78. Understanding Sleep Apnea & The Current State of Research for Physicians | Raj Dedhia, MD, MSCR

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 healthcare. Hi everyone. I had the pleasure of sitting down with Dr. Raj Dadia. Raj began his medical journey at Northwestern University where he obtained his MD. He then went on to the University of Pittsburgh Medical Center where he trained in residency for ENT, head and neck surgery. Afterwards he decided he wanted to become a sleep medicine doctor. So he obtained a fellowship in sleep medicine at the University of Washington. Soon thereafter he started working at Emory University in Atlanta. But now he's at the University of Pennsylvania where he serves as the director for the sleep surgery division. Currently, he spends half of his time doing research, looking at different therapies for obstructive sleep apnea, as well as looking at patient outcomes. He's got a ton of papers under his name, so just a quick Google search and you'll get flooded with his name and results. The other half of his time he's spending either doing surgery or acting as a clinician. So to him, he essentially has the trifecta, which he will talk about later in the episode. But we start off talking about all things sleep apnea, the who, the what, the where, the when, and the why. Who really becomes affected by sleep apnea? Is it only adults or can children as well? How does sleep apnea happen? What are the therapies for it? What should clinicians know about it? What should patients know about it? How do we know when we need to get a sleep study? What actually even goes into a sleep study? So don't worry. I know it seems like a lot, but Raj has a great way of breaking down everything. In the last half of this episode, we touch on the current state of research, especially for premed and med students. Right now, there seems to be something in the air that talks about how in order to be competitive in this field, you need to do research, even if your heart and soul is not really into it. And that's a shame. But Raj and I have a great discussion on it, and we talk about ways that maybe this really doesn't have to be an issue. Anyways, you guys will hear a bunch of apps, you'll hear about research articles, everything should be linked in the show notes, so be sure to check those out. I hope you enjoy this episode. All right, what's up, listeners, medicine redefiners? We've got sleep extraordinaire, Dr. Raj Dadia in the studio, virtual studio that is with us today. Raj, thank you so much for joining the podcast. So rightfully slow, sleep has finally gone the attention it's needed, right? I mean, Matthew Walker has come out with the book, Why We Sleep, so that's kind of put it on the map. And even on this podcast, we've talked about a couple of times. One, we talked about sleep in terms of what it's like to be insomniac, sleep deprivation, sleep hygiene. And then we also talked about it in terms of pain and sleep and kind of how those two are related. But with you, you are a sleep apnea specialist, so to speak, you know, and you've done sleep medicine. Now, I think people know that sleep medicine is a field, but to get there is a different story. And I don't think a lot of people, even in medicine, quite understand how one becomes a sleep medicine doctor, take us through your journey a little bit, maybe, you know, starting from med school to where you ended up and kind of what guy you interested in doing sleep. Thanks for that question, there's my, my path was a little bit typical. I was an ENT surgeon in training in Pittsburgh. And I happened to pair with a guy who did a sleep fellowship out of ENT, and I thought, oh, man, even a surgeon can do a sleep medicine fellowship, which is true. So I was an ENT, spent time with this young doctor, and I realized that he was helping people breathe while they sleep, which seems like a God given right. And then to say that you can't do that, and it wakes you up every one minute or two minutes. I cannot imagine what you feel like in the morning. And then on top of that, what you hear with the spouses are like, yeah, I feel like my husband is dying every night, you know, choking and gasping, and the partners often don't sleep very well. So really kind of, as a surgical resident, being on call every few nights and getting waking up at the night, I mean, I know what it's like, I don't sleep well, being disturbed. I could, I could actually empathize with the patients, which is you go through training when you find something like that, I think that really is helpful as a training to say, you know, what I think and do this, because I get it. And so I think I got it. And then at that point, I thought, okay, I want to do a sleep medicine fellowship. And you're asking, how can you get there, you know, even medicine is not really clear. There are, I think, seven specialties that are allowed to sit for or to be part of a sleep medicine fellowship. I don't know that. Yeah. So you have a, you know, pediatrics, central medicine, psychiatry, and then within the central medicine, pulmonary area is a common one, but even neurology and asthesia. So these are different pathways to get into sleep medicine, including, and of course, ENT surgery. So that's, again, I'm, I, I was one of two ENT residents to do a sleep medicine fellowship the next year. So it's a very small, still pretty small field, but that, that's, that's my journey. Yeah. So, you know, you can relate to it, you know, both of us can relate to it from a, from a medical trainee perspective. I was just going to call this weekend, probably walking out five, six times, exhausted this morning. We can only imagine what patients go through who have sleep apnea. What about from ENT perspective, where did you see the connection between ENT and sleep apnea directly? You know, sleep apnea is a problem of the throat, plain and simple, you know, for your sleep apnea is obstruction, you know, how, similarly, you know, that's snoring, then you have a gas and then person breaks the gas, but that's the pharynx, whether that's the palate, the tongue-based sidewalls, that's collapsing. And so, nobody knows the anatomy better than an ENT, and I think that was what I realized there's a, there was a need, right? We can usually flock to a need, there was, I flock to this need saying that, hey, you know, there are very few ENTs that are treating sleep apnea, other than basic surgeries, but nobody really understands the physiology behind it, I mean, few people do, including my mentor, and that's what's allowed me to, you know, take that and run with it for the last eight years. Awesome. So, let's, let's actually break down sleep apnea. So, you said it's an obstruction. Can you break that down further? What are the patients experiencing, you know, to the T, if you had to explain this to a family member? Yeah, no, this is a common part of my clinic is to explain to people what's going on. So, sleep apnea, plain and simple, is repetitive obstruction of the throat during sleep. And, you know, most of us won't, let's say, we don't have sleep apnea. When you're asleep, you have muscles in place that are counteracting the negative pressure when you breathe it. You know, when, when you think about it, your diaphragm descends, you're filling up your lungs, you have negative inter thoracic pressure. That negative pressure is that, of course, it's going to be applied to the throat to help pull air in. And, if you don't have counteracting dilator muscles, then you're going to collapse and you're going to snore, essentially. So if there's some problem with usually it's anatomy, so tonsils, small jaws, something that's going to limit the airway, that's not enough to counteract that negative pressure than you have collapse. Conversely, Dersh, if you have a woman, for example, who's postmenopausal, menopause, we have a withdrawal of progesterone and estrogen, and progesterone is really important to maintain muscle tone. And women, maybe in PM&R, you may say this in your own world, where women, perhaps, especially after that age, are after that part of the phase in their life, will suffer in different ways with muscle tone loss, even bone wasting. But for me, it's muscle tone. So we see, my clinic is a lot of women over 50, over 60, that are thin, that we didn't snore much beforehand, and now they've got bona fide sleep apnea. So it's a good example where in older patients, we see more of this muscle tone issue, and younger patients, the kids, for example, big tonsils, it's more of an anatomic issue. But you kind of need that two-hit hypothesis to hold true, where you have an anatomic insult and an neuromuscular loss. And that is when you're in that throat, it causes the obstruction. That's interesting. So I think most people, when they think about the typical patient sleep apnea, they're thinking like, you know, the thick necks, the football players, with absolutely thick necks when they're sleeping, it's like, oh, that makes sense, it's going to obstruct because they have so much muscle. But you're telling me here, you can even have thin women, right, once they hit the men of pause age, or even young kids with big tonsils. So have we been seeing an increase in sleep apnea throughout the years, or is it more just the awareness of it kind of coming through and showing light on it? Both. Yeah, it's absolutely both. You know, there's a really nice series of literature that describes, this is fascinating that the human jaws are shrinking, I don't know if you know this, but the human jaws are shrinking since the industry. James Nester. James Nester, breath, you got it, yeah, he's James Nester, I think we had him on our, at Penn, we had him in our department grand-round, so we got a chance to talk to him and spend time with him. But, you know, that book touches on this idea, since the Industrial Revolution, 1800, human jaws are shrinking for several reasons. But the point is, if that's true, well, then of course, if you're, you know, bony cage for breathing is shrinking, well, then obstructions are more likely. So I think we are seeing, I mean, it's why you see how many kids have worked at antics now. I mean, that's almost like the norm. Well, that, you know, I'm at Penn, at the Penn Museum, just down the street from the hospital, there are these ancient skull collections, and if you ever walk through them, any, any skull before 1800 has perfectly straight teeth. I mean, I'll, I'll say that statement, and they don't have any sign of crowding of the teeth. I mean, now it is really the norm that kids have crowded mouths, and so there's something to that. I mean, I think it's, to me, it's pretty clear, but the point is that, yeah, so that there's more of that, there's also more obesity. But now you're throwing a smaller bony cage with more subcany's fat. Well, it's, it's a recipe for this now, you know, prevalence is about 10, 20% of people have sleep apnea. That's a high number in the, in the US. And then you sit on top of that as awareness, like you said, sleep, the American Academy of Sleep Medicine was, was founded in around 1980. I should say, see pap and sleep apnea was discovered in 1976. It's pretty young, right? In the spectrum of what you've learned about insulin or even penicillibs. I mean, this is, this is 45 years old. And so before that, who knew, and you know, I'm sure you, you know, I have uncles in India who just snore and you say, oh, you know, he's like, he's a deep sleeper, you know, God bless him. Right. You know, like, like, he must be really tired. Well, he's really tired all the time, and he's always sleeping. I don't think it's, you know, a good thing, but, but that was, it's a cultural acceptance of that, that now I think it's changed. So yeah, speaking, speaking on the symptoms, right, you, you, you touched on one there about being tired all the time and snoring, right? I think those are the two major complaints that I typically hear in the hospital that was like, okay, now we probably need to think sleep apnea. How specific or sensitive are those symptoms when it actually comes to sleep apnea? Or should we be looking for other markers? Yeah. Yeah. Thanks. These are great. Snoring is a common sort of symptom, or she's a bed partner complaint of sleep apnea. It's very difficult to have sleep apnea without snoring. You can have snoring without sleep apnea. That sort of, we think if snoring is one of the precursor to sleep apnea, you know, if you just have snoring, okay, usually snoring is accompanied by choking and gasping in that sleep apnea. That, I would call that a nocturnal, you know, marker, but daytime symptoms, sleepiness is a big one. But, you know, only about a third or 45 people have sleepiness with sleep apnea. About a third of people are actually not sleepy. They're just, I'll use the word pissy. I mean, they're irritated. They're, you know, they're irritable. That's why I am when I don't sleep, you know, and the kids are a little, I mean, so I think that's, that's the different expression or phenotype of the disease. And then the third people actually have no symptoms. I mean, they come in because they're cardiologists and them because they said, you know, you have, or they're a white symptom, but they're like, Dr. Dady, I don't know why I'm here. I don't have a problem, you know, I feel fine. I work at nine to five. I don't, you know, so that's what we see is the sort of clusters of three groups, the sleeping group, the sort of the irritable group, and the asymptomatic group. What are the downstream effects of sleep apnea, right? So you're talking about the people who may not have any sort of symptoms, but yet a different provider is going to be sending them over to you because they're probably seeing something. What are those things? Yeah. So, you know, as, as doctors, we have to think about the medical ramifications. And the biggest one is cardiovascular, you know, untreated sleep apnea, let's call it moderate to severe disease, doubles your risk of high blood pressure, doubles, triples your risk of diabetes, increases your risk of atrial fibrillation by sixfold, death by about twofold. So these are like two to six odd ratios for different, you know, bad things. It doesn't mean you're going to get it, of course, these are associations, not causation. But you know, the idea is that I can tell patients that if you don't treat this, you're going to double your risk of developing these things. So those are the things that we think about. Now, you can go beyond that version, think about some of the neurocognitive effects, you know, we think about dementia, as many as you would sleep apnea. But I was sort of sick to cardiovascular and neurovascular things that happened with this. It's interesting. Yeah. I mean, you know, obviously in rehab, we were talking about this offline yesterday is that we, I see so many patients come in with sleep apnea, so many. And it makes sense. Right. A lot of these people have cardiovascular issues. They're going through cardiac rehab, pulmonary rehab. And then you keep going down the stream and then you say, okay, they're going to need a surgery, they're an increased risk of fall, et cetera, et cetera, right? You see that morbidity and mortality kind of go up. But one of the biggest things with sleep apnea that I've seen is that if they don't have their CPAP or they're not actually getting adequate rest, I mean, man, that is really taking a toll into their three hours of therapy that they really need to do with us. So you know, just for the listeners, the kind of just drast that, hey, this, this one thing about sleep and having this apnea can definitely have these downstream effects. They've not only your day to day, but also kind of thinking long term. Yeah. And with that, there's just like, you know, one of the common sort of anecdotes is a patient who gets treated for sleep apnea. And they say, you know, doc, I lost 20 pounds afterwards and said, well, why? And in fact, CPAP alone makes you gain weight because you're not struggling to breathe at night. So you stop burning calories of choking, believe it or not. But what happens is people say I'm rested and I make better decisions, which I think we all can relate to right there. So if you're asleep deprived and you know, you're up late on call or saying, for example, I mean, you eat the Doritos and drink the Coke and you wouldn't do that otherwise, right? Or you skip the gym or, you know, what I'm saying, you don't feel like yourself. But once you have that quality of sleep, it's amazing what you can do. So I tell patients, I said, you know, I'm going to help you get sleep quality. I'm not going to make you lose weight per se, but I'm giving you the tools and hopefully the state of mind to make those good decisions. And that's what you're saying when it comes to rehab, you know, they're proofed after one hour because they don't have it in them and they don't, you know, they choose or they can't do it. But I think you give them the, you give them that fuel to carry on with their day. Yeah. So quick tip, if you're trying to lose weight, sleep apnea is not the way to do it at least. They are not being able to see that alone will actually make you get better. So don't do that. But again, I tell them, you know, use that energy to make the right decisions. Got you. So okay, let's talk about the normal patient out there. They're having some of these snoring, maybe their partner sees it, they're getting tired. When do you recommend, you know, let's hear a listener or somebody's out there, they're older, when should they get checked out? You know, so most sleep disorders are defined in our manual as having a functional impairment. So something that you feel as a patient is affecting your daily life at least three times a week. These are some, some of our definitions have include verbiage like that. So that's what I tell people, but something is bothering you one or two times a week. If you're feel tired, you know, not once a week, but a few couple times a week and it's a chronic thing, then, you know, talk to your PCP about it. And usually if it's for sleep apnea specifically there, so we're talking about, you know, things like snoring as you mentioned in sleepiness and some of the usual constellation of symptoms. But yeah, typically snoring is going to be there with this and so having a bed partner or an app that's out there to measure snoring. But I think snoring in some degree of fatigue, that's enough to trigger her own likely asleep study. Yeah. Speaking of apps real quick, are there any apps that you recommend that, you know, you've seen people use over time that are pretty reliable in terms of seeing if there's a lot? Yeah, and it's, you know, before Apple watches and this whole flurry of activity wearables, you know, I mean, right, because I haven't kept up with huge things. Yeah. I mean, I get all kinds of download and clinic with patients showing me, you know, this and that, you know, but, but I, and I think what's been really pretty basic apps called snore lab, snore lab, it measures your snoring at night. So it's just like a microphone from your, from your phone. And it just, it's got a nice algorithm and as a nice, I would say format so you can look at your decibels on average, you can actually scroll and hear your snoring when it gets to the loud peaks and so people will bring those samples in which are pretty helpful. So that's one that we use to monitor treatment. So after treatment, strongly should go down and patients say, you know what, hey, my number one from 50 to 30 or 50 to 10, like, okay. So they don't have a bed partner, which not bed partner sleeping, it's not their job to monitor snoring. So yeah, it kind of unburdened the bed partner from being that, you know, being that person. So that's snore lab is a five dollar app, I think it looks pretty well. Right. Okay, cool. I remember I was using sleep cycle before this whole launch of wearables came on. I think I don't know if that's still around. It's still around. Just come and still using that and say that that helps them, you know, avoid a REM cycle wake up. I mean, I, you know, that's, I think that's that's, that's of, that's of pretty good. I mean, it's okay. I think you can put in a properly in the mattress and, you know, other things, um, but yeah, those are the two that have been around historic lectures, nor lab and story cycle. Okay. Cool. And I know nowadays, you know, if people want to upgrade their data, they can do whoop. There's a aura of rain, eight sleep is something I use for temperature regulation, which is, which has been pretty cool too. So there's definitely a plethora out there. People just kind of take a look and see how they want to track their sleep. Awesome. So let's transition kind of a patient now in the hospital, right? Because this is, you know, my bread and butter patients come from the hospital coming into the PM and our inpatient and coming over with sleep, apnea. So a lot of the times what I see is patients are desatting overnight. Is that something you would typically see in sleep apnea and by desatting to the listeners, meaning their oxygen saturation goes down, you know, into the eighties, let's say. Yeah, there's, I think really a path to an amonic sign for sleep apnea is what we call soft tooth desaturation. So if you look at this saturation profile, you know, look at it. There's a desaturation followed by rapid resaturation, right? And that's an event. So if I'm going to simulate it, I know for your listeners, maybe the auditory is useful or maybe it's foolish, but you know, if I'm snoring and I stop breathing and that's the throat closing. It's a 10 second event by definition for sleep apnea. So give you count right now. That is the shortest event of sleep apnea. Now imagine that goes on for 60 seconds in some patients. I mean, and you're the bed partner, right? Imagine you know, your wife's doing that and doing, oh my gosh, you know, and you, you actually you're a little bit concerned. They're not going to breathe again because their chest is moving. They're it's a violent and the chest is moving, the belly is moving and but there's no air flow exchange, right? Because it's paradoxing of the wrackle abdominal cage. I mean, your diaphragm is descending, but your chest is sinking in because there's no air flow coming. So you're seeing this person sort of fixate in front of you and then also in the gasp and then it's like, okay, well, what the what just happened? Well, what happened is what you said, the oxygen is not going anywhere. So they desaturate, then they have that recovery breath and then about 20 seconds after that they resaturate. That's a long finger circulation time. They resaturate. So that ping ponging is pathodomonic for sleep apnea. I'm saying that because in your in your, you know, your hands and your spear, you might do something else like a COPD type picture or where we call it hypoventilation, where they're just, their sats are just 82 the whole night. You know, we're like 85 the whole night. That's not sleep apnea. That's usually a primary or secondary lung disorder. So I'm differentiating that from, you know, just to say that if oxygen goes down and comes back up repetitively over the night, you have sleep obstructive or central sleep apnea. So it doesn't make sense to give oxygen to these patients when you know there's going to be a resaturation event coming. You know, oxygen, there's a really nice study in New England Journal medicine 2014 looking at CPAP for oxygen for sleep apnea and their primary outcome was 24 hour blood pressure. So, you know, as I told you, blood pressure goes up. If you think about it, when you asphyxiate and then you are relieved of that obstruction, you end up getting causing the adrenaline surge, right? It's like if you were choking and I choke you, then you let go. So every time that happens, you spike your adrenaline and you spike your blood pressure on every one of those events. If I had it, you know, an arterial line in your, in your, let's say, your radial artery, you would see that spike every time you took that first recovery breath. So that's going to, we think is one of the two mechanisms where blood pressure is increased in sleep apnea is that you have this adrenaline rushes. The other actually is the oxygen, you know, when the oxygen drops and it comes back up, you release free radical species. You know this from some of your work on, you know, oxidative stress and inflammation. So you end up creating these free radicals and that causes vascular remodeling. So the blood vessels become hardened and stiffened. And so you can imagine then that, that, that combination of oxygen fluctuations and, yeah, with the combination of that, of the adrenaline is why we see blood pressure rises. So in that paper by Dan Gottlieb and others in 2014, CPAP reduced blood pressure, oxygen did nothing to blood pressure in sleep apnea. And what that tells us is that the oxygen itself is sort of like, you know, just pouring kind of putting a bandit on it because you're not actually helping with the obstructions, right? You're, you're putting oxygen to help your measurement of oxygen improve, but you haven't treated the underlying problem, which is a throat is closing every minute or two, right? So you're helping the oxygen, but not helping the underlying in my mind, the problem. And that's where CPAP actually is a pneumatic stent. It blows air through the obstruction, keeps it, you know, stabilized the whole night, because there's, you know, air passing through that, that compromised segment. So the answer to question, oxygen is okay. I mean, it might placate the nurses because they don't have the alarm triggering so often, and it might make us feel a little better because the oxygen is better. The other, the other challenge in your patients with, especially with brain injury is that they're often have, if you do that, their CO2 levels are going to rise. And so, so imagine this. So if I just give you oxygen, right? And I might be blunting your ventilatory drive, and now your CO2 is going to build up. We don't measure CO2. I mean, I don't think you do it in the rehab floors, you know, customarily. So we're not measuring entitled CO2. So you don't know if your CO2 goes from 40 to 50 to 60. And now you're talking about getting CO2 comatose, and now you have a problem, especially in a light of sleep apnea. So I would just be very careful, especially in the impaction setting, in what you do, if you slap oxygen on there, you want to make sure they're not getting a CO2 coma. And so that's where you just have to be careful with that. Yeah. That's a very good point. I mean, we also, you know, think about oxycodone benzos that we're putting on these patients as well. Just exactly. I would come with anxiety. Modern was so much pain, you know, also just slowing down that, that, that ventilatory, ventilatory drive. So, um, no, that's, that's really good to know. And again, I think this is such a misconception out there, um, apart from your world, like the rest of us over here are thinking, oh, man, there must be a decent. We have to put the oxygen in over at her. She would call it the oxygen ferry. But, you know, I think one of the biggest points is oxygen isn't always just a treatment. It's, it's a medicine, right? And it, it can also have bad consequences. Judd by just getting someone those two, three, four leaders, um, even though you think it's, oh, it's, it's natural. It's what we breathe, right? So, um, important to understand. Yeah, it's not always the case. Yeah. I think your point about that if they're on, and let's say they're on narcotics or benzos, you know, I'm not sure what your patients are getting, right? And they have, you know, got rid of, you know, history of brain injury and now they have sleep apnea, which is not uncommon in that scenario. You're, you're right. I mean, that's a recipe for, for a problem, um, especially not monitoring CO2. So what happens with, with CPAP, alternatively, right? CPAP is able to not just oxygenate because it fills the LVLI and it pressurizes the chest, but it also ventilates. So you're getting rid of the CO2, you know, there's an escape valve for CO2. So you're able to actually ventilate the patient, um, and that's why it's such a good treatment in that situation. I mean, and, but you know, one of the challenges in Dursan when we get this later on is that CPAP is the compliance is poor, you know, 50% of people don't use CPAP long term, right? So, yeah, you got a good treatment, but, you know, it's not very effective. It's more efficacious in that controlled setting. So maybe they, maybe you can get them to use it in the hospital, maybe you can't. And then what do you do, right? And that, that's maybe what you're resorted, you're often resorted to doing something like temporizing, like oxygen. Absolutely. Yep, that's exactly what it is. So it really just depends on the supply. If we have the CPAP great, otherwise we ask them to bring it from home or else, hey, we're going to be putting that oxygen on. So, um, you know, one of the things I want to touch on that I think a lot of people don't understand is what actually goes into a sleep study. So typically in the inpatient side, let's say internal medicine, before they get discharged and we say, hey, we want to get you outpatient to do the sleep that near like sleep study and stuff and make sure you have it. So, you know, when they actually good and when they actually return to do that study, what are we looking for? What is it over night test? Is it at home test? Do they sleep in the sleep lab? What exactly goes on? Yeah. So there's two main types. There's in lab, like polysomniagram or or second type is called an outpatient home sleep apnea test. So, how do you do it in the lab with a bunch of wires? I'll talk about or you do it at home with minimal sort of equipment. There are different indications. If you have a patient that you're worried about, for example, CO2, hypercarburet, increased CO2 because they have a history of hyperventilation, if you're worried about somebody that's going to have limb movement disorders, things that are not just bread and butter sleep apnea, seizures, for example, then you want to get it into the lab with a full hookup. That's typically what you think about that. Home sleep apnea tests are just what I said. They're sleep apnea studies. So, we're just looking at sleep apnea and somebody has a reasonably high predisporability of having it. Home sleep apnea tests are just fine. So, again, in lab study, you come to a lab. It's quite an experience for the patient because they come to the some foreign lab. I mean, usually in a hot in the basement of a hospital or in some kind of funny place, right? There's no windows, you know, by design. They come in, they get hooked up with a full EEG. I mean, this is 12 lead EEG. You know, it got the goo in your scalp that comes off like five days later. You've got electrodes. So, that's EEG. You've got E-O-G, monitoring your external electrode oculogram. So, rapid eye movement, okay? Ram sleep, we are able to detect that based on the eye movement. So, we have these EEG pads here for the eyes. We have chin EMGs in Ram sleep is also when you have paralysis. So, you look at how the chin muscle activity drops out during Ram. So, this between the chin and the eye is we can detect around pretty well because the eyes are going crazy and the chin is totally silent. That's a very unique, you know, sleep stage we have. So, we have, you know, you have electrodes here. You've got, in your under your nose, an nasal flow, in your mouth and oral flow, you have a chest belt, abdominal belt. Yeah, I'm not done. And you have, on your legs, you've got leg EMGs to look for leg limb movements. And this is not a wireless technology. So, these are all wires. And all these wires have to go to an input box next to the bed. So, you know, it's like Frankenstein, it's like you're hoping up all these things. Yeah, and you see, you're like, gotta sleep in like this if you move around things, come up. So, it hasn't changed in 40 years. You know, honestly, the sleep lab, it really hasn't changed much. And so, that's what people do. They come and they do this. And, um, but if we get great data, there's, I mean, I love reading these studies. You know, I read probably five, six studies a week. And it's great because I have all my leads. I'm like, you know, looking at the monitor. I've got all the leads. And, you know, people say, well, am I going to sleep doc? And usually they sleep at least two to four hours, usually four or five hours. So, we get enough sleep to, you know, to know what's going on. And it's obviously very, you know, comprehensive evaluation. But that's sort of that one type. That's an in-lap sleep test, insurance pending, clinical indication pending. That's what that is. A home sleep api test is relatively speaking at PCK. The typical one is there's something around your nose. You, you know, around your ears, like a canula to measure your airflow. You have an effort belt around your chest. And you have an oxygen on your finger. That's it. And you go, well, go up to, to a device and you sleep and we can look at your oxygen, look at your airflow, we look at your effort. And that's really the things that we need to look at. I can, you know, pretty well look at your sleep apnea severity based on that. Okay. Pretty simple, at least for the home stuff. Well, yeah, it seems very intimidating going in. It is for the in-lap test, you know, and I think the future, though, really it's going to be wearables. You know, as wearables become validated in our world, I mean, think about it. Do I want a one-night test or 39 test from your Apple Watch? Yes. You know what I mean? Right, you much rather, there's a lot of night-to-night variability that's well understood in sleep apnea. So you may have a number of sleep apnea number of five to night and 16 tomorrow. And that ends up, you know, really dictating different treatment paths. But that's because, you know, it's just the one night you're on your back, one night you're on your side. So if I get 30 nights of view, boy, I feel pretty confident that, hey, I've really got this guy characterized. And so I think that's the future is having wearables that are, you know, FDA clear to prove for our use in the, you know, in, you know, and I so I think that's going to be really, for me, really exciting to have that level of data. Absolutely. I think wearables is such a cool topic. We actually had a cardiologist come on here, a cardiology fellow, talk about wearables and whoop especially because I mean, you can talk about anything cardiovascular, to sleep, to rehab, to pulmonary. I mean, it just goes on and on about what we can do with wearables. So it's definitely a super fascinating technology. And I think with it within the next five, 10 years, it's just so rapidly moving. I mean, it's insane. Even Apple Watch is telling you your stride length now. I saw the commercials in that. Yeah, it's even hooked up to your leg. That's pretty impressive. So, um, yeah. Okay, so let's say the patient is diagnosed with sleep apnea. We're now starting to think about treatment. In your mind, when you talk to that patient, are we thinking short-term, long-term, where does your head kind of go whenever you're kind of discussing with the patient? Um, long-term, right? There's, I mean, like as doctors, you want an all-night, every night treatment. I mean, that's my, my adage, right? All night, every night. So if you tell me I use it for the first three hours of the night, the CPAP, and I rip it off in the middle of the night, well, you've now basically let yourself, uh, succumb to REM sleep. And REM sleep, by the way, which happens in the second half of the night, is the most sleep apnea prone, because you have muscle paralysis, right? So your throat muscles are essentially paralyzed, and you're relying on other muscles to help you breathe. So sleep apnea traditionally is worse during REM sleep, which is the last couple hours of sleep. So you have to have that protection. So we tell patients, again, it has to be something that you're going to use all night. And of course, every night, you don't want to miss a night. That's not the point. So it's a long, it's a long-term play. And, um, you know, in it, we're, we want to stick with adults here. I'll talk, we'd suck about adults. You know, in adults, either or? Yeah. First-line therapy is CPAP, because it's not invasive. A lot of data behind it. And that's really great if you can use it. Half of people use it. Half don't use it long-term. And that's my whole being, frankly, it's people helping people that can't use CPAP and looking for other options. Gotcha. Okay. So what other... So let's talk about compliance, actually. Let's just try back that. So I know a lot of patients that I've talked to me, like, hey, was your CPAP like, I've been warned that in like five, 10 years, I'm okay without it. So are there alternatives to somebody who doesn't want to wear CPAP? Yeah. And again, I run and founded the CPAP Alternatives Clinic here at Penn and Philadelphia. And this is designed for people that are like that. You know, it's... They come in and they're told they're, yeah, you've got a CPAP and they try and they try. And then the doctor says, well, you know, you fail. I mean, you're a failure of CPAP. And that's what... So he said, it's been the closet for five, 10 years and they're told that's all you have. And then they come and they see us and they, you know, realize there's often other options. And, you know, when I say often, you know, if the patient is morbidly obese, there's often not much I can do because the often obesity is driving out of the sleep apnea. But if they're not, a lot of our patients are not obese with sleep apnea, then we look at other options. And that starts with things like, you know, weight loss, of course. But then even something called a mouth appliance that moves your lower jaw forward while you sleep. You may have heard of those. They're basically made by dentists. They pull the lower jaw. They stabilize it forward and that kind of opens the airway. And that can work for maybe half of our patients that come see us. Some people, about half of people are with mild sleep apnea are just on their back. So you may have heard of the old tennis ball in the back of the shirt that hang you. I mean, there's ways to keep you off your back. That's called position therapy, you know, to get people out and on. And you'll hear the bed partner and the wife will say, you know, I give him an elbow and then he's fine because she ribs, she put elbows in the rib and then he turns over and then he stops snoring and then he comes back and she elbows again. So that idea of like turning over, it's gravity, right? If you're on your back, your tongue, and your palate are going to go back and you're on your side, false side. So that's how effective for some patients. And then, you know, getting really what I spend my time is talking about surgical options. Especially in young patients, you know, who don't want to be, who don't want to be wedded to a machine the rest of their life. There's something else that you can do and often, you know, if they're right candidate, we do a full work, it's quite a workup. But figure out, you know, what's, what is the offending agent? What is the problem? Is it your, is it your tonsils? Is it your jaws? Is it your soft palate? Is it your tongue? You don't, what's causing this panatomic issue? And from there, we can start to talk about different class of surgical treatments to help them. Dr., okay. What about like mouth taping, right? That's something that I know a lot of the functions from medicine doctors out there, talking about a lot of the breath work gurus, you know, is that something that can prevent sleep apnea at least? Cause I mean, it sounds like if you already have it, that might just actually worsen it. Yeah, it's mouth tape works well in a very small group of patients that I have. So like a lot of things to earth, I mean, you know, there are, there are treatments at work that are, the indications are, obviously, much too broad in, you know, in, in, in, in late terms. In books like Breath, while they raise awareness, they also sort of make people think, oh, I can just do this and I'll be better. Well, no, usually that's not it. So mouth tape works well in, you know, patients in my mind, who have usually snoring or mild sleep apnea. And the issues that are, their mouth opens during sleep. And so when you apply piece of mouth tape across the lip, you force nasal breathing. And nasal breathing is, is, is essential to normal sleep breathing. In other words, if you're a mouth breather, in my mind, you're pathologically, it's breathing at night because the mouth is meant for eating not for breathing. And you know, the nose has a very nice pathway around the back of throat to the trachea to the lungs. And you create this nice laminar airflow. And if your mouth is open, it's a, it's a very turbulent path to get there. That creates snoring typically. And you lose some of the benefits that have been reported about nitrothoxide, and other things that you want to get as the air is filtered, warmed, modified by your nose. You don't get those benefits by, you know, in taking through your mouth. So, in that, from that standpoint, mouth tape can be helpful. But again, that's really a subset of patients. Again, in my practice, we're coming for sleep apnea. Maybe more common, there should not lay people who have a little bit of snoring and that kind of thing. Yeah, sure thing, sure thing. I do want to quickly touch on pediatric patients at least, because, you know, obesity raised or at 38%, they're only climbing. We're seeing it so much in our young population, which, of course, you know, could be contributing a little bit at least to sleep apnea. What do you tell parents to watch out for? Because I'm sure a lot of these teenagers aren't going to, or, you know, is that the common age at least that we're looking at with sleep apnea in the younger population? Is it like those teachers? And kids, school age kids. And that's because of tonsil overgrowth. You know, tonsils get big, you know, about six years old, you know, eight years old, and they get bigger a little bit earlier than that. And then you talk about, you know, and then the kids, it's interesting. There are the kids, you know, I tell you about sleeping this irritability in adults. This is, you know, the kids, can I can ask you a question? What do you think of the kids? Home-marked symptom is of sleep apnea, behaviorally. Tired? I'm guessing like just out of it. And that's what you're not doing well in school. So you don't know. That's right. Not doing well in school, but not because they're tired because they're hyperactive. So children have the opposite response. They're actually not, they manifest tiredness, which maybe that's correct, but they manifest it as being hyperactive. And so it's amazing what parents will say after you treat the sleep apnea. Wow, I thought ADHD, but actually used just sleeping like, you know, sleeping poorly. And then it can be really profound. I mean, right after the surgery, the kids are able to listen. I mean, it's, so, you know, yeah, I don't treat kids regularly. So, you know, as a trainee, I did a lot of that. And I still think about how the examples are pretty dramatic. And again, it's a very different expression of that. And the way the kids are, you know, they get a hyperactive kids with big tonsils. That's the kid that needs the sleep apnea. It's funny. You mentioned that. I'll never forget now actually going back to my piece rotation. My third year of med school, I worked with a phenomenal pediatrician who had a very integrated, like functional mindset as well. And so, you know, when patients come to you, I got to believe my kid is ADHD. I got the paperwork. This is what the teachers are saying. First thing he'd always ask is how are they sleeping? So, yeah, that makes a lot of fun. Yeah, because, yeah, I mean, there's to give a kid that's snoring and that's hyperactive. I mean, the first thought would be anti-evaluation. For talks like that. Yeah. Right. Cool. Okay. Awesome. Anything else you want to talk about in terms of sleep apnea before we kind of move on to talking about research? You know, is there anything you wish more people understood about sleep apnea? In the medical field, patients, parents. Yeah, I think we covered a lot of it, there's, you know, I think again, maybe this is a little shameless plug here, but I mean, there are options that are not CPAP, you know, and one of the cool ones that's come out that we've, it's been a lot of marketing, but it's actually been very helpful, something called Inspire, which is a device that's implant, we implant. It's basically a tongue stimulator, we implant. So, it's like a pacemaker for the tongue, and this has been a really good option for people that are especially older patients with sleep apnea. It's a relatively non-invasive procedure. And it really helps with sleep apnea and it's basically kind of very comfortable, and it's a remote control. You just, you know, turn it on, go to sleep, and wake up. In the, again, in the right patient, just like mouth taping, it works really well. And so, we spend a lot of time, you know, understanding what those patients are, but the, you know, these patients are very grateful. They say, man, I thought there's nothing else I can do about it, but boy, I, I like this, you know, I liked it. I hate it, my CPAP, and I actually, I like this thing, you know, so that's nice to hear that there are things that are palatable to patients with technology. Perfect, yeah. We'll, we'll, we'll link that into the show note, so I'll talk to you afterwards, and, you know, I'll get whatever links you, you suggest, and we'll, we'll put in the show notes for people to click on. Perfect. All right, so let's get into your current practice, because, you know, when, when people think physician, they think they're seeing patients 24-7, and that's not necessarily what you're doing on the week to week. So, break down kind of what you're doing from a Monday to Friday standpoint. Yeah, I'll start by saying, I have the best job in the world. I mean it. I mean, you, you couldn't, how wouldn't do it any other way, and it's not by happenstance. This has sort of been curated over the last 12 years of my life, but, you know, it started with understanding that, you know what, there's more to medicine than clinical care, as you just said, there's, you know, and, and for me, like one of the challenges is I was going through medical school and residency was like, you know, I don't want to be a cookbook clinician. You know, I don't want to read the latest algorithm from this journal and then just, you know, do that. I want to help actually design the algorithms, you know, I want to, I want to be using to create my creativity a little bit. And so what I realized was research allows me to be creative. You know, we all have different avenues. I know there's you do and others do and how to use that, you know, this podcast, it to me is an example of your ability to be creative outside of your residency. So, you know, how do you do things that are expression of yourself but actually allow you to be creative? So to me with research, you know, designing a clinical trial, I really enjoy that. I have a master's in that, I can talk about, but, you know, I thought there's something else that I could do that's not that. So that's sort of the, that's the backdrop. Now let me, let me answer your question. So Mondays today, I worked from home, right? So I'm a surgeon that works from home on Mondays. And that's, to me, wonderful. I get to do things that matter to me, like take my kids to school this morning, see my personal trainer, and I have, you know, eight hours of meetings in between. So I'm, you know, doing research, reading sleep studies, trying to notes, you know, doing high-level things, but I'm able to do it for my home. And I think for those that are, you know, younger your audience and the thinking about work-life balance, you know, we don't have to talk about this for a long time. You know, this is important. This is how I'm going to do this for next, you know, until I'm 80 years old, I think. I mean, I really feel, I don't feel burned out. I feel like I have a good balance. And so, you know, the research day gives variety. You know, so this is my, I'm home on Mondays doing research primarily. Tuesdays, I have a full tomorrow, a full day clinic. You know, it's full day clinic. And I drive a lot of energy from clinic. You know, seeing patients, I'm hopefully like, you feel the same way. We give a lot. I mean, every time you've got meeting new patients, it's like, you know, interviewing somebody's or doing now. It's sort of, it's exhausting. But at the end of the day, you realize when you help patients, you know, how rewarding it is. So, and that's where the questions develop. Right? Clinic is where the research questions are born, because you have a patient that comes back from a procedure. Let's say you did some, whatever procedure you did. This is for any clinician. You do a treatment, you come back, and they're not better. You know, what do you mean? They're not better. Of course you're better, right? This is the right, I give you my treatment. No, I mean, you look at the test and they're not better. The sleep test didn't change at all. They don't feel any different. And you ask yourself, you know, what did I miss? And the failures are what teach you the most, right? Success as you say, yeah, okay, I knew that, you know, you know, or sort of, you know, you know, you pack yourself on the back and go to the next patient, right? But the ones that really, you know, hit you from the front, oh my gosh, I didn't, I was blindsided by that result. And then I make a note and I go back to the lab on Wednesdays, one of my, you know, or Thursday, my research day. And I go to the, we have a group of now 10 of us in my lab. And I say, you know, I had this patient yesterday or on Tuesday and I did this and I don't know what happened. And we have developed for each patient streams and streams of data from their sleep study, from their CAT scan, from their sleep and doskippy, from a surgery to help understand what happened. And, you know, that to me is really powerful because we have that ability. So, so, sorry, so that's Tuesday's my clinic day. Wednesday I usually operate and that's, you know, doing procedures from sleep, from endoscopies to jaw surgery, really the gamut of, you know, minimally invasive to more invasive surgeries for sleep apnea. Thursday again is my lab meeting and we get together as a group to talk about it. And Friday is either, is either research or it's more surgery. So, it's, it's a balance of clinic, of procedures, of reading sleep studies, of doing research. And I think for anybody that's a spot in an aspiring physician, thinking about how can you keep your life interesting on a daily basis, right? I mean, you know, we're used to four years of college, four years of medical school, four years of residency, four years of, 40 years of attending hood. Like, four years of, welcome to like 40, you know, it's like, oh, okay, what do I do after four years? Like, you know, you're gonna, you're gonna, I mean, probably gonna get sick of it and frankly, a bit burned out unless you have the ability to mix it up. And in my case, you know, I treat the individual patient and then I'm treating the next generation of patients with my research. And so I've got that, you know, ability to feel like, not just what's in front of you, but it's what's beyond me that I'm gonna influence. Oh, and by the way, you know, I have two fellows that I train every year in a cadre of residents. And so I also have the ability that I'm really training the next generation in my midst, you know, so it's like, yeah, so that, I mean, I prefaces it by saying I'm the best job in the world because it's super fulfilling. I have a pretty good work life balance. I get paid pretty well. So it's, it's, it's really, I really think I've found it and hopefully I'll hang on to this. Yeah. I love it, man. I think it all starts with something you mentioned earlier, right, before you were, you were, you were saying all this. It comes out of creating value, right? Like, where can you create the most value that you can every day, right? And everything else kind of just falls in place. The fact that you like to teach, the fact that you realized you liked research, right? I mean, you, you, you tried it, you got a master's in it. If you didn't like it, great, that's more information for you to say, hey, I'm not going to incorporate this into my attending ship. But you like that. You like the flexibility of the work life balance spending time with your kids, your family man. You also like the fact that you're doing different things every day, right? But it all surrounds, it's, it all surrounds around creating value, right? So I'm, I'm a huge fan of that. I always talk about that. It's the reason why I chose PM and R is like, I saw this need an exercise physiology and functional integrative medicine. And I thought, if I just create value every day, things are, things are going to fall in place. So I just think that's a great advice at least for, you know, pre-meds and, and med students who are looking to go, you know, slowly going to residency and attending ship, but are hearing so much about burnout and the, what are they calling it right now? The great resignation with COVID and how many people are leaving medicine because of COVID and just wanting work like balance. So it is possible, even from a surgeon. So it's, it's definitely possible out there. Yeah, and I like that, Derek, I mean, yeah, creating value and, you know, because I think that gives you energy. You know, you, you feel like you are creating value. And that honestly gets me up in the morning. And I, and I, I get up in the morning and, you know, and I, I really, in the end of the day, I treat one disease, but I look at it as a, in the clinic, in surgery, reading sleep studies and doing research. So you, you're able to take one, you know, think of the spectrum of medicine. I'm talking about a truck of sleep apnea, which is a little, a little piece of pie, right? But you're able to look at that and look at it from all angles. And every angle teaches you something else. And, and I think that's, you know, I mean, the best advice I got, I think I was a medical student in Northwestern. And somebody said, you know, Raj, choose a field where every patient seems different to you. In other words, you know, this is like the podiatrist finds every foot to be different and interesting to that. God bless that, you know. So like, to me, you know, every airway is unique. And when I do a scope exam, I look at the patient and I go, yeah, I don't, I'm not sure what it is about you, but I'm going to figure it out. And that keeps me going. So I, I think, you know, if, if you're again, pre-med, thinking about what to do, think about that idea. Because look, what's called the surgery may be gone in five years. Well, it shows something basically you like this surgery. That's a bad, my mind, that's bad, it's a bad decision. You know, choose it based on the disease process that captivates you. And from there, you kind of, you move with it, right? You, you got to adapt to what's what's going on. And so you never lose interest or focus on what you're doing. And I think the other thing you were kind of just talking about there is you create the breath while you focus on the depth, right? Like you're just focusing on sleep apnea, but because of it, there's so much other that that you're learning and understanding, right? We talk about the downstream effects. We talk about different patients going through different things. So yeah, it's, that's definitely a really good advice. I think I'm going to steal that as I, as I coach some more pre-meds. So none of it's just patented. So it's, it's all, you could think whatever you want. So speaking about, you know, pre-meds, I've done a lot of coaching. And one of the most common questions I get is, hey, Dr. Darsh, I'm very interested in research. Is it worth doing an MD PhD? Now, from your experience, you've done a master's in clinical research and I mean, you're very research-heavy. I'm on doxymity and I keep seeing Roger Dadia this. Roger Dadia of that, right? You're just, you're pumping out papers, you're pumping out studies. What is your advice in terms of at least the difference between doing like a master's in clinical research versus going down the route of an MD PhD? Yeah, you know, let me start by I think a really common thing. I hear from medical students that, that's, if it divulges to me, you know, their, their deepest darkest thoughts. It's usually something about, you know, I know he's competitive. I have to do research to get in. So it's, it's a, it's a means to an end, which I think a lot of people are exposed to research in that way, which I think is a problem. You know, it's like, it's not a stepping stone until like getting into something. And actually, that's how it was for me. It's like, oh, I'm like, you know, applying to this. So I did research and, you know, I can talk about it on an interview trail and I can flash from publications on PubMed to them and they'll be all be impressed. But like at the end of the day, that's actually not what it's about, you know, and I think when people see that, hey, you know what, this research that you're doing is, I mean, we have been changing the field over the last couple of years of sleep apnea surgery with the work that we're doing. And it's really revolutionizing how we're practicing. I want to say across the world recently now, because we understand these measures. And that's really exhilarating that our team is developing techniques and understanding. Because I think that's, and it's hard, Dersh, as a medical student, you know, you're not in a situation where you've been in practice for five years. You don't like your outcomes. And now you're under something about it, but you have no, you can't do anything about it. You're not training research, you don't research time. And so it's like, okay, well, I don't know, now what I'm going to do. So, but when you're a clinician and you're in that situation, you wish you had the tools to actually act on your disappointments or things you want to change. But I struggle with this. Maybe you can help me as you know, if you're a pre medical student and you're coming into it, thinking like, hey, I got to do research because I want to do, you know, maybe they're asking you, like, should I do it? And like, you know, what, like, is it number of papers? Like, you know, basically, do you want to get published in publications? You know, as it goes on the CV and that might lead you to opening doors. But what I hate is, what I hate about that is that often that's, you know, to pump out papers, I'm going to use a term, you know, in a pejorative way. Pump out papers is really a term that I hate because it's sort of saying like, I want to get things out there. I want to do that and somehow that's the end goal is to publish a paper. The end goal is actually to change patient care, you know, that's really what we're doing. It's not to write another paper, another me to paper that nobody's going to read that, you know, go whatever that has, you know, shoddy methodology, that's not helpful to us. But it's hard because like, real science takes time, you know, it takes a well-designed study, it takes something that those two are doing, it takes resources. Like, you know, I'm lucky to have funding from the NIH and several industries. I mean, we have funding to do these projects, but you don't have funding. It's hard, you know, it's hard because you have to have expertise and resources to get it done. So I think this is the challenge to me is that you have to be able to, as a medical student, appreciate or to be inspired that research is not just a means to an end, but it's a way of life to help patients down the road. And this is hard, man. I don't, I know because I know this because the admissions committee for residency or whatever is going to look at your CV, look at your publication list and is going to be impressed or not impressed based on how many publications you have this first author, let's say. But it doesn't really just, I mean, I've interviewed many people from medical students, the residents, the fellows, and I realized some of them know a lot about research and what they wrote and some have actually no very little. I mean, they know they published something, but they couldn't tell me about a sample size or how, you know, they couldn't defend the research. And that's, to me, I rather, you know, one paper and show me that you know what this means and how it changed behavior. But that's not, this is a deliverable, oriented society, especially when it comes to this kind of stuff, right there. So I mean, yeah, I'm putting it back to you. I mean, is there a way to sort of help people understand that it's not just a means to an end? Yeah, no, I mean, I totally agree. So my engineer and me and my co-presidents always talked about this, right? Like the only thing we found meaningful in terms of research were like quality improvement projects, like QI projects, because there was some resident benefit usually to it. And we're saying, hey, how can we improve resident life? And then we were so invested into it, right? Because wow, we're actually changing a system. And there's the foreign actor and the projects weren't taking so long. But when we talked about, you know, how do we hop on to a project? Right? Everyone talks about, hey, can I hop on to a project? You're hopping on for what? Right? Are you actually interested in this subject? Sure, you might be. But is it the role you want? Right? And I'll never forget, I mean, talking to you, you know, early back when I was undergrad and trying to get into when I was at Penn doing my cancer rehab research, you always talked about, hey, there's three things you like, you kind of want to do. I might be forgetting something. But one's like trying to understand scientific writing, two is like actually getting involved with the patients, right? Actually getting involved with the systems, trying to figure out from top to bottom, where is it that we need the most help? And then a third, I believe, I think you said was like, well, I talked about medical writing. I think it was more just understanding the topic as a whole and presenting that, right? Right. Good memory, buddy. Even, yeah, yeah, I don't forget lessons. But a lot of the times, like even at my residency, a lot of it is just, okay, what's the timeline? How do we get you to present something, right? And something doesn't necessarily equate to good or great, but great and good also doesn't have to be the answer, right? It has to be something that you actually enjoy to say, hey, I'm interested in this. Let me do a lit review. And I think that's the first step. Like, if you're not interested in doing a lit review on the topic, you probably shouldn't be doing that research, because I mean, there's a lot of articles to go through, a lot of it can be boring, a lot of its numbers, but a lot of it's just delving in and doing the deep work and being like, I'm going to sit here, I'm going to challenge myself, and I'm going to have to use YouTube and other videos to learn stats and other things to make sense of this. So what's tough, I'd say, as a pre-med, because, you know, I don't know if you heard of this, they're calling at the Fauci effect now in terms of the number of applications for medical school. So ever since COVID happened, the number of medical schools have skyrocketed, they're calling at the Fauci effect, but what people are realizing is it's not because of Fauci is because it's virtual, so you don't have to spend as much money to like go around and people aren't taking the MCAP. Anyway, so I'm talking about a different end there. I don't, you know, just to be competitive now, it seems like you have to have research, and I totally get that. So sometimes, like you said, it is a means to an end, but in regards to an MD-PhD and, you know, something like you did, where's a master's, or not even doing a master's, I don't think you necessarily need to have that PhD to look competitive or do research, right? And I think you're a prime example of that. I think the skills that you have as a researcher are just as equivalent as somebody who goes through their PhD possibly, right? Like, would you say that's wrong? I mean, I think... Well, yeah, it's self-burned, right? It's sort of, I think one of the things you have to think, you have to sort of, we have to just separate is clinical versus basic science. You know, I'm a clinical translational scientist. I am not a basic scientist. I don't want to be a basic scientist. I never want to be a scientist. You know, I don't want to be in a lab doing stuff to animals. So, you know, I think, you know, if your interest is basic science-related, typically a PhD is a natural progression, a natural home for that, because of the rigor and the time it takes around an experiment, and you get mentorship along the way, and how to do probably basic science research. Now, there are more clinical translational PhD things that are happening, but in bio-stacks or some of the big data stuff that you could do, but that's still a less well-trodden path. And, you know, for me, my interest was really more clinical. So, the masters of science and clinical research, to me, makes a lot of sense. It's one year. You get to learn, you know, the applications and how to do conduct clinical research in a setting of patient care, you know. So, I think that is a really nice thing, but yeah, the MD-PhDM, that's five extra years, or, you know, four years of your life. I mean, it's a huge commitment, right? I mean, I wouldn't do it unless I was really passionate about it. I mean, there's a monetary savings, perhaps, but maybe not in the long-term, but in the short-term there is. So, I think you can imagine that if you, you know, if you're serious about it, okay? But again, this is what I'm saying. It's like, are you doing it just to do it, or do you really get excited about that kind of stuff? So, yeah. Yeah. No, and I know a lot of people are doing it because of the prestige. I mean, you're 18, you're 17, 18 years old. I talk about this all the time as a pre-med. You have no idea what your life's going to be at at 30, 31, 32, right? And we're forced to make a decision so early on to say, hey, this is what you're going to be doing for the rest of your life. And, you know, that's obviously a reason why burnout rates can be very high. And I think one of the things, again, as you've done, is adjust to that, right? As you keep getting older, constantly changing your values, right? Every year, just saying, hey, what do I value? What do I want to do? And kind of playing that game. But yeah, I think it's a sad state that we're in for research right now, at least in terms of the medical school residency level, because I just don't see a lot of people going into it unless they're kind of forced to do it. And then have has really been like, oh, wow, I fell into something I like, right? Right. Right. But I guess, yeah, go ahead. No, I mean, I think that's, you know, I'm one of my goals. We have a medical student now from Temple, who was with us for a year. And, you know, the goal is, you know, I mean, he's coming wants to be into me and be going into residency and, you know, to get experience. And but really my, my hidden, I guess, not anymore, my hidden goal is to inspire him to become, you know, a certain scientist down the road, right? To say, hey, yeah, this, this, I thought this was a means to an end, you know, but actually, this is really invigorating. This is intellectually very stimulating. And I miss this as being a trainee and I see a future in this, you know, down the road. So I think that's in some ways, you know, leading by example and people see my genuine excitement for research and hopefully that triggers others. I know one of the things you've always told me too is like, it's not always about publishing about that headline, right? That thing that catches the conference title. It's also about publishing things that didn't work, right? And I think that's important. So we're not wasting years and years of just duplicating research. And that's why it's taken 10, 20 years down the road. And I mean, I know internationally right now we're definitely having an issue of, of actually peer-reviewed looking at it instead of falsifying data, right? We start with Andrew Wakefield, right? About MMR vaccines, autism, the gut, microbiome. And now Ivermectin, you know, that was a whole thing during COVID falsifying data. And now even COVID itself in terms of reducing transmission, right? That the Pfizer executive came out and said, oh, we actually never even tested transmission. So there's a lot of just like mistrust going on. And there's no real police out there. There's no real police that's able to go to these researchers, hunt them down, find them and say, hey, what did the data actually show? No, you're... So it's almost like, what do you believe? What do you not believe? You're right, man. I think that cynicism is what I remember feeling that way early on as like, this is garbage. I mean, I can make this Excel sell, say, one or five. I mean, the power was in my keystroke, you know, what I mean? And you realize, and that's the primary data. So like, if I just hit, if I didn't select this cell, because I forgot, and inadvertently, or maybe on purpose, I changed the whole meaning of the, and it's like, wait, I'm the one that's responsible for this? Like, where's the data of monitoring board? There is not one. It's just me. And so, and the same thing, like you said, is that it's so easy. And so, yeah, I mean, I get it there. I mean, there's rightful cynicism about this stuff, you know, and I don't know the way to correct it. And, you know, peer review is peer review. It's not like some objective, you know, measure. It's like, okay, if I know this guy and I review it and I trust him, I'm going to trust his work. I mean, it's, it is, right? It's a lot of that's reputation and how things go for grants and papers. And so you hope that somebody's not built on a house with cards. They actually have done work properly. And, you know, you can, you know, and ideally, you do validate data, you know, people don't like to do that, but that's an important part of, you know, the scientific communities. You got to validate what that landmark paper just showed. And if you can't, then there's a problem. So, but, you know, in COVID and we're searching for, for, for, for Cures, I mean, nobody has time to think to do that, right? Or the resources to do that, maybe let's say for, you know, can't run another Pfizer trial and that takes forever. So you're right. So, so, then you really are relying on the initial investigators to, to be truthful. And so like a couple, a couple of people that I've really enjoyed listening to, Peter, Tia, Elaine Norton, for those that are very interested in laying out the lifestyle and medicine aspect of this podcast. There are two researchers or two scientists at least that do a lot of research, go into statistics and teach you how to read papers, right? So I think there's also that gap where how do you read a paper? You know, so those are two resources. Then examin.com is also another one that I highly recommend for for the listeners out there in regards to trying to learn how to read a paper and extract value out of it. You know, you're, you're exactly right there. And a lot of, you know, we're, we have a resident program now that that I'm helping to, to, you know, not just we, I call it two modes of research. There's research consumption, research production. Not everybody's going to come out and produce research, right? But you should, we all should be able to consume research in a way that, okay, like you said, maybe these resources that help you consume research in an educated fashion to make your own, you know, conclusions, but really understand the methods of the paper. So I think you're right. Research consumption is, is a, is a must for any clinician. Yeah, that's funny. I mean, during COVID, a lot of people are like, oh, you got to do your own research. You guys, like, what does that mean? We haven't even taught the public how to read, what an abstract is, what like a Nova is, right? Like, what's a P value? How are you going to tell people to, to do their own research when they, when they don't know the methods behind it? I mean, yeah, go. No, I, and I think you're right. And other pieces that, that's really hard is, you know, often you have a paper that has a conclusion, but it's not generalizable to you, right? So like, okay, in this population, this happened, but, you know, it's really difficult to say, okay, to, to you or the patient in front of you, does this apply? You know, it's, you know, it's like, it, it gets a little bit nihilistic, but you think about like, you know, Tylenol works in like two thirds of people or something like that. So if the people, Tylenol doesn't do anything. So is it effective? I mean, I don't know. Yeah, I, it depends. It's effective in, in you, but not me, but I'll give it, but Tylenol is Tylenol, man. You don't, nobody argues with Tylenol, right? Or, you know, you, you, you name the medication or, or, or the intervention, and it works in a subset of patients, but not others. But so, you know, so how do you apply that data to, and this is where it gets really difficult with even reading a paper and applying the data. So I don't know, does it apply to my patients? I don't know. Yeah, this, I mean, I'm getting a little bit, but I mean, this is like things that we just think about it is, you know, how do we take this stuff and actually apply it? It's, it's, it's, it's, it's not easy. Very important stuff. So, definitely. Dude, so what is next for you? You know, I, I, I hate to ask what's the next five years, but what do you think in, you know, the next months, next year, um, in terms of your research, in terms of your life? Um, yeah, I mean, you know, it's, it's, it's professionally, I think, uh, we are, uh, we're growing a lot. So again, I'm at University of Pennsylvania until it helps. And we developed a division of sleep surgery. And we've been here for over three years now. And it's grown exponentially. And, um, you know, to me, it's, uh, it, it's interesting. Like it really comes back. There's two clinic on, tomorrow's clinic Tuesday clinics. And what I, I, I, I, I, you know, drive home. And I, in my mind, there's usually a couple thoughts in my head that drive home. I think it usually about a patient or two that I saw that day, new patient or patient I've operated on. And I, if I think, I don't understand this, you know, and, and I write those down and then it becomes a common theme about what I don't understand. And that becomes sort of what I want to study the next to, that, that's the next grant application, VNIH. And so it's just a matter of, you know, as we start to stomp out these fires in our field, more, you know, our, our, our, our, we're aware of more and more come up. And it's sort of just, you know, there's a logical progression here. But I think it's, to me, it's sort of that's how it goes. It, you know, what is the greatest need for addressing that now? And hopefully, it needs to become smaller. And we can start to just march our way down and getting more understanding of that. So, I mean, that, that's sort of a long answer to your questions. I think it just, you know, it comes from what we see in front of us with our patients. And look, one patient at a time, one patient at a time, and you've got to be honest with yourself. And you, and you've got to be honest, it hurts. I mean, literally a little piece of me dies when I have a surgical failure. I mean, I'm literally like, you know, my, some patients are a little bit consoling me because they can see looking at my face like, that's really, it's okay. And I'm like, no, it's not okay. Because I didn't, yeah, I'm giving you issues for me. You know, I'm like, I'm like, it tears. So I'm like, I didn't expect this. It's driving me freaking bananas. And, and, but, but that's what I use. And so I think like, I hope that doesn't die there in me that I don't feel callous to these, to these events because it happens. You know, you just I mean, long enough, yeah, okay, it happens. Like, no, I don't know why it happened. And I have to, it has to be there in, and I think to sort of to, to, to say this a little bit more generally, the minute you stop giving a crap, you know, as a doctor, go to something else. And that might happen to me. It might happen to some, you know, it happens to people all the time. And it's, it's true. I mean, go do something else. It's not fair to your patients. It's not fair to you to do that. So my part of my whole sphere in developing my, you know, unique variable variety is to never get to that point, right? And so, you know, we'll do podcasts in 10 years when you're somewhere and doing some great things. And maybe I'll be interviewing you at that point and my own podcast because I'm bored of medicine and I want to do something else. But, you know, it's yeah. So I think, I think that's that story. And just keep doing what I'm doing. I think there's a lot of things I, I really feel like we've just, so we've just built the infrastructure here at Penn to really answer questions. And that's really invigorating. It takes a while to, you know, develop infrastructure for research. It's not an overnight thing. And I think once we're at that point now, it really becomes fun to start answering questions. And there are a lot of them. Very cool, man. Well, hey, you've got a, you've got a curious mindset. So I don't really see that flame dying, dying inside of you, man. One patient at a time seems like, seems like you got under control and you're trying to learn something new. So love that. I think I think the listeners can take away something from that as well and learn to not learn a lot. So speaking of the listeners, trying to find you, where can they go if they want your assistance? Well, my assistance is a little scarce at the moment. You know, my, my practice is, it's fairly niche. In other words, people that see me have to have had a sleep study and had to have tried and failed CPAP. And if they meet those through criteria, they can certainly settle with me. You just ways, just go on the pen, medicine website and find me or maybe I can put, I can send you an email there. So with the direct even like, you know, my, my scheduler, that kind of stuff, they're interested in that kind of thing. For sure. Definitely. Yeah. We'll put sleep apnea research or sleep apnea links up in the show notes as well, just so people can get some more education on that as well. Awesome. Hey, man, last question we ask everyone is, how do we put the health back in health care? Health back in health care. It's something that I told you about long ago, I was on this path of integrated medicine at Northwestern. And I really felt what you're doing now is what I thought I'd be doing 15 years ago. I would be doing Andrew wild integrated medicine fellowship after medicine and then doing a functional, we didn't call functional medicine then sort of integrated medicine. I think it was the term that we were using back in 2006. And that was about putting that, that, you know, wellness, the health back in health care. And now I'm a surgeon. So, you know, the challenge with what I do is that I'm really, I am at the end of the line when these is progressed so much, right, that we missed it. And actually what I do now telling a lot of my patients who have young kids is to see ENT and orthodontists who can help expand the jaws, to hopefully prevent what's happened to them, to the parents. So, it's kind of cool in my world is that I can try in the next generation because I have, you know, most of my patients are older with children, some of my young children is what can they do at that age? And most of that is really jaw development because they often inherit their parents' small jaws to try to help educate them about their things that you can do at an early age, age of five, even with expansion, the upper jaw to help that. So, and so maybe that's that's in my little world what I do to try to put that, that the health back and health care is that I don't, I want to be out of business in 20 years. I really do, I don't want to do any more surgeries on people's jaws and then because I want people to have, you know, fixed that or addressed that back in their, in their school age. So, that would be my goal and it's a matter of educating people and, you know, the books that come out like breath and you prefer reference others that are helping understand that we are devolving as a human species and at least we can do it to hopefully alter that trajectory to young age while we're still, you know, somewhat supple and able to be modified, that's what we got to do. I think this entire episode, I've been clenching my jaw, putting my tongue to the roof of the mouth and you're like, so try to get to try and understand that. Yeah, yeah, yeah, yeah, man, John will be proud, yeah, yeah, that's right, that's right. Well, hey, Ron, I appreciate it, man, I think this is such a valuable and valuable show that we're doing for the listeners, you know, we up again, we touch on sleep a lot but we've never really touched on sleep apnea, which I know is affecting so many people out there across the world. And so what you're doing is spreading a good word, so appreciate you coming on, man, thank you. Actually, you're spreading the good word by this podcast, so thank you. You got it, man, thanks. Okay, good night. Well, there you have it, everyone, that is a deep dive into sleep apnea. I'm grateful that we were able to bring on Dr. Dadia, his way of explaining things just make so much sense, you know, not only to clinicians, but also to patients. And it's amazing to see that the research he's doing, you know, being one of the leaders in sleep apnea research and just really changing the game and changing the field. I'm excited to see what else he can do in the next five to 10 years and how sleep apnea research and awareness will constantly be changing. If you know anyone with sleep apnea or anyone with sleeping issues, please send them this episode. As you heard, sleep apnea is becoming more and more prevalent and we need to do our job in terms of spreading the good word, spreading medical education out there and getting this episode into the hands of people who really need it. And be sure to check us out on social media. If you want to hear the funny snores and noises that Dr. Dadia was making, I'll be sure to put those up on our Instagram, TikTok, Twitter and of course my LinkedIn. And of course, the medical disclaimer, everything in this podcast is for educational purpose only. It does not constitute the practice of medicine and we are not providing medical advice. No physician patient relationship is formed. Anything discussed in this podcast does not represent the views of our employers. We recommend that you seek the guidance of your personal physician regarding any specific health-related issues. As always, if you have any questions, if you have any videos that you want us to check out and any myths you want us to bust, please send them our way at MedReDefine at gmail.com. See you later.