90. What We Didn't Learn in Med School, Defining "Root Cause" & Influencing Patients | Nikhil Verma, MD

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. Our guest today is Dr. Nikhil Verma, who, like myself and Altamash, is PM&R trained, and he is a practicing physician within the realm of sports and spine. He's currently located in Ohio. So the reason we brought on Dr. Nikhil Verma is because he is active on social media, and like myself and Altamash, we're all trying to filter out the noise. We're trying to extract the good information, the good voices on social media while trying to navigate that complex world that we now live in with so much misinformation. Dr. Verma also has a YouTube channel where he talks about the things that we don't learn in med school. Yes, there's a lot that we don't learn that we truly need to understand whenever you become attending and you start to see patients in the quote unquote real world. So throughout this episode, we're going to be talking about the things we didn't learn in med school. We're going to be talking about how to filter the noise from the signal on social media. And we're also going to talk about what the scope of a physician is and how do we truly approach patients. And so throughout this episode, you're going to hear all three of our opinions and kind of our mental models. So without further ado, enjoy this episode. All right, Nikhil. Welcome to the show, man. Thanks. I appreciate you guys having me on. Yeah, I'm, I've been excited for this conversation for quite some time, particularly because, you know, I think, well, I guess now we, we officially met down in Baltimore though we don't really get to chat much, but I've been following you on social media for quite some time. Thanks so much. She introduced me to you and I really love because you, you have some strong takes on social media. So I'm really interested in, and getting some of those hair, hopefully things will get a little bit spicy, and hopefully nobody will get in trouble today. That's not going to be the purpose. But before we, we kind of get into that and get your take on a variety of different topics, I want to talk a little bit about your background. I know you did some training over on the East Coast, right? You did residency in New York, is that right? Yeah, that's right. Brooklyn, New York Kingsford Church Medical Center. Yeah, it did. Yeah. Yeah, where did you grow up? I'm from, uh, North Columbia, Ohio,querida, Ohio, small town. Then I went to Ohio State, from undergrad, so kind of wanted to come back here, long time finally didn't even go way back. Where was med school? George University. Okay, I was on the global scholars program, which is pretty cool. For the first year, I was over in Newcastle, England. And then the same year, we went down to Dernayda and then my clinical rotations were in Brooklyn. And that's kind of how I looped into the Kingsburg system. Awesome, it's good time. So you've kind of got a taste of a variety of areas, variety of environments, a variety of patient populations, I'm sure. And then you ended up back in Central Ohio. Is that the three practices, right? Yeah, yeah. So I have two offices, one in Columbus, and then one in my hometown, Marion. To add to that point, I think that's like a good starting off point in itself, because yeah, so I saw all these hospital systems from, you know, not just medical school, but then in residency, you know, we rotated through, or med school, we rotate a bunch of hospitals. And in turn year, I even went to Rochester Hills, Michigan, and I was exposed to three or four different hospital systems there, and I practiced science, and all that stuff. And then I went to a residency where we were rotating into different hospitals, especially third and fourth years. So quite the background of experience of that, I feel like I have. Did you always know you wanted Indigo to go into something musculoskeletal sports spine related? Yeah, I think a lot of people that, you know, got drawn to the physical medicine rehabilitation world, we either have an injury of our past or something along those lines. So I actually had a par's defect that took me out of Plank football when I was in high school, and it really led me into like a deep rounded depression and depression and back pain, as we know, so common and interlinked in all that stuff. I started really getting into working out and lifting and strengthening and stretching and all this mindfulness and all that stuff. So you know, I kind of figured yeah, I would go to med school, go to sports medicine. You know, I love sports, as you know, most of us do. And what happened, I was doing my sports medicine rotation electives in my third year slash fourth year at Kingsbrook, and I was going to learn the clinics. I'm like, well, man, this is just sports or this is just physical medicine rehabilitation clinic with four sideline coverage. And that was living wrong with sideline coverage, especially if you want to do that. But I would rather be watching the game, having a drink with a friend and saying and feeling like I'm working. And also I didn't particularly care or watched, you know, JV high school boys volleyball. Not really in my cup of tea, you know. So I was like, okay, so I was actually lost words at that point. I'm like, what do I do? I was talking to my, at that time, we were PGY three years. And he was like, hey, I'm going to do this intro or interventional spine and muscle skulls will help nest fellowship. You should apply to because it seems like that's what you want to do. The more I read into it, I'm like, wow, that's awesome because it's all the procedural stuff, but I could still do muscle skeletal stuff, where my real passion is. And yeah, you know, thanks a friend for recommending it to me and never look back. Yeah, I don't, the poor JV athletes that that might even be listening right now, it's just so about hurting at this point. There are better hands than I could treat myself. So having this diverse background and just, you know, so in Brooklyn, I mean, you've seen patients from all walks of life and in the central Ohio drastically different population, you know, down in medical school during your rotations, again, you're kind of stationed in all different places as you mentioned. So you have a sense, and I've heard you talk about this, just kind of the system of medicine, the business of medicine, all kinds of things. I guess, if you could go back and think about it when you were first going into the field, maybe before starting medical school, I mean, you must have shadowed some folks, you must have had some exposure into that. Yeah, yeah. After, and you've been practicing for how long now? I opened my practice at the beginning of 2020, so going into the field. So a couple of years right under your belt. So how would you say the medicine of today is different than what you expected as you were entering or matriculating from medical school? So I think that's a great question because, you know, we get indoctrinated into hospital systems and how the hospital system works, and then you have this shiny star object of a, you know, university hospital. It's above and beyond everything else, it has all the credentials, you have all the books, you have all the authors, all the people putting out these good research papers, which is fantastic if that's exactly what you want to do. But I can go have a conversation with one of these individuals. Heck, we can talk about my own fellowship director who's in private practice. I ran into him in New York, thankfully, and we got a great chance to catch up. And he's like, what he doesn't know about the backend stuff is just blows my mind. And it's medicine is not runefficiently. We're not getting the care to people that need the care the most. We're not getting the education to them. We're not getting the resources and all that stuff. It's, it's, you know, Darshan has like such a great positive outlook on life with all these, all these things. And I, I, I used to see myself in that, but I've been like so jaded because I know when I walked into Brooklyn Hospital, if this person who just got his leg imputed, they're not going to listen to me if I want them to change or die it and go smoke free and stop eating this and get out of the blood better for my case. And I know full fact that they're going to be back in every half possible in six months. And because they ampute you now, now they don't have the access to go around an exercise. And I'm not sitting here going to blame the patient, which we, four source, we don't force ourselves these social media influencers, not you guys, but you know who I'm talking about. These people who don't know anything about medicine or how healthcare works. And they're like, oh, it's easy to go take care of yourself. Just go walk and, you know, like, you know, these people have access to good food. You know, that $1 cheeseburger is what they have to split between their family. So that's like what my realistic view of the world is. And I still believe that we can all be our own advocates and fight for ourselves. So I certainly agree with you that Darsh has an incredibly positive attitude. In fact, that's one of the reasons I wanted to link up with him, because I was like, I'm going to steal some of that energy. And so far, I've been unsuccessful. He's holding on to himself. But you know, that's an interesting point you bring up. We had a previous guest come on. And you know, one of the things we always like to ask people towards the end is, how do we add the health back to healthcare, right? That's kind of loosely the mission of the show. And this person responded by is like, we don't we have to kind of destroy it and just create a new one. I see the that point. But at the same time, you know, I do think that the next generation of doctor is a little bit different, right? We have different tools. We have different mediums of communication. Patients are more informed. I mean, we've got the internet, right? And so our approach has to be like what we were the way we were learning the way we were communicating with patients the way we were practicing 20 years ago. It doesn't it doesn't work now. And it's not going to work 10 years from now because of how rapidly everything is evolving. And so, you know, I still like to think that there is something that we can impart. And we're still part of that new generation, right? Because we're all fresh. Like I'm a brand new attending. You're still a couple of years out. So what is it that you wish that you would have learned where maybe you wouldn't have been as jaded, so to speak? Yeah, I guess you know, jaded is a hot as a lot of work. It's yeah, it's a hard term. I know, I know you don't mean that literally, right? But I see what you're saying. Yeah. I just see it a different perspective. And I am with you guys. Like I want to make this a positive place. And I do spend the time and that's part of the reason I went into private practices. I will say here, talk to my patient for 45 minutes. Like, yes, I'm looking at the clock and knowing that those are patients in the next room waiting for me. I know I have a procedure going on. But if that's where it takes, especially these chronic pain patients, which is so poorly understood, even in the medical society, even in the pain society, that you know, I know what it takes to get them to listen. Will they go the wrong way? I don't know. But I think we have some advantages to it that we have enough people like us who are positive about this. And if we can keep our head steam, we can find the right ways. I think one of the wins was getting a health coach being paid for by insurancees. Now, I feel like, yeah, I should be limited to doctors and stuff like that. But it's finding centers of excellence. I use that term loosely of, all right, how do we get family medicine doctor all the way up to orthopedic neurosurgeon getting all the specialties working well within the network. And this is something that's been proposed that they're called accountable care organizations, doctors, hospitals, other care providers. They financially benefit their patients who have chronic illnesses. And if they keep getting quality care, then and they get their patients better, then they're going to get the reimbursus more and more. I think that's one huge way. And that's taken away a little bit of the power from insurance companies dictating, oh, you can only do this test or it's going to deny this procedure, deny this medication. I think that's the first place to start. Yeah, now I agree with you. The whole insurance, you know, the fee for service model is really interesting because it even indirectly biases you to have to do more. And that's not, you know, more doesn't necessarily equal better, even though in Western medicine, in the United States, we think more is always better. It is an interesting point that you bring up. Actually, I had this happen to me yesterday and I was running just crazy behind in clinic. And I walked into the room with the patient. And you know, it seemed like a straightforward case, like in the chart review. And I walk in and this patient had, she's been through the ringer, was referred to me by somebody who essentially just wanted to kind of look at the holistic approach and talk about exercise prescription and whatnot. I had forgotten that I got heads up on this for a long time ago. So I didn't have that in the back of my mind. But I walk in and the first thing patients says to me, you're my last hope. I was like, oh boy. And she had told me how has had EMGs and the symptoms were so incredibly vague, just like heaviness and weakness of the leg. I was like, okay, no pain, right? And so it's like, okay, not a lot of people come to the clinic when they don't have pain, they don't have weakness, they don't have the construe pathology or dysfunction that's going on. But just subjective describing these things, but didn't want anything, didn't want medications, didn't want to do any further diagnostic stuff, wanted essentially at the end of the day, what I walked away after that and had reflected back on his one or reassurance and just wanted the blessing to, hey, let's continue exercising. Let's try to stay as mobile as possible. But I had to get there by actually just taking motivational interviewing 101, which I didn't have the time for. And I was already pressed for time, I was already behind. And you know, this is something interesting. Darshan has been asking me about that we should talk about what it's like to transition into attending hood. The pressure is just night and day. It's different, right? But you're just not prepared for that. Like I was never prepared for that. And I think I get pretty good quality training. I've had some of the same mentors there, Melenga, that I know that you were spoken about and people like that have prepared you to have this conversation. But until you're the guy or the girl doing that thing and the pressure is on you, the patients are on you, you're a schedule, you're billing, you're a time. It's just a different animal. But at the same time, I don't think about it. How do we get the students ready for it? Because students work with me now. Resents work with me now. Do you have trainees rotate with you? I'm open to it. A few medical students have got by and rotated for a day or two. I have the benefit is I can kind of keep it honest with them, when they're in there and tell them, listen, a lot of this is a lot of work. And I haven't told any residences, but I have some fellows that graduated after me for my program. It's like, listen, that first time you have that needle in your hand and no one else is coming to save you even though it's all on you at that point. And if something doesn't look right, it's not going to look right. So it is a steep learning curve at that point. Yeah, you know, Nekil, I think one of the issues, as we're going to talk about, is kind of pre-meds have no idea what being a medical student is and then that transition to residency and then attending it, right? Kind of what Ultima just talked about. And that becomes a question in terms of, you know, well, then what is the scope of the provider? I thought I was going to do XYZ, but now I'm doing ABC. And, you know, I never knew you, you were in the UK, if like, your first year of med school. How did, so, you know, go into Caribbean school, how do you think, you're, was your education any different than doing an MD or DO school here in the States, at least like the first two? And then like second fold, having that experience in the UK, did that teach you anything in terms of maybe different healthcare systems? So, the first question is, let's see how I want to work this. So the first two years, I mean, in my opinion, are the same. It's the same books, we take this, we read the same textbooks, we read this, it's, you know, just different people teaching you. So, you know, I don't know, I'm so anal-retensive, I want to get all A's and B's on all my tests at all time. So like, I was still studying all the time. I kind of isolated myself, and I think I needed isolation from my friends, my family, weddings, and all that stuff in America. And yeah, it was a little miserable, but it was what I needed to do for that time. I don't think we had to, we definitely didn't have the close access to hospitals in our medical school, rotating, see the cool surgeries, go to these green lectures. We had a little bit, but it wasn't like the same, and we know it wasn't the same. And then, secondarily, we were learning from a lot of therapy and trained physicians, UK trained physicians, which is fine, but their hospital systems work so differently. So, you know, that was the first time that we call it, or A and E, at ED here, in accidents, incidents are something there after they're exactly what it is. But that's the first time we hear that term, it's like, what is that? When we have a clinical vignette. But the physical exams, they're the same. You know, heart murmurs sound the same. So, you know, we take that stigma away. And then, you know, we come to the US, and, you know, I didn't notice any difference between the med students that we went to, to the med students that went to US schools, at least in New York, now, across the nation, I'm sure there's going to be outliers on both ends of the curve. Sure. Sure. And then, that second part, you know, in terms of the UK, what was that experience? Like, was there anything that you were just being by the UK, you thought the healthcare system might be differently, or in your mind, you said, oh, well, I can now look back and see either the advantages or disadvantages between the two nations. There wasn't anything specific, because we didn't do very many rotations or clinicals as there. It was, yeah, we did, we practiced some of the stuff, clinical exams on each other, but we didn't go to any clinics or hospital systems. So, just based on what they were teaching us. Gotcha. I want to jump back to kind of what we were talking about a second ago. Like, you know, you were, you were very passionate about making sure that we addressed the business of medicine, right? At the outset, we started with that. And also, a lot of these philosophical topics, things just don't get taught in those first two years, in textbooks, then in 30 years, you really have these, I mean, we call them comats, you're an MD. So, I forget what your shelf exams, right? And then, then you're worried about step three, and then, you know, then you're worried about matching. And then so, we're so tunnel vision, you know, as Darshan alluded to before as well, is, do you think, like, we can have this conversation now, you know, I put this in quotes because we're enlightened, but if you rewind the clock, and if we go back, it's like, were we ready for this conversation? Right? So, I'm thinking about, it's like, how do we educate the current medical students or residents and stuff like that? It's like, when we're so hyper focused, and you're just worried about that next carrot match, like the sports match was last week, and I was just thinking about that, residency matches, like, you know, like, if I have these conversations, like, I don't want to hear that, right? It's like, how do we do that? How do we put that into the curriculum? You know, if you were to starve a medical school or just the medical ACGME system, it's like, how would you instill that? Where would that be? And is that even the appropriate time for medical students or residents or fellows? Like, what's the level, you know? Yeah, I think you would want to do it towards the end of MS-4 year when there's more time. There should be more real talks about these kind of things, and that's, you know, what my whole YouTube channel is about is just having a real talk and sitting down and having conversations that things I wish I would have learned. I think another time to look at it is that last year of residency, where you similarly, you have more time, and I think it's hard to find mentors that are going to be straight shooting and talk about those things, because if you're at a high university hospital, they're kind of, they can't talk about it. Even if they can't talk about it, they might not even know it. So I think those are two valuable times, but I think to your point, you might need to just get in there and feel it for yourself. I can make 10,000 videos and have 50,000,000 hours to you, but until you actually do it, you're not going to really feel that. I totally agree. I mean, you can tell any 18, 19, 20-year-old pre-med student about not going into medicine because of this, but there's just something about being at that age and saying, you know, what? No, I'm going to do it because this is what I want, and this is my perception of it, right? I mean, I was in a 70-year BSM or BSCI MD program. Thank God I didn't make it through, because honestly, having those gap years is kind of what led me to just being more mature in terms of my thinking and going into medical school. I do want to transition into social media. So you started a YouTube channel. You're active on social media, and you know, one of the back and forth we were having was on the Paul Saladino video talking about root cause, right? And this term root cause being thrown, thrown around everywhere. What is your thought on that? Because Paul Saladino says we're not taught that in medical school. Obviously, he had a professor rebuttal saying, well, you know, we learned the root cause of TV. How do you break down the word root cause when so many people, patients, as well as providers, are looking at that as not only a marketing, you know, term, but also people believe that. People believe that we truly need to reform the education system to talk more about root cause. Yeah, I think that's a, I mean, that's a deep question, right? Like, I would challenge any of these people, let's say I'm creating the root cause. Okay, what's the root cause? Spinal stenosis. The spinal stenosis is because, you know, you have bad posture, and this, and I was like, well, you know, actually because an enzyme isn't actually working in your body to eat up the collagen adjacent to make your ligaments. So how are you going to go back and treat that? Do you know how to go and treat that one to the end of the enzyme? So it's so easy to say this, but when we break down root causes, like we're talking like micro, micro DNA RNA changes that cause cascades of events. We can talk about any root cause, like when we talk about inflammation, you know, that's increased ILs and lucatides and proctides and all those things in your body floating around. It's not just a one small thing, like, oh, you got a picture eating, you know, root cause, like what is the root cause? That's where I see it. Yeah, no, I agree. I think when we look at root cause and even look at like the functional medicines or certifications, right, they go so much into the biochemical pathway, which is cool, right? Because it can at least tell you the evolution maybe of a disease. It's kind of what we learned in medical school, but maybe maybe we just haven't learned in that much depth. The way I see root cause, I've wrote this times comments too, it's kind of, it's kind of what is your approach, right? It's like the treatment root cause which we do learn in medical school. You learn that, hey cigarette smoking can cause this, and if you have this disease, you can trace back. But then I think people confuse root cause with preventative medicine, which I think is what we should probably be using more of and focusing on goals and themes at least, right? If we're talking about nutrition and exercise, how do we set up things so that we can prevent those diseases? Let's start at a root, right? Now more than ever, let's not go backwards, but let's think forward. And so I think that's the way I think about it. Ultimately, I don't know if you have a different definition or kind of what pops into your mind. Yeah, no, you know, what does pop in my mind? And I think, again, I think about one or two challenging patients I had recently where they came in and they said, this is what's going on, and I need to know what's going on. And again, they've had all the tests and stuff like that, but then I had to ask them, I said down, I was like, well, what's more important? Is it more important to know, like, to find out what the cause is of your symptoms that you're experiencing, or is it more important to get your life back? What you're telling me that you can't do and you want to do it? Like this person wanted to run a marathon and was like, I was running half marathon and said, like, and now I couldn't, I was dragging my feet and people 10, 20 years younger than me were able to do this. And so I asked that person and the person paused and said, yeah, I guess the latter is more important to get my life back. And I was like, what would it look like if we never found out what the cause is, but we were able to get your life back. Would that be acceptable? For someone like, yeah, I guess that would be acceptable. So I was like, so maybe let's focus on the latter, right? Oh, yeah, of course, look, we got to rule out the red flags, we got to make sure everything's safe. We got to, but to me, sometimes it's just not practical. Sometimes it doesn't even matter because we talk about this for diagnostic tests all the time, right? It's like, if it's not going to change your management, why are we ordering something? And so, you know, these biochemical pathways, I love doing this. I mean, Dars, you know, we, we like to nerd out, we talk about it offline so much, we're texting back and forth all the time. It gets really interesting. We listen to a lot of the same thing. And Niko, you do as well. I mean, we're all sharing the same stuff. But, but when it comes to actually seeing the person in front of you, a lot of the basics carry, you know, they care, they go really far. And so sometimes it doesn't even really matter. And so I'm less interested in identifying the root cause and more interested in just helping people and whatever it's ever tools or how are we get there? I don't know if that answers your question or not, but yeah, I think so. You know, I think again, I think all three of us here are looking more towards progress rather than going back and focusing on having your cake, you know, and then having to, right? I was like, okay, I'm too. So, no, I agree. Niko, if you have any more comments. I got a good question for you guys, one of your chance. Yeah, no, yeah, I do because I feel like, wait, wait, you don't get that much. I'm kidding. Sorry, go ahead and go. No, yeah, so I think it's also because we all kind of do have the same, and we have a different, all three at different approaches, which is I think even better, right? I've said multiple times to patients who might come to my office, all tests and all this and everything's negative. And it was like, listen, you're the exact person who should have been seeing a doctor because you're gonna get all these thoughts in your hand. I'm gonna tell you this, tell you that. Yeah, yeah, yeah. So we all have our different ways of saying, and that's how I say it. You have a different way. So my question for you guys is, do you feel like P even our doctors are gravitated to that kind of receptiveness and how we view medicine? Or is it talk to us? So born with him or do we learn it? Oh, wow, that's a good, it's a good question. Oh, yeah. Oh, I think it's, man, it's tough. It's a lot of bias. Of course, I gravitated towards that, but I do think in residency, it was emphasized a little bit more, which is why. So I knew about Peminar, my first year, which is very early for I think, now it's more popular. And I only knew about it because in the sense that I wanted to practice non-surgical musculoskeletal medicine, right? And really sports medicine, because I went to medical school, I was like, I'm doing sports. And I only knew that you could go into sports through ortho or family or something like that. I didn't know about Peminar. Once I learned Peminar, I was like, oh, I'm doing non-surgical MSK. That's what I'm doing. It wasn't until I shadowed Jerry Malenga, Niqueo, where when I took this stuff, I was like, oh my God, right? We were talking about quantum mechanics. And I was like, what does that have to do with anything? But it has to do with everything. And so again, so I'm an osteopath, right? And so we were taught the quote-unquote holistic way, but Dr. Malenga is not. And he's talking about a white man, he's talking about this. He's talking about curcumin. We're podcasting about this now, like 10 years later. And I was like, okay, this is the guy, like the way that he thinks about a problem. And so, and then I went, did my residence, or sorry, my away rotations, and I found a lot more people like that. And so I think it's hard to disentangle whether it's attracts or if that's taught. But maybe it does attract, and those people are now teaching, and they just continue to pay it forward. So I don't know. Yeah, I don't know. I guess it's tough. I mean, when I look at it, I think a newer generation of physicians, the ones in Mexico right now, us, I think we tend to be more holistic. I think we're more data-hungry, right? I think the advent of social media has caused that. It's caused us to have debates and actually talk about seeking the truth, right? Something that I think all three of us really do talk about is, Nick, you put a great video out lately on your YouTube, right? Like things that you thought were true, but aren't. And I've been, you know, and that's inspired me to kind of make a list of like the last like five years, what are those things that I'm looking back at? And I think that's the beauty of kind of our generation, right? Is that we're really trying to look at in terms of coaching, but also trying to receive as much information from patients. And so motivational interviewing, but I almost find it really impossible to do, given a 30 minute limit. And it sucks to see how insurance dictates the way we even ask questions, right? Not even what we kind of ordered, but just even the way we ask things just so we can be more time sensitive. And so I've kind of adopted this philosophy at least when men students are with me is that I'll try to like ask and influence at the same time. And I found that patients enjoy that. And I just try to teach, I try to teach, teach, teach patients things that they may not have known, but will make sense and try to just break it down. Like, hey, exercise. This is what it does. No one's probably taught you this in terms of your heart rate. And like just just like one or two facts that they're like, oh, whoa, I never knew that. I was always taught something different. That's been my approach lately, at least like in the clinic. And I think it also depends on the patient population, right? Like I plan on going fee for service, probably just given like what I want to do and kind of how I want to work with things. And that's going to attract a whole different, you know, patient population, for sure. Can we compare to what both of you guys are seeing right now? Now, I know Darsh wants to get your take on an approach. And as do I before we do with that, we talked a little bit about social media. Again, and we're all somewhat active on that. Twitter is your YouTube and Twitter. That's where you're primarily. I'm on Instagram. I'm on LinkedIn. I get pretty active on LinkedIn too, more of business side of things. So each each up platform has its own. A little bit different. So as I mentioned, you know, I think a lot of people now are getting, you know, sometimes their primary source of information is social media, one of these platforms. And we're pretty active too. And, you know, one of the things that we try to do is put, put out good information. You do the same. And so, you know, the good comes with the bad. And sometimes there's a lot of bad. So I want to ask you is how do you, when you talk to people, if you're making a recommendation about following somebody is, how do you suggest people can filter, you know, through the noise, all the noise or so much noise when we're talking about this root cause, or you know, those people talking about root cause, you know, it's dairy. No, it's gluten. It's this, this, this to get the signal of like what health means and stuff. What's your thought on that? Yeah. So it's fun to you ask that because I'm battling with that myself. And it's actually going to be my next, you two series or next video, kind of talking about, you know, really comes out to this. And this is it. What is the primary motivator of that individual? So we'll start with that. And it's like, oh, I really want to help people. Okay, that's fine. If you really want to help people, then go help people. Don't go on videos saying that I want to sell all these things because like, I don't want to use anyone's names, but because I'm trying to get away from that. But like, there are these influencers out there that say all these things, but then you go look in their backlogs, look at their tax records. They're getting flown out to these conferences. They're staying at these hotels. They're, they have their supplement lines. They're, they're all over. And now it's became a joke. You don't want to help people. You just want to make yourself money. I mean, let's call it, let's call it. Like, there's nothing wrong with that too. If you want to make money, go make money. But don't say it's trying to help people and educate the world when you're just using your own data points. And I think that's, that's usually my, my biggest filters. What is your real ML here? Let me push back on that a little bit. Yeah. And I have no idea who you're talking about. But I mean, can somebody do both? Can somebody like make money and also have the, I mean, because at the same time, this is a business, right? We talk about the business. You have a private practice, so you are intimately involved in every single business decision you make. We don't make money. You don't get to help people. You know what I mean? So can somebody want to do both? Absolutely. How willing are they to change your mind? Like I said, in my YouTube video, this past last week took a couple of weeks. There are things I thought 100% there's no way this not true last year. And here I am this year. I'm like, well, damn, I was made. I was thinking just today, man, I need to go to more courses. I need to go learn more. You know, I've done thousands of cases. I've done, you know, tens of thousands of cases throughout my training too. It's like, no, I'm going to go learn more. So these people that patient hold themselves in the always studies that fit their narrative doesn't make sense. Yeah. Thank you. I want to delve into your approach with patients now, right? Because I think, you know, earlier you just talked about, you do talk about kind of the pillars of lifestyle medicine or just, you know, health in general. But let's first start off, like, who is your typical patient coming in? I have a good referral sources from physical therapists that know that, you know, I'm going to sit down and talk to patients and, you know, they've gone through physical therapy, some chiropractors that similarly have war talker in the patients, like, hey, just not getting there. But most patients that end up coming are between 50, 60, 70 years old, have chronic back pain or new onset of back pain exacerbated, whatever. So that typically is who's coming through my door. My target audience is any muscle skeletal injury, as I think all of us kind of want to focus our strengths on. Sure. Okay, so 50, 70-year-olds, you know, different generation from us, obviously. What are their expectations when they're coming to see you? Is it mainly just pain relief or is there maybe something extra that they ask for? I think that that comes into when you're sitting down and talking to them. First off, I don't do opioid management out of my clinic. So my MA, my scheduler, they know, as soon as they pick up the phone, okay, you want to get a point? Are you on opioids? Do you want to remain on opioids? Because we're not going to take on those cases. So at least we filter that out. They still come through and that conversation starts really quickly. In the same, the conversation starts the same way every time. And I think, and when you've experienced it, you know, but you go along with it. And it's the motivational interview, like, okay, what are your goals? What do you want to do? And I think that's the point is, what would you do if you're out of pain? So, you know, I have this one patient. All they want to do is they want to go back working. Like, great, that's a fantastic goal. How can we get you there? And that's typically what I'm saying. It's like, if the first thing doesn't work, we got another thing. If that doesn't work, we got another thing. We'll get you there. Yeah, I love that, right? That's a, that's a true Peminar motivational interviewing, asthma goals, you know, and that's like the one thing that I've been taking to the neuro clinic or sports medicine or, you know, is asking a patient, what do you want to add? Like, what are your goals? What can we do for you? And what are you hoping? And back can, honestly, safe 10, 15 minutes out of a visit and direct better care. So I definitely agree with that. I love that. So, again, 50 to 70 years old, do you feel like they might be out of touch in regards to the way you practice health care, right? Because they might be used to a different system how it was when they were looking at doctors with paper charts. How do you navigate that? Yeah, so I think a lot of them are used to, oh, just give me a pill and let me see how it goes. And so, you know, I have my handful of NSAIDs that prescribe, most of the relaxures that I prescribe. Don't love giving you a pen to all the time, but that's another one I'll give, you know, some chronic pain stuff, SNRIs, you know, you know, the families of medication, so it's like this might be the best thing. And sometimes that's all they really do need and perfect. That's fine. But no matter what, 100% of my patients are going back to therapy or chiropractic. And the right chiropractic, in my opinion, you know, you need to know what they're doing and stuff. But yeah, so that's kind of how I functioned out of my practice. Almost I'm going to give you something that make you mentally feel better in the goal that you're going to go do the work to make yourself feel better. Okay, so when you talk about the work, right, how do you approach that topic? Because the work can mean different things to different people, right? It could be getting more sleep so that their pain goes down by a little bit. It can mean, hey, you actually got to go through physical therapy and actually show up to your appointments so that pain can go down. How do you influence in that in that regard? So, yeah, you know, it's a very sensitive topic because I think it's personal for everybody. If it's like, oh, you know, I went to physical therapy before and it made me worse. I'm like, okay, show me what they talk to you. What'd you do? And then, you know, I don't know if this was like, that's trash because of the therapy. You went to some cookie cutter place that didn't work upon you one-on-one. And this is how I talk in clinic. I'm like, that was a waste of your time. Like, then I literally will get on the floor and show them stretches and movements like no one's ever talking to that. I was like, well, let's try this for a month. You know? I think that's the way I could just motivate them. I was like, I'm literally showing I got beans in my office. I got, you know, clean my floors all the time. And I clean my own floors so I know that I'm doing it right. And that's what I do. And I think a lot of people see that and that I'm actually listening to him on the other end when they're telling me their problems. I think those are the two biggest portions. Yeah, I love this. The conversation you guys are having about, you know, active participation. The patient is the active participant in their in their own care. Often I'm telling my patients, I'm like, listen, this is your show. Like, I'm just not long for the ride. And it's not, again, you know, to Darshan's point, like that, that mentality of, you know, they go to the doctor's office, that paternalistic relationship, doctor tells me what to do. Doctors write, I'm so excited when patients come in and they've already watched YouTube videos on the procedure that I'm going to do. You know, I have had a patient ask me to do a different approach. And I'm like, okay, let's, that's where we draw the line. But I love it because I'm like, listening to you, you got to do the work. Like, I can't, you know, I do a lot of OMT as well. And then we have these patients who are talking to students about this today is they just, they get, they come, they get treated and they're like, okay, can I come back next week? And I'm like, no, no, no, we have to, once we quote unquote, fix the alignment, you know, you have to do the exercise after that we've talked about to make these changes stick, right? And I tell them, listen, I'm going to prescribe physical therapy. I'll write one, two times a week. Physical therapy makes their assessment. They might make a suggestion, but with a whole exercise program, like, you're not going to do that work or whatever changes you're making. And they're not going to stick from a 45-minute session twice a week max. Like, that's not going to happen. And, you know, we're just used to, in this culture, it's like our idea of recovery is going to get a massage. Again, it's all passive, right? Darshan's doing, you know, the, the ready state, right? The virtual mobility coach, just like active recovery. You have to, do your formula. You have to do your stretches. You have to make sure you're doing your squats or whatever it might be. And, you know, I don't know if we're unique as a country where we're more into that where like, we don't believe, you know, we're more into passive modalities, massage gun, heat ice, stem, that kind of stuff. But, but that's such a critical point, I think, when we're talking about chronic musculoskeletal medicine, because I think that's, that's what we're essentially talking about here, right? Like, the acute stuff, that's different. Fracture care is different. Bones sticking out, it's a little bit different. Wounds are different. We're talking about chronic musculoskeletal medicine, which is what 90% of what we see. I, uh, I'm dealing with the shoulder thing right now. And, um, you know, I scheduled my physical therapy. And I'm like, literally like, okay, I can do one stand on my left arm straight out. I'm going to go my right and start shaking. And they can see, it's like, this is why I'm going to physical therapy, because I know if I don't treat this now, that's going to be torn rotator cuff, that's going to be a surgery. So why don't I fix it now? You know, anything you put off is going to bite you in the butt of the long run. Yeah, there's a really good quote I heard from, uh, Cressy, who, I think he's not the, I forget who he said, he talks about, I think it goes something like, pay attention when it whispers before you have to listen when it's when it yells or something like that, you know what I mean? So that's kind of when you talk about, it's like when people have this little nagging injury and they ignore, ignore, ignore, and then it's just completely shut down now. They can't, they move their arm. So I think that's really, really critical. I think people do that earlier on, and not just push through the pain and stuff, um, will be in better shape. Or mask it with like non-star royals. Sometimes it's like, that's actually kind of more detrimental for your chronic muscle skeletal health. So, you know, my friends always ask, oh, you don't have diabetes for open your house. I'm like, no, because if I'm in that much pain, then I need to go do something about it. Yeah, I think, I think it goes back to the culture too, ultimately. Like you were saying, I mean, we in the US believe in this no pain, no gain, mentality, right? And like, for, for those of you guys who know ET, the hip hop preacher, right? He has that like amazing motivational speech about not sleeping, asleep is for the week. And so it's funny that we buy into this culture of like hustle, right? A hustle culture that leads the passive income and wealth and, and essentially retiring early in being lazy. And I don't know how much of that actually translates like you're saying into kind of, you know, we've, we've experienced pain. So we've done the work already. So now we should be rewarded for a complete solution, which could be heat or ice or whatever it might be a little too passive. I don't know. That's funny, Dasha. It reminds me of that story, the fisherman who's like fisherman in Spain. You buy the fish right off the boat and it's wealthy business man is like, oh, how much the money make? Oh, I make enough. Oh, what do you spend about? How many hours? Oh, just three, four hours a day. What do you spend the rest time doing? I sit at home, cook with my wife, play with the dog, take a nap. Oh, well, he should be working all the time. Go out and buy all the boats and get all the fish. You can make millions of dollars. And then you can retire. And the fisherman is like, and then what do I do? Well, then you could be at home with your wife and nap and play with the dog. It's like, yeah, when you start putting these in perspective, like this, it matters. Oh, it's oh, my God. This is it's home right now because I've been I just picked up this book, Bill Perkins, die with zero, great concept. And he talks about this. I know you guys might have heard about some of the podcasts. Yeah, that's exactly what he talks about. It's like, you know, most of the people, they save, save, save, save, save, and they give up hundreds of thousands of hours of their lives and there are different seasons of your life where you can enjoy the stuff. So we're talking about, yeah, when you're 70, you can play with your dog and that kind of stuff. But when you're 70, you might never get to go skiing or snowboarding or wakeboarding that talks about and stuff. And so why not do that when you're 30, 40, and 50, and just work a little bit less? It's something that I've been thinking a lot about now. I'm very, I mean, and I get the sense you are too into financial education. We've had a couple of podcasts about that as well, you know, student loans and stuff. And I was big into when I first started, I was like, oh, yeah, fire. I'm all about the fire movement. I was like, yeah, 45, I got to get rid of my disability insurance. That's my goal and stuff. And I've been revaluating that whole thought process for the last month and a half now. And I'm excited to read this book. So, you know, maybe, maybe after I'm done, we can talk some more. But dude, you talked a little bit about your practice, kind of your approach. Thank you for sharing that. Tell us, you know, what's next for you? What are you excited about? I know you got the YouTube stuff going on. You're active on different social platforms. You know, what are things that get you excited? And what are you looking forward to? Yeah, I think I'm still the growing phase in my practice or as I feel. So, trying to make that most efficient as possible, in talks with some people around the community and partnering, you know, either, you know, loosely or directly, however that might work out, just always looking for an opportunity to help more patients, find people that are like minded and have a common goal. I have a goal that there's this Oklahoma surgical center, a surgical center of Oklahoma, which is like all cash-based, everything. So, you know exactly what you're paying. You can go pay the plans, all that stuff. And it tends to be a lot cheaper than the facility fees of hospitals and other surgery centers. So, trying to find a group of people in a central Ohio area that are motivated by that and getting some chronic pain lectures out to the public. So, that's where I'm at. I'm excited to see where AI goes. I don't know how it's going to fit in for us yet. I know it's going to be advantageous. I just don't know how quite yet for us. And yeah, really just trying to spend some more time with family. To your point, Oklahoma, it's one of the reasons I moved back to Ohio is to be close to my parents who are here. It's like, it's been talked about in different rounds. It's like, you know, you look at a scale of your life. It's like what? Okay, how many more summers do I actually have with my parents? So, it's real important for me to be here with them and we're enjoying so much time together. So, it's been a big blessing for that. Yeah. I love that. For sure. We'll definitely link the wait to why article. I think it's by Tim Irvin who talks about the how much time he has here. Yeah, parents and stuff. It's a great, great read. Nickel, where can our listeners find you? What are your socials? Yeah, I'm on Twitter, LinkedIn, Facebook, Nickelverma, MD. There's also a Nickelverma MD in Chicago Illinois. So, don't get confused. My YouTube channel is called things I didn't learn in med school. Not popular enough to come up just based on looks itself. And then I'm just confirming my updated. I try to uniform my name across all the platforms. And I think it's Dr. DRNV sports spine. I just don't check it over. Yeah, and I'll I can also find I'll put in the show notes so that you know, for listeners out there easy, easy click on it. And yeah, honestly, anyone reach out if you have questions, if you'll comments, if you have topics you want me to explore, I'm happy. I love doing this stuff. I love researching for these kind of things. So, yeah. Nickel, I want to put you on the spot here real quick before we ask your last question. If you could go back to being pre-med medical school residency, what are three things that you would tell yourself to learn that you get in in medical school? I think one would be, yeah, how would how to communicate with patients and how you can communicate with even hospital staff. I see how poorly even doctors, a little medical students do that and it breaks my heart. It should be nice to everyone at all the time, even if they're not nice to you. Is there is there a resource for that that you recommend people do like how do you recommend people do that? I don't know. I don't. I was honestly thinking about starting a course just for that and maybe we can put our heads together and record different ways to do that. That would be awesome. I think that would be a must-be-seen thing. I think it's worth your time to understand every step involved, getting that patient in the door and how does the patient get scheduled in the door, how do they get their medications and every step involved because it's not just, oh, doctor, I suspect it's done. There are 14, 15 layers that you're not even looking at. I think that's important for people to know. I'm not saying you need to memorize just like, oh, wow, that's why everyone's role has a spot. And to understand how insurance model works because right now it's not working and these fee schedules and all that stuff is pretty insane. Even with these no surprises, that didn't really stop people doing what they wanted to do anyway. So I think it's worth the time we'll go read and look into that as well. Perfect. Yeah, no. I think you have some videos already on some of those topics. So we'll definitely put your YouTube on there as well. Well, man, thank you so much for jumping on here for an awesome conversation. I'm excited to do more of these in the future and I agree with you. I mean, those are all must, you know, must know is essentially that's the only thing, but things for people to consider and learn more about. And like I said, I'm excited. I think the next generation of physician has more opportunity to do this. You know, even people tuning in, well, at least if they peaks their interest, then they might go Google and read about it and everything's accessible now. So that's what's cool. But my last question that's that they kind of, that I cannot give you a heads-up on in the beginning is it's very, very important for us to kind of think about all the time is, we talk about practicing a sick care system, right? Not a healthcare system. So the question becomes is how do we add the health about here and can we even? Yeah, I think it starts and ends with the education that we can provide our patients and friends family talk about what's right and talk about what we talk about family and clinic. It's never the one patient that comes back to you that's like, oh, this didn't work for me. It's the one that comes back to you and says, you changed my life. I'm going to trust you with everything. And that's that's what I had a really crummy day today. But I thought about like those patients just for a brief second and like this is why I do, this is why I put up with the crummy days because the back end makes it work. So I think that if you keep that mindset, we can go so much further collectively. Like that. Well, thanks, ma'am. Awesome. Thanks to you. Appreciate you guys. Have a good one. Hope to do it soon. Thank you so much for tuning into that episode. Before I ask you for two big favors, I do want to let you know that on our next episode, we will be starting to publish this podcast on Tuesdays. Previously, we were publishing every Monday, but this time, it will start on Tuesdays. So don't be surprised when you wake up in the morning on that Monday and you don't see us, we'll be there the next day. Now, of course, back to the favors. The first one, if you enjoy this podcast or you think you know any pre-medical or medical student that would benefit from this, please send it their way. I believe it is our duty to really prepare the next generation of positions so that they don't get caught by surprise when they're in our positions and they're about to become attendings and have to start understanding the business of medicine and really looking back at why they didn't learn the things that they should have in medical school. Now, the second favor on your preferred platform, please take the time to rate and review this podcast. It really helps us to broadcast all of our episodes to listeners just like yourself. Special thanks to our team, Iman Bershiri, Herida Yapuri, and Ethan Zhu. It is always the medical disclaimer. Everything in this podcast is for educational purposes only. It does not constitute the practice of medicine and we are not providing medical advice. No physician-patient relationship is formed and anything discussed in this podcast does not represent the views of our employers. We recommend that you seek the guidance of your personal position regarding any specific health-related issues and we'll see you next Tuesday.