Carr Nixon author of kept from all contagion, germ theory, disease and the dilemma of human contact. When is that available? And where can we find it
should be coming out in June? I have not been willing to ask it if it’s delayed because of the COVID issues, and it’s coming out from SUNY press. You can follow them on Twitter, and they’ll definitely be there promoting the book a lot lately because of
its relevance to the press. I’m a Sunni graduate, myself and your alumni in Washington.
Yeah,
that’s awesome. So you press All right. Well, Professor Carr Nixon. Thank you again. And hopefully we will get to do this again. 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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Trauma Response for Good Samaritan Physicians with Stephanie Streit, MD

Stephanie Streit is a trauma surgeon at University Medical Center in Las Vegas. She went to med school at the University of Cincinnati and did a general surgery residency at MUSC. She is currently active duty in the Air Force. She is also the host of the Breaking Scrub Podcast, where she interviews surgeons about the interesting things we do outside of the operating room. She is convinced that success outside of the OR breeds success in the OR. Did you hear that, med student? Stop tying knots and pick up your clarinet!

We start out talking about some of the more routine and mundane parts of being a trauma surgeon. We then discuss something I didn’t quite expect: how important it is to her to address the mental trauma, not just the physical trauma, in her patients. We then discuss the beginning of a trauma assessment, which is CAB, not ABC and how stopping a life-threatening hemorrhage is likely the only thing you can do if you find yourself at the scene of a trauma. Hold pressure and stop the bleeding! We close with discussing why we podcast and her biggest takeaway from her show.

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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.

Stephanie straight is a trauma surgeon at the University Medical Center in Las Vegas. She went to med school at the University of Cincinnati and did a general surgery residency at USC. She is currently active duty in the Air Force. She’s also the host of the breaking scrub podcast where she interviews surgeons about the interesting things that we do outside of the operating room. She’s convinced that success outside of the or breeds success in the or did you hear that med students stop tying knots and pick up your clarinet, we start talking about some of the more routine and mundane parts of being a trauma surgeon. We then discuss something I didn’t quite expect, how important it is to her to address the mental trauma, not just the physical trauma and her patients. We then discuss the beginning of a trauma assessment, which is c a b, apparently not ABC. And how stopping a life threatening hemorrhage is likely the only thing that you can do if you’re finding yourself at the scene of a trauma. So hold pressure and stop that bleeding. We close with discussing Why we podcast and her biggest takeaway from her show?
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 is that they are quickbook professionals with over 20 years experience focusing specific Typically on health care, 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.com. That’s OCB m Ed, or call at 833-671-3873 or 949215 6200. And check out the show notes for more information. Dr. Stephanie stripe. Thanks so much for being on the podcast.
Yeah, thanks for having me.
So if you had a medical student who was considering going into trauma surgery,
what is it that you’d want them to know before choosing the field that isn’t readily apparent during the rotation? So you got you got your third year student, they love the rotation. They’re like, Oh, torture, shredding. Definitely. I definitely To be a trauma surgeon like you, and you had to sit down with them, what were some of the things would be some of the things that you would tell them that maybe they weren’t, wouldn’t be privy to?
Yeah, you know, this is happening more and more and it for some reason, It surprises me still that I get these young people who and even I’ve mentored high school students who want to be trauma surgeons, and I didn’t even know what a trauma surgeon was when I was in high school and college.
Yeah, er isn’t on TV anymore,
is exposure. And even most of them it was only Eric was out. It was a surgeon and all the other ones were doctors. I didn’t get that when I was in junior high either. But no. So, you know, a lot of young people will get excited by the pace or the adrenaline or they’ll have you know, one really intense interaction. Maybe somebody comes in really sick after a car crash or they’ve gotten shot and they students experiences really intense interactions, and wow, I really want that But maybe what they don’t see is the what we’re doing when that’s not happening. A lot of trauma care is not exciting. It’s following up on CT scans and doing wound care. And, you know, a lot of times it’s telling people that they’re going to be fine, because they’re not injured. And you have to be happy with those things, too. You have to be sustained by the boring stuff. And you can’t just rely on the adrenaline rush, because it’s really actually depending on where you work, it may be really few and far between how does
the well then they can fill their time by getting active on the blogosphere, they can share they could get involved in real estate investing or something like that. Like we’re, you know, we’re seeing a lot of that out there. Well, first you said, you know, you see some patients that are fine, how I would think that those wouldn’t end up in front of you like what are the patients our the patients that are fine, ending up being evaluated on it? trauma surgeon if they’re fine?
Well, you know, it really depends on what kind of center you work in and what kind of trauma system you’re in, that most trauma centers are dictated by some variation of the CDC guidelines on what’s called pre hospital trauma field triage criteria. So those are CDC recommendations for who should be taken to a trauma center that doesn’t necessarily say who should be a trauma activation, meaning the trauma surgeon is there when they get there. But every center and every system is a little bit different on how it actually brings the trauma surgeon to the ER how and when or for whom I should say the trauma surgeon is brought into the emergency department for when the patient arrives, there’s a degree of what’s called over triage in every system, which means that it’s basically Better safe than sorry, that you would rather over call your trauma surgeon than under call your trauma surgeon. So there’s always a person percentage of people who end up you know getting a full evaluation and going home at the end of the day because even though things look bad on the scene, you know, by mechanism, maybe it was the car was dented by more than 18 inches in the passenger compartment for example, which is a can be a marker for somebody being injured, but in modern day vehicles, that’s often just a reflection of how the materials are meant to crumble and is not actually and people are actually quite safe. So those those triage mechanisms are meant to be better safe than sorry, got it.
You were kind of getting into that. And this is something we spoke about on your show, which was finding joy in the routine. So you said you know the routine stuff for minefield it would be like ear wax and that’s what we discussed. Like I just didn’t I enjoy it. much I enjoy removing it but like I have, you know, these recurring patients where it’s like low stress situation, how you doing, talking about your family, I’m kind of like a barber it’s, you know, if I find out join it. So, first, you mentioned a couple. But could you elaborate more on on some of the more routine things and then go into some of those routine things that you manage to find the joy in that on the outside look kind of boring?
Sure. So you know, blunt trauma is most of what we do. So that’s people who get into car crashes or motorcycle crashes or they fall. And they often have relatively low energy injuries. And the ones that bring them into the hospital most often would be things like having broken ribs, and there’s a lot of anxiety associated with broken ribs because it’s your breathing. And if you if it hurts, every time you breathe, a lot of people will become very anxious about that. And they can get into this kind of mental spiral. And, you know, and then they’re coughing and then they’re not using good respiratory mechanisms, and then they’re actually ending up in a more morbid Not that’s not the right word. But they they can end up in a being a little sicker than they necessarily were to begin with because they become so anxious and so fixated almost on their breathing and on their on the injury. So part of what I tried to find comfort in or not comfort but I find joy in is coaching people on the experience of discomfort, fulfillment, I think you find your mean you find fulfillment in this Yeah, that’s that’s a better word for it. I when I can coach people through the discomfort and have them be more be you know, just breathe easier, literally, and figuratively breathe easier on the other end of it. That’s a really common thing that I didn’t think that I would find fulfillment in but I do
wonder the difference between your field Mine is, you know, I’ve ongoing relationships with a lot of my patients. And, and you don’t. And so when you choosing the field, I would think that that’s something that you kind of actively decide is less of a priority, right? Like is is the doctor patient relationship yet somehow you’ve managed to make that an important part of your, your practice. Like that’s something that’s that’s become important to you that you find fulfillment is that is that interaction?
Oh for sure. It’s definitely different than what you have where I don’t see people over and over again. Well, hopefully I don’t see people over and over again. And so maybe don’t necessarily get to know their families or follow their kids sports, like you might get to but the intensity of the situation definitely creates an opportunity for a really meaningful patient interaction, just the same
real human connection. Mm hmm.
And it can be really hard, you know, a lot of patients, probably one of the things that I hear You know, really, really often that is frustrating to me. And almost hurtful is how often patients say, well, you don’t understand. And it’s no matter how hard I try, no matter how long I sit and try and listen, the intensity of the situation really is isolating to patients in a way that’s very unique and very personal. And so I can’t possibly understand I don’t know what their what it is that they’re losing out by being in a hospital bed. I don’t know, their financial situation or their family situation that’s being harmed by them being in a hospital bed and not being at work or being in school or whatever it is. But it’s, I still find that very motivating, to try to try to understand,
well, you’re you’re highly trained for the physical trauma, but you’re also managing to treat the simultaneous mental trauma
you know, I try but that’s something Our whole system just really doesn’t do a good job of, we’re just now starting to recognize the long term psychological consequences of physical trauma. More somewhere between Some studies have said, you know, 20, and up to 60% of patients will have symptoms of either depression or PTSD or both at six months after a significant trauma. And our system just is not good not capable of absorbing that right now. But the first step is is acknowledging that it’s happening. And and that starts with the immediate post trauma care while they’re still in the hospital.
Yeah, it seems like a great opportunity to even you know, once they’ve had time to process the whole situation to inform them that this is a possible outcome that they need to be aware, so that rather than you know that they they see it happening to them.
And I, you know, that’s a conversation that I have in clinic and follow up a lot. And sometimes even just acknowledging it is a huge relief to patients when even just saying it out loud and saying it’s okay. And this is normal. Sometimes that’s enough to take a little bit of the burden off in the short term while they can while they’re still recovering. But we definitely saw a lot of work to do as a as a system.
Oh, I’m sure I’m sure they think they’re going through going mad. You know, they’re they’re falling apart at the seams and, and this is they don’t know where it’s coming from. And yeah,
yeah, they feel weak. They feel like they did something wrong and they feel like, you know, other people don’t feel this way. It’s incredibly isolating, especially when you end up you know, relatively homebound or missing your work or your school or whatever your routine is. And they definitely get into a spiral and sometimes just Now alleging the spiral is enough to at least slow it down, if not break it.
This conversation with a trauma surgeon is definitely not going in the direction that I thought it was. But But still, it’s, you know, extremely interesting, extremely informative. So but let’s get let’s get back on the path of the of the physical trauma. So, let’s say you get called to evaluate a patient and you’re the second physician to see this patient. So, you know, it’s still still I’m not so clear on the pathway of who gets seen by the ER doctor and who gets seen by a trauma surgeon. But let’s say for whatever situation, either the ER doctor and internist, maybe in a resident that’s rotating on your service, either way, you are the second physician to see this patient. What do you hope has already been done and I know I haven’t given you any information about what the trauma was. But that’s kind of what I’m looking for is like, you know, ABCs the ABCs of trauma
What I was going to say, I hope somebody already did the ABCs Yeah, depends on depends on the situation because if somebody has already seen them before me, then the chances are they’re not as sick. But yeah, I hope somebody has done the ABCs and somebody got an IV and Okay,
come on, you’re stuck in the elevator just like help me out with this scenario here. Right? You’re you’re running down seven flights of stairs because the elevators broken and there’s already another doctor there. What are you hoping this doctor has already done by airway, breathing circulation, so that
breathing circulation so in in trauma, you know, a lot of people will put it as Civ especially for penetrating trauma. You know, so if there’s uncontrolled bleeding, I hope somebody put some pressure on it or put a tourniquet on it. If it’s an extremity
and don’t do that nosebleed please.
My neck, you know,
we cut off the circuit Quarter
stopped, we stopped,
can’t get the start at two been in the immediate care for trauma, you’re looking at the things that can kill you right away. So those are your tension pneumothorax, your cardiac champ, an odd traumatic brain injury related respiratory failure, and then uncontrolled hemorrhage. Those are your immediate life threatening things that I that are always on the top of my list whenever someone comes in to make sure that they’re not present. So I hope that somebody is doing that for me.
And then and then what happens from there. So so you’re going to control a hemorrhage, you’re going to make sure that there’s not some immediate like life threatening injury, like tension pneumothorax, cardiac term temper nod or they’re going to herniate their brainstem potentially and stop breathing. And then and then what happens from there with regards to the assessment,
so depends on in general, we’re following what’s the American College of Surgeons advanced trauma, life support and so on. After you do your primary survey where you’re looking at airway, breathing, circulation, disability and exposure, then you’re looking, you’re using things like chest x rays and fast exams, which is an ultrasound to the abdomen and the heart and the lungs. And, again, looking for those immediately life threatening things. And if those aren’t present, then you moving on to your secondary survey, and you’re creating a plan to finish your assessment. So in most cases, if people don’t have an immediate life threatening thing, they don’t need to go to the operating room right away. Most patients are going to end up in the cat scanner.
So we’re going to change the scenario a little bit. So one thing that I like to cover on this podcast is, is how to be a good referring doctor. So if I’m interviewing a specialist, what is it that you want your referring doctors to know so that they can do something before they refer to you or stop referring you this type of patient or something like that, but I would imagine you don’t really have referring doctors right now. You know, that they’re just that’s not helpful. end up in your travel bag. So on the other hand, right. The other thing that I like to cover is what every doctor should know about your specialty because we’re all doctors, right? And so there’s a certain expectation of what we’re going to know. And so, you know, I had spoken to an ER physician about a cardiac arrest. How do we handle that? If we’re a pathologist, who knows what cardiac tissue looks like, under a microscope, but right, they don’t know how to deal with cardiac arrest. so in this situation, we’re gonna make it more of a trauma situation. I’m out for a walk with my family, right. And I see a car Korean into a tree. So I run up to see how the drivers doing. And everybody’s looking at me and expecting me to know exactly what to do. If you could walk us through a trauma assessment where you don’t have access to your cat scanner where you don’t have access to maybe a syringe to to emergently drain cardiac temping odd if I if that’s actually you know how you do it or put it another way Let’s say I’m in Iraq. I like to choose other specialties, right? So put another way, I’m a neurologist that happens to be a bystander at the trauma. But I’ve left my reflex hammer and tuning fork at home.
But everybody’s looking at me to do something because I’m a doctor. Sure.
So I would say, first of all, your pre hospital providers are your best friends. So first thing is just call 911. You can’t you really can’t do a whole lot without your tuning fork. So if the things you can do on scene after trauma would be to assess for life threatening bleeding elbow, I’m sure a lot of people have heard of stop the bleed, which is a campaign that was started by the American College of Surgeons along with the joint trauma system and the pre hospital organizations to teach bystanders how to be lifesavers when it comes to life threatening bleeding. So I think any physician should be able to look for and assess for life threatening bleeding and then try to stop it. I carry attorney Get with me almost all the time, but I don’t expect everybody else to. So just doing things like holding pressure to an area that’s bleeding to try to slow it down until pre hospital providers get there. Did you use something like a belt? You know, we don’t really recommend that people try to improvise tourniquets mostly because while you’re trying to improvise the tourniquet, there’s still bleeding. And the majority of bleeds can be stopped with direct pressure or with packing a wound with something like a you know, clean t shirt. Most bleeding is going to be venous so you can overcome the pressure in the venous system, just with direct pressure most of the time.
Sorry, while we’re on the topic of tourniquet, I think it just bears mentioning for my specialty that you can’t turn a kit a nosebleed so a lot of people when they’re trying to stop a nosebleed will put the pressure over the nasal bones. Mm hmm. Thinking that that’s where the blood supply comes from. Mm hmm. That is not where the blood supply comes from. The blood supply comes from underneath the septum. It comes from behind the septum. It does not come from the the skin or the nasal bones, you’re not creating a tourniquet effect by doing that, you’re just waiting for the blood to clot. So if you are going to stop a nosebleed, you pinch the nostrils shut. That’s it because the vast majority nosebleeds are from the anterior septum. And you put pressure on the ampere septum by pinching the nostril shut. So sorry, I thought you mentioned the tourniquet and applying pressure, so I just wanted to put that little PSA in there. Okay. Sorry. Okay. So, so, so don’t go looking to improvise a tourniquet your bandana? Whatever, just put pressure on it.
How much
Okay, so that but you said it’s not ABCs? Right? It’s si si a be
a lot of time, man. It’s me. Okay, because, you know, in the majority of preventable deaths from trauma is from hemorrhage. So if you can find external hemorrhage or an external source of hemorrhage and slow it down or stop it. That’s the most The way that you can be most impactful, got it.
Okay. And then you can even task somebody with doing that, once you’ve identified it, put them on it, and then you can go over to the airway.
Yeah. And you know, because there’s not a whole lot you can do without your trusty oxygen tank, they you carry around. So there’s not a whole lot in the pre hospital setting that a doctor can do, apart from try to do like a jaw thrust, because in general, we don’t, you know, and when people are in a significant trauma to the point that they have an airway problem, we also worry about their spine. Yeah, so you don’t want to move them around a whole lot. Or for example, put them in a position of comfort or recovery position, which is typically kind of on their side towards almost towards a fetal position.
Although you don’t want them to swallow their tongue turn them on their side. Yeah, not not a good idea.
Right. So that’s where the pretty much the only thing you can do pre hospital before your MS folks arrive is to do something like a job for us to keep their their fair is open if their mental status is altered, otherwise, you know, the majority of people will breathe, it will be breathing just fine on their own.
They’re awake, just stop their bleeding. So that remain awake. Yep. Okay, and then just wait for 911 I think that’s, that’s something that separates physicians from from lay people in situations like this is we kind of understand when we’re at the limits of what can be done, like, you know, someone else might be running around. I don’t know, what else can we do? What else can we do? What else can we do? The doctor you know, we know this is it. This is what we can do. We just have to wait. And then you know, wait for em is too common?
Yeah, I’ve you know, I’ve stopped it car crashes and motorcycle crashes and even as a trauma surgeon, apart from I literally will come to the scene with my tourniquet in my pocket and assess for life threatening bleeding and somebody’s bleeding. No. bleeding. Are you bleeding to death? No. We’ll wait. We’ll wait for the ambulance. See at the hospital.
Yeah, just picking up the shift right now. So let me reach it. I’ll be better if I just get back in my car. Exactly. Right. He there.
Exactly right.
Okay, so is there anything else about trauma surgery? Knowing that this is a primarily physician audience, maybe some trainees that that you want to tell us?
Um, you know, it’s a really it’s a changing field
changing Really?
Yeah, that you know, there are more and more women in the field.
More and more people are getting involved in advocacy and public health and are really trying to be a part of injury prevention solutions. So in the same ways that cars were made safer through research and advocacy in the 50s and 60s that, you know, has drastically brought down the rate of injury and death due to Road Traffic incidences. physicians are just are trying to do the same sorts of things when it comes to violence, interpersonal violence, gun injuries, especially when it comes to children. And also things like elderly falls, which is the fastest growing mechanism for trauma. activation these days is elderly people who fall so a lot of your trauma surgeons are out there trying to come up with solutions to make your community safer. Not just the not just the Cowboys slinging scalpels in the emergency room.
Yeah, the social determinants of health, the things that are more likely that you will be the person that ends up in, in the trauma bay is something that that will have a far more powerful effect on the outcomes of the population, you know, minimizing how social determinants of health can affect outcomes, I guess, will have an outsized influence to, you know, our ability to suture,
right. And so, you know, ultimately we’re trying to put ourselves out of business through, you know, public health mechanisms. Yeah, another,
you’re not likely to happen anytime soon.
Well, but you know, you say that, but in Europe, for example, trauma surgeons are orthopedic surgeons, because the vast majority of trauma there is falls in Road Traffic incidents. And so the majority of injuries are orthopedic interesting, whereas in America, they have always been general surgeons because there’s an outsized proportion of interpersonal violence that needs immediate, you know, life saving intervention within the first hour of injury that is in the chest or abdomen or the peripheral vasculature. That’s why general that’s why general surgeons are trauma surgeons in the United States. So there’s examples across the globe of how, how we can do better how we can do better. Yeah, good way to put it.
See, I thought in Europe, they were they were all the surgeons were barbers, because they were the only ones with the sharp instruments
back in the day. Yes. But yeah, the trauma surgeons are the orthopods. Interesting.
So taking a little turn away from trauma surgery. I know you’re not No longer doing the podcast, but I loved it while it was around. And is there anything that you would like to mention that you learned from doing your podcast about medicine? from some of your guests? your podcast wasn’t about medicine, right? It was outside the operating room. It was all about what we do outside the operating room. So one or two highlights of your favorite interviews and you know, it doesn’t have to be mine.
I did learn a lot and
I think the
I think I needed the podcast more than any listener did. Because that helps me to remember that we’re all just human beings trying to do our best and what your best is, and my best is and somebody else’s best is not the same thing. So you know, one of my guests was a woman who, I mean, she just had it all and did it all and she had the the world’s greatest A CV, that every you know, college kid who wants to be a doctor would just dream of.
She hated it,
and was miserable and almost quit before she, you know, took a step back and found different ways to look at her life and what she wanted and how she was going to get there. And, you know, she’s still a very intense, very driven, very motivated person, but it was through having an executive coach and then becoming an executive coach that she was able to just put a different lens on her path and her motivation and what she ultimately wanted to get out of life. And it was enlightening for me to see somebody. You know, when we, when we think about, we see stories of people who change careers or who change who burned out, you know, terminal a burnout. You know, we think of people who like run off and be Yogi’s or run a smoothie shop or something. We don’t think of people who burn out and come back. And she burned out and came back even stronger in a way that was really, really motivating, really powerful to me. And she also reframed burnout for me a little bit in a way that I guess kind of unburden me a little bit of my own guilt, about, you know, the days when it’s hard to get going. So that was probably the thing that, that I was most impactful for me about doing the podcast. And like I said, I think I think I sought out the guests that I needed more than what anybody who might have been listening needed.
Doesn’t this is this is you’re basically saying my podcast right here, which is I just, I have questions. I would like them answered. And I figured if I’m interested in finding these answers than others, People are interested in finding these answers, but it’s still all about me. So
one has to be right. Because, you know, like, people don’t realize how much work this is, you know, you’ve got a wife and three kids and it’s nine o’clock at night. And here you are, you know, talking to a relative stranger on the other side of the country. It’s, it’s work, it’s fun work, but it’s work and it takes time. And so you have to get something out of it too.
But I think to what you were saying about the the burnout and and how you got something out of it. I think it’s it’s important to have these haven’t cultivate these outside interests. You know, I when I joined my practice, I was, I guess, 3332. And this was after that same training, the rest of us do, right, I went to college. I took a year off in between, I went to medical school, I did my residency. So every four or five years, you were onto something different. Mm hmm. I was hired. I got My job, had my exam rooms, and I looked at my exam rooms. And I said, Okay, so this is where I’m going to be for the next 38 years. Hmm.
And isn’t that horrifying,
like doing the same things over and over. And so you need to have those, those those other things. And you need to be able to evolve in your in your job, right, you need to be able to keep improving to know like, you know, keep going to conferences, keep reading, keep learning so that you can keep evolving. And it’s not the same thing. Because the way that I’m treating sinus infections now might not be the way that I’m treating them. 10 years from now, the way I’m doing sinus surgery now, there’s probably not going to be them doing sinus surgery 10 years from now, so you know, so improving your craft in this way. But also you got to have that outside stuff. You got to have the outside stuff. So you’re not just grinding and grinding and grinding and grinding and grinding. So there’s like a different, something just completely takes you out of that. And that’s that’s what it sounds like that’s what it was for you and that’s what it was. That’s what it is for me.
You know, and the, you know, the thing that my guests said the most, which, you know, I still kind of hold on to is that whatever it was that they were doing outside of the operating room, it made them a better doctor. Yeah. So, you know, we go through all that training and you know, I spent 11 years after college, and every single day, it was all about the patients, and it was all about the patients. And if it ever wasn’t about the patients, then you were wrong. And it’s got to be about the patient.
terrible person. Yeah.
Right. And you know, and then you lose what precious hours of sleep you might get, because you didn’t make it about the patients and it still is. But so many people acknowledged over and over and over again, that whatever they were doing made it easier to show up the next day refreshed or invigorated or whatever you want to call it, and able to make it about the patients because if you’re miserable, and all you’re thinking about is how you don’t want to be there then that can’t be about the patients either.
Yeah, the facts are wrong. Absolutely for sure. so wonderful. Well, I do miss your podcast. I hope you I hope you do manage to find find a way back to it but if you don’t know, I’m glad you’re finding the reason that you’re not doing it is because you don’t need it anymore. Because you found if you’re finding joy in other things in other ways like like hockey
absolutely that’s that’s where my my extra time goes now is being the world’s greatest amateur 36 year old female hockey player.
Fantastic and I love the that you drop that Slap Shot reference in our conversation before the show. What incredible movie incredible movie if you’re listening to you haven’t, and you’ve never seen it Paul Newman, the Hanson brothers.
Classic, most beautiful man to ever live Paul Newman.
Well, Dr. Stephanie strike. This has been a long time coming. I’m glad we were finally able to do this and it’s been a lot of fun.
Thanks, Brad. 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 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

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.

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

Twitter: https://twitter.com/frank_cusimano

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Website: http://survivingmedicine.org/

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

 

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.

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.

EPISODE TRANSCRIPT

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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.

 

EPISODE TRANSCRIPT

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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.
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