50. Lessons Learned: Jade Wu, Cherie Chu & Ragav Sharma

Hello everyone, I'm Dr. Darsha, and I'm Dr. Altamash Raja, and welcome to Medicine Redefined. A podcast where we will explore the often overlooked but necessary components of health, what we consider to be the fundamentals. We will investigate topics and practices that can give you and your patients the best chance to optimize a healthy lifestyle. It's time to move the needle forward and put the health back in health care. It was literally the wind just taking me all over the place, it was insane. That's scary. Well, I think Southern California couple of days, actually the week in the Super Bowl, they had a heat advisory, so it's just really about where you are, right, in state of Pennsylvania, where we're dealing with the exact opposite, but yeah, Super Bowl Week and I remember, yeah, yeah, yeah, I remember reading that and I told us like, oh, that's interesting. But yeah, man, I'm with you. When is Grand House Day? Did we pass it? Yes, February 2nd. Saw his shadow, so predicting six weeks, more would have winter, but essentially the groundhog only comes out to see if there's mates and so if there's no mates, it goes back in. But the question is, are there no mates because it's cold outside? I don't know. I do not know. Probably. I think if I was a mate and it was cold outside, I'd say inside of that. I was like, nope, not going out the front door today. Nope. Nope. Sweet. Oh, man. All right, man. All right, dude. Yeah, go for it. Yeah. So we had a couple of amazing guests for the last couple of weeks and so, you know, what where do you want to start? Where do you want to take it off? Sure. So we're these episodes, episodes, 47 to 49 here. So Jade Wu, right, so she was our psychologist that also does behavioral sleep dealing with insomnia patients. Then we went off to Dr. Cherishu, who was a wellness pediatrician, and then a PM and our colleague in that last episode was Rago Sharma, talked about preventive medicine. So let's take it off with the first episode then, Dr. Jade Wu. So this episode was all about sleep psychology, right? And what we were trying to dissect is insomnia and the link between that and anxiety. And you know, delving further into what causes this anxiety and insomnia, chicken, or the egg kind of scenario. And how do people deal with it, right? I mean, sleep, we know is such a huge issue, insomnia is becoming a bigger and bigger issue as we move forward with technology, right? I mean, we now have the invention of blue blocking glasses and happy lights in the morning. So there's obviously a bigger culture now surrounding about getting proper sleep and rightfully so. So what were your main takeaways from that? Yeah. Now I'd love to approach, right? I mean, it really, you can really tease out when somebody has a lot of wisdom, first particular problem or just in life in general, that she's been in this space for a long time working with people and she's seen the quote unquote harm that's all this information, just the overload information that we get on TikTok and social media and other platforms and books and what not. And even the media, right? Just to clickbait headlines about the importance of sleep or rather the harm of not getting enough sleep. And there is a lot of truth to that. And I was happy that Jade was able to tease out the, that hey, look, the fact of the matter is that adverse outcomes are greater for people who don't get enough sleep, not only for sleep deprived folks, but also for insomniacs, but maybe it is blown out of proportion. And also more importantly, just emphasizing on that aspect isn't necessarily helpful, right? And so she gave a lot of strategies and actually the approach that she takes when she's having these discussions. And I really appreciated that she painted a context for us all to appreciate of when what is important and how to approach it and how to think about it really. Yeah, absolutely. I think we live in this era where if we see a paper and we get a signal showing that, hey, if you get one hour or less asleep per night, your cancer risk goes up three times, right? Maybe from like 0.001 to 0.003, right? So it's about actually looking at what is significant and what actually matters in life. And you know, me and you have read Matthew Walker's book and we love Matthew Walker and we think he's a brilliant scientist, but I advise people who have read that to also check out Alexi Guzi's blog about kind of breaking down Matthew Walker's first chapter. And I think it's just so important to see both sides of the story because on one side, there's Matthew Walker who's legitimately trying to bring out good information, right? He does not mean to put out harm into the world when it comes to sleep. And he even says in his own podcast that he's not trying to scare people. He's just putting out the science and that's it. And then he'll give you strategies. And then Alexi's approach was, well, let me break down every single number you put out there and why this is wrong and how this could be causing harm. And so it's very interesting to see both sides. And you know, like I said, sleep is becoming more of this rightfully so again, it's becoming a health issue, but it's also becoming a health solution, right? So we're looking at technologies like eight sleep and whoop and aura ring that are tracking these data. But then with that comes, okay, well, now we see these issues. So how do we balance the pros and the cons of all of this? And a lot of times, it depends on the person you are. If you're a baseline anxious person, you might take that, oh my God, I'm in the red recovery zone of whoop or for the aura ring, whatever it might be, you know, I'm low. What do I have to do today to get better sleep, right? And we're going to try to implement better strategies versus like, hey, without this tracker, which you have thought of that, like you probably would just live your normal life and been fine, right? So I think we're adding more anxiety sometimes. But then if you're on the other side of, you know, if you're basically not too anxious and you know how to deal with that data, I think you're pretty okay with understanding the data and using it in a retrospective manner and saying, okay, well, these are the things that kind of made my sleep worse. So in the future, let me just try to have better habits. Yeah, no, that's extremely well said, man. I think that first and foremost, there's no question about it that lack of sleep in whichever form. However, you're, you know, whether it's truly deprivation versus insomnia is detrimental to long-term health. Right? I've already said that, but what Jade had talked about is, you know, she had all these interested in, you know, sideways approach and learning about sleep because she was learning about all these neurodegenerative conditions, right, Parkinson's, Alzheimer's, that kind of stuff. And we know that there is a good association, right, so there's correlation, but we also have some evidence to suggest there's causation for some of these things, right? And so that's still being developed. Now, associations studies are remarkably complex when it comes to that, just how to tease out what the one single thing is, that's the cause of it, and that's beyond the scope of the discussion at this point. But I think that, that we need to just get out there, it's very, very important. Kind of what you're emphasizing, or I want to come back to the point about, you know, Matthew Walker's book in Alexi Guzi, Guzi, Guzi, yeah, oh my God, hope I'm not getting away. That he only dissected the first chapter, but it comes back to this broader question about communication, right, communication and a mass level, right, kind of, but I mean, not a fraction of people are listening to this podcast as they read the book for Matthew Walker, but still it's like, you and I face this challenge every single day, right, when we post on social media, when we, when we have discussions here about how are we communicating, because it's really about the interpretation, that can be very, very challenging. And so again, I go back to why I was so impressed with Jade is because she does, right, it's when you're communicating at an individual level, it's a lot easier than communicating at the mass level. So I, I could change my mind on this, and I'm constantly working on how to refine that message. So it isn't misinterpreted, but it is very, very, very challenging to curate a message that's going to be applicable, informative, and the least amount of, for lack of a better offensive to every single person that you're talking to. Yeah. And so that's challenging. I think every single scientist is trying to communicate that or working on communicating that. I will plug in one more resource for people to listen to that. That kind of looks at both sides of this discussion. It's, I think the John Rarty podcast, but there's, there's a series, right, of calling them, I'm calling BS or something about science and whatnot. And they actually revisit this as well. And they talk about, you know, both sides, and Alexi Guzi comes on and talks about a Matthew Walker is not on it. And he brings out other experts who are, who are routinely delivering public health messages on, you know, how we can communicate that better. So I think that was very, very interesting and worthwhile for people who are interested as well. Yeah. That was actually a fantastic series. Just in the whole realm of science and data and how we interpret, like 100%, yeah, we definitely need to like that and recommend everyone checking that out. You know, to, to talk to your point about context, right, like we, we can't people please everyone, right, especially in Twitter, Instagram, where we don't have a whole chapters worth of words that we can write. And so I always encourage people whenever they might disagree with something or want to get more clarification, ask those questions, right, like ask the content creators those questions. The only problem with that is, I think we're so afraid too, because we might come across as one ignorant or two dumb. So this might be kind of relevant, maybe a little irrelevant, but I remember seeing a post like last month on sports center on their Instagram. And it was, I forget his name, I think it's Archie Manning, Jr. or Eli Manning, son, I believe, right? And he's playing basketball. He's, he's okay, he's like an average player in high school, but he's going into, you know, he's a five-star recruit as a quarterback. And some guy, you know, and the, and the caption was, Archie Manning, or like playing, basketball, but something, something football. And the first comment on there was like, wait, how do you, how do you know he doesn't want to go into basketball, right? And then all these comments came in, we're like, are you stupid, like, are you dumb? Like, why would he ever do that? Do you not see the way he's playing? And this guy responds, he's like, guys, I'm legitimately like just asking. Like, I'm not, I don't mean anything by this. Like, I'm just asking, I don't know anything about him. You know, but like, it's just crazy how people can't see emotion, right? They just see words and they just put their own perspective on things. And sure, if you're a football fanatic, you're going to know that Archie is probably going into football and not basketball. But for someone who just follows Sports Center knows nothing about football, how the hell would they know? Right? And I think that's, we see that culture so often and it, it, it prevents people from asking genuine questions because they feel like they're going to get bullied or ganged up on. And it's like, eh, you know what? It's not worth it. So it just kind of reminded me of that when you brought it up. That is really interesting, but makes a lot of sense, right? I mean, it's, it's one thing to even, I mean, they're in communication when you're just writing a bunch of words on paper, but there's so much that's lost, right? I mean, we talk about people who are really attuned with this, you know, working with people all the time say that there's so much loss when you're communicating behind a screen. Right? This is kind of the issue with schools and whatnot, body language, facial expressions. I mean, the whole, at the risk of getting into this, but like the whole one argument behind not wearing masks is because so many, so much of our communication, facial expressions, right? Right. And so you're not getting any of that. Yeah. It's interesting. Somebody that I respect a lot at, Eric Cressy, I mean, I think he had just shared like a post or something that his wife attacked him and, I don't know, there was a comment from somewhere. Like, hey, like happy to jump on a quick call. If you think that'd be easier. And then the other person responded, it's like one of those like funny little things saying, quote, there's, maybe not quote paraphrasing, there's, there's literally no situation where jumping on a call is better than email, and I found that to be very funny because, you know, as I'm having these discussions with employers and trying to find a job, I think the person that I was talking to my lawyer said, hey, it's always a better idea to go back on call because a lot of stuff is, is, is missed, is lost in translation and through an email. I've always been that person and I'm curious where you stand because I think in today, like probably a Gen X and maybe younger folks, they don't, they like texting, they, they like getting the information like that. And I'm just the type of person who'll pick up and phone call and call people. Where are you on that spectrum? Yeah, man. I agree with you. I think the face to face, the more emotion, the better, but I can tell you on the exact opposite. Like I know that's one of my issues, like I am 100% text email, one of one of the best compliments, but also probably not compliments is like, Darsh, I don't know how you respond so quickly to your text, like I'm always strapped with, it's just true, like I'll respond within seconds. And it's not that like I let my phone use me, it's just like, I always just have it, right? And for me, like, I don't know, I grew up in a family that respected punctuality, respected getting back, like that's just like, that's just what I do. I just try to get back as soon as possible. And I've learned to cut that back and be like, hey, there's actually probably disadvantages to this. But yeah, it's interesting, I don't know, man, with technology moving forward and we're thinking about avatars and metaverse and all this stuff, it's almost like, you want to keep that basic human emotion, but you also need to learn how to adapt now to more of a technological forward texting, simulated augmented reality kind of world, right? So I think just having that balance is key. But I will say, you know, when it comes to like job finding, or I know you posted that Peter Tia, like the words matter, right, like huge, huge, right? Just being authentic is what I'm really trying to, trying to bring out on myself now in like the last two years, like, how do I be as real as possible? How do I call out the BS, you know, with friends or family? How do I actually put in words that matter, right, and that actually show how I feel? Because in the end, I think that's what matters, right? If we're trying to maintain relationships, we're trying to communicate better, get information across more effectively and efficiently. Your word choice and your authenticity matter more, and you can't really do that over a text, right? I can't hear your voice. I can't hear your tone. I can't hear your inflection points. And so a lot of it gets missed. Yeah. Yeah. And to your point, and to devil's advocates, my own point of what I'll say is that you also have to know yourself, right? If you're somebody who has a very harsh tone or, you know, you have high levels of anxiety and it might be a quote, a quote, a quote, a crucial conversation that you're getting into, you might want to not use that because that might end up, you might end up shooting yourself in the foot. So that's where there are tons of tactics and strategies to learn how to communicate efficiently and email as well, not only efficiently, but also effectively, right? Email and text message and that kind of stuff. And so using those types of, again, words and, and, you know, whatever it might be, codes or whatever you're going to use to leverage your own style of communication is going to be super, super critical. I think the book changemaker that we've both read and we've enjoyed me to talk about a whole section on feedback and how to receive and deliver effective feedback. There's actually a book that's on my docket's called Thanks for the Feedback that I just looked at the summary of. It's very, very interesting, but actually receiving feedback, but also giving it, you know, and effectively not offending the other person. I mean, again, we're well outside of the scope of what we then have to discuss here. But I think Jade would be happy because, again, as a clinical psychologist, this is probably up her alley just as much. Sure thing. All right. So I'll bring it back to the insomnia. One of my key takeaways that I think is so important that I did not realize is things that insomnia has quote-unquote, do-wrong, right? And again, we put that in quotes because you're not necessarily doing something wrong. It's just how do we get you back to proper sleep, right? And so my father was someone who started all of a sudden just dealt with insomniac about like two years ago, really frustrated, really anxious with his sleep, couldn't get it, probably was sleeping three to four hours, and wasn't sleep deprived, right? So the difference between sleep deprivation and insomnia is how much opportunity of sleep you have, right? So an insomniac, you have, let's say, eight hours or something withholding you from getting that proper sleep, let's say, for however long you need, whereas sleep deprivation is, you don't even have the opportunity to sleep for however long you need. So you know, class examples, that single mother working two to three jobs, night shift workers, things like that where it disrupts your normal pattern of getting enough sleep. So one of the things she says is like, hey, if you are an insomniac, the best thing to do is undergo CBT, right, cognitive, behavioral therapy, because too often we try to fix it on our own. And the way we do that is with sleep hygiene, right? So flu blockers, not watching television, meditating at night, doing all these different things. And what was interesting is that in sleep studies for insomniacs, the control arm is actually sleep hygiene. I would never have thought that. I would never have thought that sleep hygiene is just a placebo. And what you really need to do is actually take them through cognitive, behavioral therapy, which there's a lot of components in it, but I can tell you from what I see as my father is, they essentially shorten your wake up time window. So let's say you normally want to sleep by, let's say 10 p.m., you get up by 7 a.m., but that's not happening throughout the night. So what they'll do is, okay, try to go to sleep by 10, that's fine, but first we'll work on the time you wake up and we'll shift that 7 a.m. up to, let's say, 5 a.m. So they're almost increasing your sleep drive, and they keep doing that. And they'll tell you like, hey, it doesn't matter. Even if you feel like you want to wake, keep sleeping past 5, don't do it. We're going to keep you up. And then they'll work on the front end as well, and they'll try to make it like 12. So they keep shortening the window until you're finally like able to sleep, right? And there's nothing miraculous about this in a way. It's just creating a sleep drive and making you comfortable and understanding that, hey, you're able to sleep, like you can do it. All we had to do was just fix some hours up, but boom, here you go. And I remember telling my father before he went through CBT, hey, you tried the blue blockers out, tried some Ashwaganda, do this, do that. You know, being the doctor I am, I thought I was doing some good, but yeah, it wasn't working. And then what work was going to be able to be? Yeah. And that's a perfect segue. I mean, she had kind of highlighted the different types of sleep drive mechanisms, right? That helped promote healthy sleep. And so what you're talking about largely, so the first one is the homeostatic sleep drive, right? And this is kind of the, I think in laymistrums, what is the sleep pressure that builds up throughout the day. And so it has a direct positive correlation with time a week, right? That's exactly the reason what you're describing. And so, you know, this is very, what's interesting about this actually is, this is very sensitive to both cognitive and physical stimulation. So we talked about the pressure into the more active you are throughout the day physically, the more dentistry builds up in your system. And that's what's not going to you out, right, at the end of the day. But cognitively interesting does that same day. So if you do some mentally stimulating tasks, a lot of deep work throughout the day, but not only that, if you travel on vacation, right? And you do a tremendous amount of sightseeing, just that stimulation, the visual and cognitive stimulation can actually help you sleep much better. So from both of those ends, I mean, it makes sense, right? Just in my small brain here that you need to recover after you've had all this mental and physical stimulation. So that's one aspect of it as well. And actually, the CDC website has a really awesome like module on this stuff. And they actually have a really nice graph that we can link in the show notes for that. So that's one aspect of it. And so folks who have like imbalances in the autonomic nervous system, so when you have insomnia and anxiety, your sympathetic nervous system is in hyperdrive, right? And so when that's the case, and that's why when you're stressed out or whether it might be because you just ran a code or you're stressed out about an exam or whatever it might be, if your sympathetic nervous system is in hyperdrive, it's going to make you much more challenging. So that this is exactly what for CBT component is going to be directly addressing. That being said though, long-standing history of anxiety and insomnia can start to rewire your actual hormones and brain processes, right? And that's where the circadian safe drive comes in. And so circadian safe drive gets a ton of attention, I think. And so I won't spend too much time on this, but this is the one that's regulated by hormones, right? Chiasmatic nucleus, the hypothalamus, which is the master circuit in your brain. This is your internal 24-hour-ish clock because studies have shown that it's not always 24 hours for every single person, but what's interesting about this is in terms of responding to different stimuli, exercise even influences this as much, right? However, the stimulus that affects us even more than exercise, even more than melatonin stuff like that is light. And Jay talked about how that might be the most important thing is anchoring your day by light in the morning, right? And so we all, all three of us here and a lot of people that we know and we respect actually have started implementing early light exposure during the day, how that's so critical to set your circadian sleep drive throughout the day, especially with stupidity of daylight saving times. It was our fans up. Got to move to Arizona. I don't know. Arizona, and there's another state, is it there or not? There probably is somewhere around there. Yeah. There's a couple of states, I think, but anyways. And so that's the one that influences that, and again, there's a really cool picture that I showed that even actually through closed eyelids, the light penetrates through the retina and translates right over to the SCN and will augment the circadian sleep drive. So it's super, super important to control that as well if you're going to be actually, so this is where I think one of the things that the only sound piece of advice I got when I was in intern on night shift is like we had this sleep module and they were like, oh, like if you're going to be working nights and you're driving home, just like wear sunglasses or something like that, and yeah, I'm not really sure it helped that much, but anyways. Yeah. So that's all set of that. So it's interesting. Yeah. She, Jade Lou just wrote a tweet on that actually. I think there was someone wrote like a question tweet and was like, hey, what's the one thing you would like tell everyone if you could, one thing to do in her answer was get light in the morning and she even uses one of those light markers on morning. But the last thing I'll say about this episode is, you know, if you're a clinician out there, healthcare provider, thinking about going into this kind of stuff, make sure you delve into your patient's history when it comes to sleep issues. You know, most people that come in with sleep issue will also have some sort of issue, right? It's rarely ever just solely sleep. And so, you know, I've been doing a better job at this now where I'll actually ask the patient as a sleep onset, as a sleep maintenance, what are they trying? Where they're doing, looking at their comorbidities, you know, the exercise, all that stuff. Because as you said, we know that sleep and the hormones that it plays can rewire a lot of things. And so sleep is not just a lone wolf. It's affecting everything else. And then recognizing, hey, we'll sleep hygiene work for this patient. Or should I be referring them to psychology, a sleep psychologist and undergo CBT? And I think once you fix that sleep, you'll start to notice it's a world of a difference. Right. All right. And let's shift gears. Where we go next? We're talking about children, lifestyle medicine in children? Yeah. Absolutely. Lifestyle medicine in children. So just for context, for people, Dr. Cherichu is a pediatrician. She works at a practice, I guess, with her, with other colleagues. But then she's incorporating lifestyle medicine into that practice. So unlike some of our previous guests who might have been doing direct primary care or functional medicine, having their own practice, their own lifestyle medicine practice, she is bringing in the concept of lifestyle medicine into her practice. So yeah, man, I think for me, I'm going to keep this short and sweet. I think there are two really, really big ones, which we can touch on a little bit more. The first one that we start off right off the bat, talking about the importance of treating the whole family. Right. Again, the either pro and con, depending on how you looked at it, is you have multiple patients in the room. That's not, I didn't get the sense from her that that was her approach. Or she talked about how, well, she actually had a backwards approach. I often think about, we think about how whatever the parents are doing, whatever the lifestyle the parents are going to be. They're going to model that behavior and the kids are going to follow suit. And that certainly is the case. However, she talked about how often she's treating the patient, the children, and they start making changes. And then because the parents are the one helping implement the changes, they're starting to mimic the children, right. So it's a backwards or reverse psychology type of situation. But it was really, really fascinating that I started to think about. It makes sense though, because now being a parent and the sacrifice you start making, you want the absolute best for your children. And so if you're going to start making healthier meals for them because you want them to be better, it just makes it easier to make one meal, right. I would not endorse that, you know, you have one meal, if alcohol is going to be part of it, or really a couple of other beverages that you probably, children shouldn't be part taking in. But yeah, I thought that was really interesting. That is very interesting, man. You know, families that stick together and kind of do the same thing, see better results. I think, you know, everyone can agree to that. And we always touch on how parenting and modeling and behavior is so crucial to kids growing up, right. I mean, it's like a monkey, see monkey, do kids aren't good. You can't just tell a kid to do something and they're just going to do it, right. They're going to see what their parents do and that's going to be whatever they think is most beneficial for them, right. So if they see their parents just watching YouTube at night, they're going to be like, oh, okay, I guess this is what you do, you know, to become an adult and progress. But if they see you, right, instead, you know, reading a book and doing having better practices, I think that's what they're going to model, you know, even better. Yeah. Yeah. And she had talked about exercise, right. I mean, her disclosure was that exercise is not one of her favorite things to do in terms of the pillars of lifestyle medicine. However, incorporating play, I mean, this is what I think you and I have done a good job about saying, hey, let's just incorporate movement and how do we do that, right. For her and their family hiking is a way to do it, right. And you're killing, I don't want to say multiple birds, but you're knocking off a separate thing, right. You're getting outside. So you're getting this sunlight, you're getting active, you're getting fresh air as you're, you're, you know, interact with nature and I think there are a host of benefits that come with that too. And so that's important. The, the concept of the, or the story that she shared about how, I forget how old her children were, but when they're watching TV and the kids just like flip back and I mean that one hits home with me because it is challenging, man. And again, you know, seat deprivation is, is a, is a very close part of my life. I thought I was done for the internures, but here we are again. And I have a new sense of appreciation, but at the same time, there are days when you come home, you're tired and just mindly scroll through social media. I've mentioned to you before is sometimes I don't even know how to get an Instagram. Like it's, it's even worse now, right. You're just, you're just an autopilot at this point. Yeah. And now my daughter is getting old enough where she starts to recognize the phone. Like if I put a camera on her face to just record her reactions or something because I want to get something as cute, she'll immediately stop or look at the camera. And while she's not even three months old and it's really interesting how attentive they are to you right off the bat, right. Hey, what are you doing? And stuff like that. And so it would be easier. I can imagine it would be easier as I come home and I'm exhausted and I just want to finish my meal that you just hand them something that's high stimulation, right. Like she had talked about low stimulation toys versus high stimulation toys like social media and really every colors and screens and everything happened like that. How that's the, the easier path, but she really encouraged parents and even our listeners and me, honestly, that if you take the harder path now, there's going to be a brighter future ahead for sure. So let me ask you this, right, because you're a new father and we're talking a little bit about this offline, but I think it's going to be valuable for our listeners to at least think about these topics. So we're obviously new parents are in this quote-unquote personal development generation. I mean, that's what we care about. We care about passion. We care about self-development. So how do you balance that, right, this self-growth quote-unquote selfishness, getting your career in line, doing the things you want to do, you know, we talked about meditating, reading, working out, but then also, you know, and doing those behaviors, hoping that, you know, your daughter will see that and also follow suit, but also being more present with your daughter and understanding that, hey, you're going to have to sacrifice some of these things in order for her to even be mindful. Yeah, I think what I'll say is I haven't figured it out yet. Yeah. It's a, I'm still very, really new at this and it's very challenging. And I imagine right now it's two of us and one child and imagine when you have two children like that completely, you know, you're going to get out and numbered, so it's going to be even more challenging. I think the fact that we just had a conversation with her and about, you know, mindfulness in children, how important that is, what I just mentioned that I've started really appreciating that she's looking at me or, and so sometimes when I'm looking at my phone and like I've just fed her or something and she's like looking at me, and then I see her turn over to my phone. I'm like, I was like, okay, I got to put that down, right? As I need to be mindful in this situation, as she mentioned when the baby's in the doctor's office, they're so mindful, just looking at the paper, they're looking at the toy and stuff like that and we're born mindful. And it's such a fascinating thing to me. And then all of a sudden, you know, as we get older, our attention gets hacked with everything else around us, but also internally as well, right? Your own thought process. You're not living in the present moment. So it's just a constant reminder to just keep myself accountable when it comes to that. Obviously, the other aspect of learning and stuff, the things that we're passionate about, well, what I'll say is it's good to have good support staff, good partners and I thank you for this with your flexibility, right, to be able to get on a podcast whenever and move things around and be able to carry the load. But going back to Jade's point, actually, when she talked about building in systems, super, super important, right? And so, for instance, reading a book like, okay, what am I going to do that, right? All right, so maybe now I'm not going to listen to music when I'm working out, right? Instead, I'm going to listen to that podcast because I don't have time or I'm going to listen to a book and stuff, you know, maybe a better book or something like that. Same thing like, you know, when I'm driving, I always did that anyway, but that time's going to be valuable too. And then ultimately, being okay with the fact that this is just a phase in life that's going to pass. So I think about something Kelly Starratt said, he wasn't with us at the time. I think I heard him on another podcast, like the world's best ad podcast, talking about how there's the concept of balance, right, which I thought it was really profound, that you're never always in balance, right? It's a pendulum on both sides of the extreme, and it swings like a hundred miles an hour, and there's a brief moment that you're actually in balance, and that one really stuck with me. I don't know why, but like right now, I'm okay. I'm okay with the fact that if I can get three hours of training in a week, that's a way. That's really a win. And I think those who've really known me for a long time, if they heard that, they would be appalled, but I had to be okay with that. Hey, it's okay. It's okay if I sleep five hours. That's okay. This is going to pass, like anything else, like there's an important reason. And this all comes back. I mean, we talked about this on time and time again about, hey, just be kind to yourself. Like, hey, look, no, I'm not going to develop coronary artery disease because I've missed like a few weeks. Like, you know what I mean? It's okay. You control what you can control. It's okay. It's funny. I was thinking about this yesterday when I was at the gym. I've been pretty impressed with my own kind of progress with hypertrophy, cutting, all that kind of stuff. And it's funny because obviously when COVID came around, I wasn't doing anything. You know, I'm so kind of quote unquote OCD about getting to the gym. I can't really work out at home. I try to do some things and I was, you know, plateauing or I wasn't really making gains. And I look back and I'm like, wow, it was just a face, right? Like, looking back, I'm so okay with what happened because listen, in the end, if you want it, you're going to make it happen. When things kind of, again, that pendulum of shifts and now good gyms are back open, you have that opportunity to now go and do what you want to do. And understanding that, hey, this is how life's going to be. There's going to be a point again in the future where I won't have enough time to probably go in the gym and train as, you know, which is what you're in right now. That's okay. You know? So, yeah, that's a great analogy that Kelly made there. Yeah. And to your point about training at home, like again, I'm very fortunate that I've got good tools at home that I can train. I don't, I mean, the gym that I have is literally a quarter of a mile away from my home. And it is just better. It's just better. I can jump around. I can do what I want to do. I can really train. And it's much more efficient of a workout, but a lot of my sessions, I've started training at home. So, like, if she does cry, I can stop my workout and pick her up, right? So, a 50 minute workout sometimes turns into an hour and 80 minute workout. Yeah. I already done it. So, this just goes to show you that that's a, yeah, yeah, that this is the beautiful example. That was not scripted right there, folks. But yeah, an hour and 40 minute workout, that's amazing. And it's less efficient, but I can get the tasks done. And that's all right. Like, it's not always about being 100%, it's sometimes 80%, it's just fine. Nice, man. The last thing I wanted to bring up about this, that something that's important to me, at least, that, you know, I saw a lot of when I was shadowing pediatrics as a 30-year medical student was just bad, quote unquote, bad behavior by parents when they would bring their children in to the office, you know, one of the, one of the things that got me under their skin was just blaming their child for things, right? So, child's not reaching the growth or they're reaching it too much, right, obesity, they think it was on the way, ears aren't clean, there's too much wax, and parents would be like, I told you you had a clean ear, I told you to do this, I told you to do that. And, you know, it's almost like disrespectful to kind of just blame your child in front of somebody else, and children are smart enough to realize like, damn, you're kind of throwing me under the bus here, even though I didn't do anything wrong, but that sets you up for future, that sets the kid up for future failure, and just future trauma too, you know? And I think it should really be a better rapport in relationship between the father and the kid, and working together to see, hey, what works, how can we make progress? Let's ask the doctor for guidance and say, hey, is this something that's not on the kid, is this, you know, who should take onus for this, how should we be better, and making it just more teamwork, more than anything, and prepare to be engaged in your visits, right? Dr. Two mentioned, one of her pet peezes, parents kind of just being on their phones, not present, so getting off your phone and just making sure that visit can go smoothly. Yeah, man, that's such a, the word trauma that you, as I'm glad to use that word, it's so funny because, you know, and then like we inflict this damage, I mean, we do it to ourselves all the time, right? And I remember I had an attending, he was a med peeze attending, who talked about how his frustration was, and how he liked working with kids rather than adults because most of the issues that adults present with in terms of chronic illnesses, right? Whether it's COPD, you're from smoking for a long time, diabetes, for not taking care of yourself, or whatever it might be, those are self-inflicted things. Kids that doesn't, that's not the case, right? They're ill because of a respiratory issue, like a viral issue or whatever it might be, but sometimes they have issues because of what's inflicted upon them by their parents, or the external factors, right? And that's kind of what you're talking about. So the emotional aspect is not what he was alluding to at the time, but man is that critical, right? And again, nowadays, when, again, you know, we're talking about the mental health issues and what this pandemic has unfocused from that aspect, 10, 20 years down the road, what trauma we experience now, how that's going to manifest, it's a rear, you know, a rear talk we had, that's going to be a real problem, but again, this goes back to just throwing bandages on and patching it up, don't worry, we'll patch it up in 20 years from now, right? And as we're going to talk about a little bit, preventative medicine, how could we do that? And that's kind of what you're touching through. So I think that's a good subway. Yeah. Let's sit in the preventative medicine. Cool, man. Yeah. So our last episode here was with Dr. Roger Sharma. So he's an intern right now in Chicago, but we'll be doing PMNR at Wisconsin. So it's cool to see having another physiatrist, resident, you know, closer to age to us, coming on to the show. So yeah, this episode was all about preventative medicine. He has his own podcast called the preventative medicine podcast, there we go, got that one, right? And his kind of definition and his perspective on what he's doing, why he started it, and what his goals are. Yeah, dude, impressed fellow podcaster, but I really love the mission of their show, right? And I think what I want to emphasize is what the hell does that even mean, and he asked him that it's the, maybe the keystone question, is that appropriate? On their podcast that they ask every single person. And you know, he had a really good actually blog, an article on his blog about this, which we can link for folks, but I really, really like his definition of it and his, or not even definition, but his approach, his philosophy on it. And I look this up, right, and because people talk about this all the time, we talk about this all the time, and that's kind of a sideways mission of our show as well. But, you know, preventative medicine means different things to different people, right? The dictionary definition is like the action of stopping something from happening or arising. It's pretty unique. And although that's admirable, right? It's not realistic. It's just not, right? And I think the way most of us refer to preventative medicine is like risk mitigation, or even delaying injury or disease or the outcome, right? What have you? And I think that that's really, really important to understand, especially when it comes to health. Like things are really, really, really messy, right? I go back to a story, the same intending that I just talked about med patients. I remember seeing a patient, this is me as a third year medical student, and a patient came in, and she was young, man, maybe like 32, 33, and I asked her about smoking, right? Because you get that amazing social history, like a 30-year medical student, oh yeah, like you're getting it all. And she was like, yeah, I'm smoking. And I was like, okay, well, so this is an opportunity to intervene as a 30-year medical student, so it's like, well, you know, it's good for you, blah, blah, blah. And this person was in a trolling mood, and she just wanted to give me a difficult time, and she was like, okay, well, you know, what about, you know, you could still get cancer, how do you know? I know somebody who got cancer, even though they didn't smoke, like, what do you have to say to that? True. And at the time, I was an equipped, and I wasn't even ready for that, and it was interesting. But what I'm getting at is, no, you cannot prevent every single thing. Do we know that, you know, smoking can increase your chances of lung cancer? Absolutely. Nobody questions that anymore. We've got health campaigns with all kinds of stuff like that. But you know what? There are a ton of other things that are responsible for lung cancer as well. And so, the point that I'm trying to make, and what Raghav has made over and over again, is that, no, when it comes to health, like, again, it's a multifactorial cause for a lot of these outcomes, and it's a bit of a really bad risk mitigation. Yeah, I think the one thing that Raghav said that really made a lasting impact on me was, hey, you can prevent at any point, right? Like, the way we typically think about it is before chronic disease occurs, right? Primary prevention. But he's like, no, there's tertiary, there's cortinary, like, you can keep going down the road. Like, for what stage the patient's at, and then even hospice, right? Like, for those that know, like, when we're thinking about death and dying and how to make that comfortable possible, you could even do prevent a medicine then. And he actually recently just brought on a guest to talk about that. But when I look at it, right, and I take, I look at it from a global perspective in terms of, how do we do this? It's the fact that we don't get taught in medicine, like, on the words, you don't really get taught prevent a medicine. We're almost in this mindset of, okay, if chronic disease occurs, that's it. There's nothing much we can really do besides treatment and stop them from going further, right? Which I guess is prevent a medicine, but we don't think of it that way. So we think of it in terms of preventive lifestyle, kind of together in this bunch, which we think of in younger patients who we want to change their diets, change these, us more on the surface lifestyle factors, their diet, their exercise, their movement, their stress, these types of things, so that we can prevent chronic disease from happening, right? But how can we change providers' mindsets from saying, okay, let's look at this visit, shore with the medication, everything that we're going on, but more from a preventive mindset. What, how much better would that be for everyone, right? And I think we'd start to influence patients better, I think our language would improve with the patient, our rapport would improve, and we just learn more. And I think through that, we start looking at the data even better, you know, we start answering those questions that we always had at the back of our minds that we never really ask because a lot of times we're like, oh, whatever, this person's going to get cancer, this person, you know, I can't stop this, I can't stop that. But I think it's really shapes who we become as providers, but also kind of changes health care. Yeah, such a sound point. And I think for those of folks that are still considering a career in medicine, they might be listening, they're actually residency for preventive medicine. And a bulk of the exposure that you get is, and you know, I think most of them end up with a master's degree in public health, because again, this message is to have to be communicated at the mass level, like we've already talked about a couple of times. But to your point about the different types of medicine, I'm going to lay those out because I think that's worthwhile, right, you already touched on primary prevention. Secondary prevention is the next level, right? So this is something that's reducing basically the risk of complications once you have the disease. And also like earlier diagnosis and intervention to prevent progression. So a classic example would be pre-diabetes. We know that actually that's kind of fallen out of favor too, like diabetes, like strict time points, right? I think just for folks who know that there's a marker called A1C, which is like a three-month snapshot, not a three-month snapshot, like a three-month video of like how you're blood, glucose or sugar is controlled. And when your A1C is a certain number, we say you're a diabetic, when certain number is pre-diabetic, I think it's kind of falling out of favor right that, right? When you're pre-diabetes, the the risk of cardiovascular disease down the road is actually the literature of support is just as bad as diabetes, right? So preventing like, or mitigating the risk of progression to diabetes would be secondary prevention. Tertiary would be like putting rehab measures in after somebody had a stroke, right? So this is where inpatient rehab, our world comes in with somebody had a stroke, you're again in the strongest possible, so they don't go home and fall and break a hit, right? That's the tertiary prevention type of situation. Same thing with cardiac rehab programs, you know, so they can go up and down stairs and they can be functional afterwards. And then partner prevention, which is somewhat more of a novel concept, that's what he talked about. It's like where you're preventing over medicalizations, the hospice point that you brought up like, hey, we don't want folks to end of life care issues and you want to protect the patient from excessive medical invasion and stuff right to compromise your quality of life. And I think that that's worthwhile for people to know. Yeah, absolutely. Yeah, it kind of said better, man. I think it's the perfect segue to also talk about now kind of evidence-based medicine, which was another topic that we talked about. And this is interesting, right? Because I think Robin made a great point that evidence-based medicine, again, just like preventive medicine, means different things to different people. You have the people who see one article that supports their view and they're like, boom, here's the evidence. You see people who see both sides of the view and they're like, okay, there's no evidence. You see people who just take anecdotal sides, right? There's, oh, well, this patient did this, so it must be true. So it's, and we're, and we're living in this world where everyone and everything is like, no evidence, evidence, evidence, evidence, where is it, where is it, where is it, where's the data? Show me, show me, show me. And it gets overwhelming, right? And I think it's important to kind of break this down. But also for a lot of the people out there to just take a step back and realize like, hey, this is all nuance. This is all gray area. We know from even 30, 40 years ago, the things that we once thought were true are not anymore, right? So coming in with the approach as a provider to understand like, hey, this is what the evidence, quote unquote, shows, right? This is what the data shows is what anecdotes I've seen. This is how I want to practice and how I think it could benefit the patient. It's something that we have to look more into rather than finding, you know, and looking at our biases, right? Rather than saying, okay, this is what I believe in, I'm only going to listen to people who agree with me, right? Which is exactly what's happening with the COVID pandemic. I think that's super important. And the one thing that you've said in this podcast that is so true is, you know, not letting the evidence dictate your practice, but letting it guide it, right? Like, that is so key. You can't let the evidence dictate. It's going to be a zero sum game eventually, right? I mean, sure, there's certain things out there that are strict, sure, like 100%, this is what the evidence shows. But a lot of it, I mean, I'm sure you can find a study out there that's like, uh, actually, this doesn't show as much as we thought it did. So what are you going to do at that point? Are you going to be a provider who just doesn't do anything? No. I mean, you're going to do what you think is best, but again, let the evidence guide and not dictate. Yeah. I mean, that's amazing. I'm trying to figure out what else is there for me to add is, I think the point is just that the external evidence in terms of literature and data, like on PubMed, which for anybody can access to and that's where all the, you know, the platform for a lot of the studies is, um, I think it was John A and 80s or whatever, like, you know, I have somewhere in the neighborhood. I don't know why 70,000 studies per day get published or something like that. And, uh, and yeah, I mean, is it, are they all amazing studies? I don't know, probably not. And so also sifting through the literature and seeing and evaluating the methods to see what's actually a good study versus not, um, that's also a task in itself. It's very, very challenging. The fact of the matter is we were just talking about it offline is, um, when we post something on social media, like people don't even want to click on the post to read something for 30 seconds of what makes people, I mean, what, you know what I mean? Like nobody's going to want to read a 10 page paper or like 15 page paper, a scientific paper. Like that's not, that's just not exciting. Like people can't even read books, right? I mean, what 30 second clips. So, so that's a challenge in itself. Um, and, and the other, uh, point of it is, I think that, um, to your point is like, you know, there's also harm in not doing something because if there is an evidence, right? There's a cost of doing something, right? Those are the risks that, these are conversations that I have with patient, but also tell people like that there, there's a risk of not doing something, right? That's the risk to your quality of life, uh, whatever it might be. It may be we don't have randomized control, like hundreds of randomized control sciences to support this intervention, um, but we also, you know, have, uh, enough evidence and, and, you know, all that can do is point you in the direction and then you have to decide. What, how I feel about this today, because I, I do have my own patients and then we have to make decisions on a daily basis is, I think that, hmm, when I think the, as the risk of harm gets greater and greater, I think we need to be more rigorous about the data, the quote unquote, evidence, the external evidence and the studies that we have to support that, right? I think when, when the risk of harm is very, very low, uh, I feel comfortable saying, okay, it's worth a try, right? What do you have to lose? You still have things to lose, right? There's effort, there's money, financial harm, those kinds of, I talk about this all of the time, but it's not as great as like maybe, uh, a harm of like getting a big surgical procedure done when there is an evidence behind it or injecting something in somebody. Like for instance, we talk about this in an upcoming episode, um, of emniotic tissue, right? A product that are injected into people like now, we actually have evidence to support that cause infections and morbidity down the road and hate that cannot happen. Um, um, so I think that that is really, really important, uh, for people to consider as well. Yeah, absolutely. Just a couple of follow-ups, um, for what you just said. So you mentioned how the number of papers are just so increased now, right? Um, if you look back, I think in the 70s, the doubling time for the amount of information was like five to 10 years, and now it's like two to, two to four weeks. The amount of papers that are doubled, the amount of scientific information. So obviously 99% of that's gonna be like bogus garbage because we live in this, um, time right now where people just want to publish, right? We build our resumes, our self-worth, our job opportunities all days by how much, how much writing can we put on our resume based off being a first author to the last author? Um, and it's funny if you go to PubMed, right? And you type in any key word on that left side, you'll see the years, right? From like 1900 to 2020 and you just see it go up. Like the amount of blue bars you see on that right side from like 2010 to 2020 is astronomical compared to what you were seeing in the past. Now obviously that's because, you know, we have more people, we're, we're, we're searching for things, we're looking for things, but it just also shows you how much more information is out there, right? So again, I think a lot of this turns out to be a zero-sum game when we look at everything. Um, the second thing I wanted to mention, oh my god, I lost my train of thought actually. Oh no, here we go. I was talking about evidence, right? So a lot of people like to say there's no evidence for this, right? Well, that's wrong because there's actually just no data for it, right? And so the absence of data does not mean the absence of evidence, right? And I think that's such an important part for clinicians to understand people in policy that, you know, do public health to understand is just that if we don't know something that doesn't mean we know it works or it doesn't, it just means that we have to do an experiment to understand it, right? So you can't knock it down or you can't support it. Um, there's really kind of the two things I wanted to bring up that I think. Yeah, no, no, I think, uh, I think what you're getting at and, um, I say the same thing actually. No, no, no, no, no, you said it perfectly, but, uh, but I think the more catching and bringing saying is the absence of evidence is not the evidence of absence. Oh, there we go. Yeah, yeah, yeah, yeah. That's a lot of folks off, which is true, right? I mean, what people will always throw is like, I listen, you know, I don't need a randomized control trial. This tells me that jumping out of a 30,000, uh, you know, foot, uh, airplane or whatever it is, is, um, I need a parachute for that. I don't need that study. Um, I know that it works and people kind of use that. And I go back to episode, again, I think maybe episode 14 was after Jerry Malenga when he came on and talked about, hey, this term, ABM, evidence-based medicine used to be, or it's now become like a, you know, a pseudo armor for the academic, academician, um, and say, hey, listen, there isn't any evidence and you can't, but the same time, it's like, you know, I brought up the, the discussion of worth of biologics of, hey, it's really hard. You know, you could say, and you could dismiss folks and say, hey, listen, you're, you're living on the fringe. It's very, very challenging. Um, but at the same time, discovery only happens when you're exploring things and you're, you're, you're walking the boundaries, but that being said, that is why it's so critical for the folks who are, quote, unquote, on their fringe, right? Who are maybe, or, fringe isn't a great word. So I'm going to use the word forefront, right? Who are at the forefront of medicine? Who are the pioneers? Who are looking for discovery? It's very, very important for those folks to do it the right way, right? So have the right intentions because patients are the ones who are going to end up suffering. And so, you know, actually collect data. This is why I like what Dr. Malenga talked about, the importance of collecting data is because, again, I keep using the word, uh, orthodox example, if you, you can do all the kinds of PRP, all the kinds of, um, MSC procedures and cellular procedures and make a tons of money and make it a very lucrative business. And if you know it's working, it is your obligation to actually try to collect this data and publish it. And if you're not going to publish yourself, give it to somebody who can't publish it, right? Because that is how progress gets made. That is how PRP gets covered, right? You know, the PRP is far superior when it comes to neosteroarthritis, which is the most prevalent condition, at least in this country, um, you know, for, uh, for musculoskeletal type of, uh, issues. Um, and so that has to happen and, and the onus is on us. And to Rog of's point, though, when, you know, his, his thing is all about preventive medicine, is it's also incumbent upon folks like us to make sure that we're communicating the evidence appropriately, by communicating the message that comes back full circle to the discussion that we had, um, talking about, you know, public health messages of how important it is to, uh, to make sure, hey, look, this is kind of what the sign says. And then also let's understand it well. And then to the layperson communicate, hey, look, there's a lot of nuance to this. And I'll try to explain to you the best you can. So you would really understand it. And let's make a informed decision together. Because we're partners. Yeah, absolutely, man. Last point I'll make here is now I like thinking about the future. I mean, I always tell me are these things like, hey, what, what this happens? What that happens? And lately, what's been on my mind is, you know, with the advent of precision medicine, right, nutrition fitness, we're trying to be more guided towards the individual. How does the evidence kind of guide us through that, right? I think we're going to be seeing more case reports. We're going to be seeing more, um, smaller studies to show, like, hey, this is what I did with my subset, you know, of population. So I think it's going to get interesting, uh, to see kind of where the world goes, especially with all these, uh, tech, tech companies, you know, look at the gut microbiome, go to the heart, to meditation, and all trying to make a difference in terms of, uh, making more personalized. So it should be an interesting, uh, up to my nearest. DRSA medicine is getting redefined, bro. I think so. I think so. Awesome, man. Well, guys, uh, another awesome episode. Thank you all for listening. I really appreciate you guys. As always, if you have feedback, please reach out to us. You can, um, hit us up on social media. I met redefined on Twitter, Instagram. Email us, met redefined at chemo.com. Love to hear feedback, um, but also, you know, anything good that you like that we're doing, um, whether you hate or love our voices can change those really, but, um, you know, any feedback, um, positive or negative is, um, is appreciated. Thank you. Thanks so much for tuning into this week's episode. If you're enjoying these short form podcasts, please leave a five-star rating on Apple podcasts or Spotify, or wherever else you listen to these episodes. And if there's anything that you think we're doing well or that you wish to see, please leave us an email at medredefinedatgmail.com, or you can tell us your thoughts through leaving a review. 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