Lessons Learned: Giselle Aerni, MD and Gerard Malanga, 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 health care. Before we get into this week's show, here's a quick word from our sponsor for this episode, Panninsia Financial. As a company founded by doctors, they now have frustrating it can be to work with financial companies, which is why they've created a better way. Have you thought about refinancing your student loans? Well, unlike other companies, the rates you get at Panninsia Financial for student loan refinance doesn't go up because you're credit score, how much did you have or your income level? Low loan maximums or co-center requirement, their student loan refinance is based on the respect physicians deserve and not a credit score or debt level. Join the growing number of physicians nationwide that expected more from their bank and switched to Panninsia Financial. You can visit PanninsiaFinancial.com today for a better way to refinance your student loans. Panninsia Financial is a division of Primus member FDIC. Alright guys, we have been privileged to have some amazing guests over the last couple of weeks visit our show Dr. Giselle Arnie and Dr. Gerard Malanga. With Dr. Arnie, we had a powerful conversation talking about gender disparities in sports and in medicine. We followed that up with a more scientific conversation and talking about the specific differences and how women can train considering their hormonal differences, exercise and pregnancy. We talked about some specific medical and biomechanical injuries that female experience particularly related to sports medicine and musculoskeletal medicine and we also talked about social disparities in medicine and how they influence how we practice. With Dr. Malanga, we visited the field of orthobiologics and we talked about the differences between PRP and cellular treatments and prolethoropy and talked about why words matter and how we have to be precise with what we're talking about. We have to practice evidence in based medicine but most importantly, how we can employ this into our practice. So today, Darshan and I are going to revisit some of those things, talk about our perspective and the insight that we gained and perhaps some things we'll share with you that you might not have thought about. So without further delay, please enjoy this lessons learned episode. Alright, hello everyone, welcome back to another Lessons Learned. We haven't done one of these in a while so this is a fun thing Ultimation I like to do and we love to share our perspective and our lives and of course with the new format that we have given the three episodes of the guests and now this one episode of the Lessons Learned, we're definitely looking forward to it and in this one, we will be recapping and going over the things that we learned with Dr. Giselle Ernie and Dr. Draud and Malanga. Ultimation, how are you man? Doing wonderful buddy, how are you? I'm fine, I'm doing great. You know, it's a world-day weekend and last couple of weeks, it was in the humidity, it was hot, like 85 degrees and then today it's been the fifties. Fifties and rain, yeah, yeah, although I have been somewhat grateful for the rain for the last couple of days, I got a car that's like this deep midnight blue and with the pollen it was just, you know, black cars, I don't know what color your car is, like it really shows nothing. God, freaking A man, I gotta get this car cleaned and with the rain, I was pretty happy with that, so yeah, you know, that's a win, nice, nice, okay man, I got a silver green Honda CRV, so sometimes I get the same problem, yeah, I heard that. So dude, the last two episodes, Dr. Ernie, Dr. Malanga, two powerhouses, I mean, some drastically different topics that we discussed, but yeah, super important, right? Right, right, right, popular stuff that's going on, you know, on the minds of a lot of different people, a lot of questions that people had, particularly on this quote unquote regenerative medicine topic, that's hot right now. And so excited to get into that. So where do you want to start, you want to start with Dr. Malanga, so do you want to start with Dr. Ernie? Let's do Dr. Ernie. And you know what's interesting, both sports medicine physicians, two completely different topics. Yeah. Which is a fun thing about, yeah, let's do Dr., let's do Dr. Ernie, you know, so we kind of talked about, when empowerment, right, was the, was the central theme of that part one, and the gender disparities that we're seeing, not only in the hospital, not only in sports, not only in politics, but just almost in everything around the world. What are, what are some of the things that stuck out to you? You know, over the past year and a half or so, this topic of disparities has been at the forefront of everybody's mind, right? It's not new, but we're paying a lot more attention to it today with everything that's happened over the past year. And so something that you and I have a difficult time appreciating is kind of the subtle day to day difficulties and, you know, the disparities that they experience are our women colleagues. I mean, I've told you some stories, I shared some stories on the episode Dr. Ernie, but also some stories offline that, you know, my wife tells me on a daily basis something that it's hard for me to appreciate. And even though I vicariously kind of am hurt through her, it's not something, it's still hard unless you're the actual person going through it, right? And there's just the things that she had talked about, so many subtle things, like not getting the same, you know, shape coat, right, not getting the appropriate clothing or not getting the funding at the division one level at the collegiate level. We talked about the NCAA debacle quite a bit. It's been so pervasive for such a long time and it's frustrating because change does take a long time, but this one has been overdue, right? And the biggest part, not, this isn't the biggest because there's so many components to it, but the whole concept of, hey, like, we, you and I have to continue to be advocates for them, right? Dr. Ernie is, of course, being an advocate. This is what she's doing. Awesome. And all her, not all, but most of her courses have launched her already. So she's got a lot of people signing up for that and she's going to, you know, empower them and teach them and mentor the next generation of physicians to now go through the same bullshit that she went through it. But that's just not enough, man, like you and I have to continue doing that. And luckily, she gave us some, some great tips on how we can be advocates, how we can be sponsors for our female colleagues, do you remember what those were? So I mean, one of them for me personally, actually, I'll talk about is like at Penn State here, we have a women in medicine group, right? How many men are actually part of that? How many men are actually going to those meetings? How many men are actually trying to contribute with information and share the links? You know, it's a women's group and I get it because like you said, it's tough for men to appreciate what women go through and it's easier to make a bond with someone who goes through the struggles that you do. But that doesn't mean that we can't contribute in our way, we can't go and listen, right? So sticking up at least for me in the hospital in terms of what a patient makes a comment to a nurse, you know, about their, about being attractive, right, attracted to them. Or I've heard this from my co-interns themselves when it went, when a code happens or rapid, they feel like they have to be more authoritative just to take control of the room, right? Those kinds of things, those assisting, being aware of the noise in the room and people's emotions and kind of setting that record straight, so to speak. I think it's something in medicine at least that I'm more aware of now. You know, my, my co-intern today actually was telling me that she feels like she has to be overly nice through texting nurses and texting social work just to get things done. And I've been a people pleaser myself my whole life and she's like, yeah, but it's different for women in that regard because she feels like they do it to get things done. And so it's, it's definitely interesting and like you said, I mean, it's, it's long overdue. And I'm not here to say this change is going to happen overnight, right? Because I think we're all, we all grow up with schemas in our head. And you know, there's that, there's this one reddle, riddle that people might have heard and I'll share it here and so it's, you know, a, a boy and a father are in a car driving on a windy road during a rainstorm and the car crashes and the father dies. The boy survives and he's transported via the ambulance to the operating room. The surgeon walks in and says, oh, my God, I can't operate. This is my son, right? And for the listeners out there, you guys can pause, think about it, what your answer is. And I'll share the answer here in a little bit. But the surgeon's his mother, right? It's a, it's a schema that we have that a surgeon's always a male, right? So it's just, it's, it's one of these gender biases that we have kind of growing up, right? And when we think of a surgeon even, we think of them with the mask, right? And this is getting off topic, but even the data for like mask, you don't need to have a mask and go, right? Is what the data is, I've completely, I've have shown since like 70s, 80s. So we're, we're stuck with schemas and we kind of keep those schemas in our head as we go through different avenues of life. Yeah, so one of my friends, we were having this discussion actually before, we even, Dr. Arnie came on and kind of got some thoughts riled up in my own brain. One of my friends asked me like, you know, how does, and what would be your advice to, to help do that, to kind of break that mold, like you mentioned your coin turn, to communicate effectively and, and get people to kind of cheat you with a quote unquote same respect. And my immediate answer was to, to project confidence, right? But here's the issue that Dr. Arnie talked about, right, is that if a woman does that, and she's viewed in a different light, right, whereas male is like, okay, he's bold, right? And I mean, I think she gave her own personal experience with a pharmacist I think it was where he was considered to be a great leader and, you know, taking charge and all those things, whereas if she had done that or if a woman does something like that, then it's like, okay, you're not, you're not a team player, right? You're stepping out. And again, so much easier for me to have given that a device at the time, but, but I've never been in those shoes where somebody's like, wow, you know, what's wrong with you? Why are you so selfish or like, you know, why are you bitchy like that, right? And I don't know what, there is, there is some good to that though, let me give you, you know, a couple years ago, not a couple years ago, I guess a couple years ago, when I was in medical school, I remember working with a surgeon and this guy, I was a 30 medical student and, you know, old school mentality, 20 something years, immigrant, European, not that it hasn't been done with it, but just old school. And he was giving me an example on, you know, this, this one student, like basically just saying, you know, it's our students, like our mentality is different and he was kind of venting and complaining about the student before me, how she kind of, you know, made his life difficult because I don't know exactly if we get the details, but the essence was that he had made some comments about her physical appearance to her about what she had worn and what he was looking for was acknowledgement that she was in the wrong, right? And he was like, yeah, isn't that so ridiculous? And at the time, you know, I just gave one of those nervous chuckles and I laughed, but I didn't pause and say, no, bro, like that is beyond inappropriate, you know, and I think about that is, that would have been a perfect opportunity, right? But this goes back to what she talked about, you know, you know, when, when you're a, a trainee, right, and you're a resident, you're a fellow, you're, you're concerned about the repercussions, you know, and other example is this actually happened during my residency time where one of the physicians, the leadership position had talked about, I think one or two people in the program, not my current program, actually one or two people had a program had, had gotten pregnant and this person, this attending had made a comment about how, you know, these girls like, they shouldn't be getting pregnant because that puts a burden on the residency program, like, you know, and I'm just finding coverage, I mean, it is challenging, absolutely, right? I've heard that multiple times, yeah. And in my mind, I was like, I can't say that, like, you can't say anything, like, what? I was like, no, that's not okay. But again, I didn't say anything. And, you know, I wish I had, but again, you don't beat yourself up for it, right? You look forward and you see where you can make, make those changes and this again, goes back to the point that now that I'm a little further removed, I'm closer, one of your closer to being an attending, one of your closer to being, it's a little bit easier to kind of advocate for those people, right, for your colleagues, especially the ones who are medical students, who are residents who are on the bottom of that totem pole, who are terrified to say stuff and they're the ones who are being taken advantage of the most. Mm-hmm. Yeah. Yeah, absolutely, absolutely, man. And I think the other idea that Dr. Arne had was, you know, let's take it back to when we were talking about that whole NCAA, NCAA, debacle, and, you know, I didn't really hear about that or even the foul call that happened in the Baylor Yukon game, which is a huge deal until LeBron James posted it. So it took a big celebrity athlete to post it in order for, you know, whatever ESPN Sports Center and Instagram just to highlight that. And, you know, Dr. Arne said, well, I heard about it right away and you know, I said, oh, how? And she said, well, I'm following people that follow that, right? And you're not. And I was like, oh, that's very true, right? I'm following the mainstream. And one of the things that we can do is follow people who, quote unquote, don't necessarily, I don't want to say align with our ideas, but maybe have a different perspective than we do, right? And it doesn't even have to be about gender disparities. Just having a different perspective and all realms of life help you to figure out kind of your perspective, right? On the right side of the left side, a black and white, the gray area. And I think that's how we learn and educate ourselves and become more comfortable with learning a topic, right? And learning especially a topic like this where we see it so often, but we don't know how to approach it. And so the more we see kind of the empowerment side of things, the more examples we see, the more mentors we can collect that are doing these types of things, it gives us more power to kind of be that next person to kind of pass the torch down. Yeah, you can become intellectually well-rounded, right? So you start following people who don't necessarily look like you, different gender, different race, different religion, get their perspective, right? It's again, yeah, like you just, you already said it is so easy to kind of just agree and not and agree and not. And we've talked about this offline and sometimes I'm working on this actively in my life where I'm trying to have more conversations and look at the other person's perspective, somebody who I don't agree with because that's where the learning happens. And if you and I, and there's not everything that you and I kind of see, I do, I own and we have some different perspectives. So most things do overlap, but if you always just hang out with the same inner circle and everything that you guys agree that nobody's going to challenge you, you're not going to grow. So that's another reason too. Yeah, since then, I've actually made it a point to try to go follow people who, in the past, I would have been, I've got to cut that out, you know, I've got to cut it out because, you know, sometimes you get so much unnecessary stuff, so we've talked about social media how it can, it's already a problem. I'm on the fence about that, I just haven't figured out which way to go, but if I'm going to be on there, I do think that's really, really important. So I think that the ultimate takeaway in terms of immediately, you know, what I would encourage my male colleagues to do is, you know, in terms of being a sponsor for females is something that, that I think that I've done a good job with in my role as being a chief resident here in a leadership position is to kind of, some example she gave, were that, you know, when, if a woman is in a meeting and she says an idea, then a guy will repeat it immediately after you can just pause, you can interject because culturally, that's appropriate, quote unquote, and say, oh, well, I'm so glad that you agree with Dr. Arnie's idea, right? Or, hey, actually, they were wrapping up a thought, but you know, sometimes even, I've worked, I've worked with so many brilliant women that because of, they've had these experiences throughout their life, they don't speak up even in large meetings, even though I know that they have amazing ideas because we've talked about it in a one-on-one positions, but they don't speak up or they'll apologize if the other person misinterpreted. And it's not like they gave offense, it's actually my shanks, and I said that you can't I forgive offense, you can only take offense, right? And so they have to, oh, I'm sorry, that's not the way that I communicated, well, no, like, you're good, I understood the way you said it, and so highlighting saying, hey, like this person has a great idea and try to do the best possible. So yeah, those are some things that I'm going to continue to work on and anything else that I miss that you got. Yeah, man, no, just to the listeners out there, I mean, you can hear us say it, but it's ways, how more powerful listening to this whole speech and this whole topic from Dr. Arnie, episode 12 was super powerful. So I just recommend anyone listening to this who hasn't heard episode 12, go back and listen to it, you will not regret it. So yeah, definitely goes to awesome. And actually, you know, another thing that was really awesome is, again, going back to the idea, hey, there are some actionable tips that we just talked about that we can do immediately, but also long term scale, right? Being optimistic, we're looking at the 10 year, 15 year plan in the culture of medicine. And just even outside of that, you know, she gave that terrifying anecdote that when she was doing a a hip injection on a patient and how they made this inappropriate comment, and she called them out, right, snip in the butt right there. And she said that, you know, 10 years ago or 15 years ago, she would have done that because she did this when she was attending. And only until she got further in her career, that she felt comfortable enough to be able to do, you know, make a stand like that. And I remember asking her, you know, how did you get there or like, what recommendations would you have for current trainees? I think that, unfortunately, the answer was, and it wasn't as satisfying because you do have to buckle up. This is going to take a long time, which is why we're going to keep advocating for it, but what was beautiful about why she could dial it in and she could push forward now is because she said that she had her finances dialed in. And she was like, you know what, I don't need this shit anymore. I can step away. You know, a person of finance is a big thing of mine and I keep advocating for this as well because, again, student loans are on the rise, right? And we don't make good financial decisions, so we've got to get coming in the near future to talk about, you know, making sure that you dial that in. So when this kind of stuff happens, it doesn't necessarily have to be disparities for the opposite sex, but, you know, other stuff, if you don't feel fulfilled by your career, whether it's professional satisfaction, if you don't see eye to eye with your employer, right? There's lots of things in medicine that happen that, you know, even outside of this topic that if you don't agree and you've got your finances squared away and you're not hamstrung and you don't have to pay, you know, student loans and you don't need it. So all the more you said not to make stupid financial decisions at a young age in medical school and undergrad and more to come on that soon. Yeah, yeah, absolutely. Cool. Well, let's move on to episode 13, which is again with Dr. Arne. So this is the part two that we had with her, but transitioned a little bit more towards women, female health, an exercise. So kick it off, man, what would you take away from that? Yeah. So here was the, I mean, the first one was super powerful, but this was the nerdy part of us coming out, right? We're learning about different female specific training, female health. And you know, one of the first topics that we talk about is ACL injuries and how it's an endemic, right? We have early sports specialization. That's a big thing, but female, she said, are anywhere from two to eight times more likely to care their ACL, even though I think on a global scale, men share their ACL more, but that's just because they participate in more sports than women do. And so she mentioned, she did a beautiful job mentioning for all the reasons that might happen, some of them were because of bio anatomical reasons, other were because of, you know, ligamental acety and hormonal differences, but also not in proper training. And so we're working all those different types of things. But the newer concept, the reds, which is relative energy deficiency in sport, right? Historically known as the female athlete triad was something that she did a great job explaining as well. And what was interesting about that is I did not know this that this was the first area where women were specifically targeted for research. Makes sense. But I thought that that was pretty interesting that, you know, again, it goes back to the kind of women are not tiny men, as she mentioned. So we can't just extrapolate the data that we get from, you know, taking from 18 to 22-year-old collegiate males and say, oh, this is how women sports are going to participate. And these are the issues we're going to see. And this is how we gear their training. So got to do more research for your target population and then get information about that, right? Because their physiology, because of the hormonal differences, is so drastically different. And we understand very little about that. Yeah, absolutely. I mean, I think that's one of the more hotter topics of recent is, you know, people who look at the academic research saying, how does this data actually even make sense for my own patients, right, or a certain population? And I think we're starting to see, like, hey, we need more research on women. We need more research on actual healthy people, not just a set of people who have disease, you know, 40 to 75 male, white, right? Which is like the most generic as we go in research. So yeah, I mean, that was super interesting. And I think when she mentioned about training and improper training, you know, I know from high school, from myself, you know, I've played about two, three sports. The guys would always be in the gym doing weight training. It was emphasized, whereas the women would be out practicing, right, just their support. But there was no supplemental weightlifting or exercises, you know, any kind of training that I noticed. So it was very interesting kind of to just see that. And then she goes on to kind of give some stats, which, you know, I can't recall at the top of my head about how often females will forego a sport if they don't play it by a certain age, right? And so if you don't play it by 10 or 15 or by, you know, the time you turn into an adult, you're less likely to work out for the rest of your life, which I found super interesting. Yeah. Man, I wish I'd remember something, but I know that it was, it was, it was big. That's why I was. Yeah, it was super, super high. So definitely worth getting them involved in an earlier age, and which is why it's funny because people always ask me, I mean, football's my favorite sport and people always ask, always, are you going to get, you know, get your child or your son or whoever or even your daughter nowadays to play football? And just because, you know, physician sports, medicine, concussions, that's hot as you already know. And my answer was, no, I mean, I would love for them to play some sport and whatever they're going to be happy with, but yeah, that's going to be a big part. I mean, because again, we can dive into all things that teaches you, doing some type of activity in the discipline and, you know, putting the work in, but, but, but getting them involved in an earlier age, and it's all about modeling, right? If they see you be active, they're going to be active as well for that reason. And then just going back to the hormonal and physiological differences between men and women, right? We talked about, she cited a couple of studies. One with McNulty was a great review. They came out looking at exercise performance and the effects of menstruation and in difference a different phases of the menstrual cycle. There was actually, you know, we've talked about nutrition a lot. There was actually another paper published this year in the International Society of Sports Nutrition. You know, it was a narrative review looking at the, it was basically given sports or nutrition tips for active women, which I thought was really good. I recently came, I think, I don't know if I'd send it to you, but if not, I will. I mean, matter of fact, it's an open access to review. So we'll put it in the show notes here, but there were four key points from that as well. Again, highlighting the differences for men and versus women and talking about how, you know, key point number one, that the menstrual cycle obviously correlates with changes in macronutrient metabolism, right? And for those who don't know, macronutrients are basically protein scarves and fats, right? And on a basic level, like for instance, depending on what phase you're in, like in the follicular phase versus a luteal phase and the follicular phase, your fat oxidation is going to be decreased, your protein oxidation is going to be decreased, your carbohydrate and oxidation is going to be increased and your glycogen store is going to be decreased, right? So that's important to understand because, you know, depending on what phase of the menstrual cycle, you might want to, again, this, this is all relative. It depends on how high level one is competing at, but for collegiate at the professional athletes, these are important things to understand. And I'm confident, actually, that dieticians support nutritionists understand it. Actually, I got, I learned about this from Angie Ash and a huge fan of her. I think she has elite nutrition on Instagram and I don't know if she has Twitter or not, but I highly recommend follow her and she, she's a great nutritionist that she talked about this. So the second point from that is, again, you know, different specific macronutrient needs can depend on, again, phases of the menstrual cycle. So they also give some recommendations on, you know, how many grams per kilogram per day, we know how often women might want to feed, again, this can be individualized to every single person, but you know, they talk about different supplementation that you might want to take as well. So it was a really, really good review. We'll post in that. Yeah, for sure. So switching gears, man, yeah, obviously we've talked a lot about training. Now this is a interesting topic about training and pregnancy, right? Yeah. Yeah. What, I'm curious, what, what is your experience been? Have you seen any women in clinic who are pregnant in your life, whether maybe in your family or inner circle, people who have gotten pregnant? How have people treated those individuals who have gotten pregnant with caution, I would say, you know, more so watch your step, watch where you're moving, watch where you're going, everything, you know, you essentially treat them like a robot when they walk, right? Like there's that lack of flexibility, that lack of mobility, you're not letting that person move and be kind of who they are in a sense, right? I think you almost treat that pregnant woman, I don't want to say it's an outcast because you're very attentive to everything they do, but you know, as, as, as brown culture, it's very like, okay, let's protect this woman, right? And in a way, right, put a bubble and, you know, we talked about how important it is to exercise pre pregnancy during pregnancy and how that helps post pregnancy. And I feel like so often we're told these old wives tales like, hey, when you're pregnant, just like, make sure you eat a lot so the baby gets food and I've never heard anything about exercise, never, not once. Yeah, you, they're like this, it's a delicate, I mean, it is, it is a sensitive period, right? I mean, you're growing another human inside you, I get that. Again, the body is a tremendously complex and phenomenal thing that they're protective mechanisms, right? The body is adapting and accommodating this, this life, life form inside, but the person can continue on, I mean, there's, there are, there's ample amounts of evidence supporting that it is safe, but again, this goes back to traditions take time, man, you know, especially natural traditions, it takes time to, to kind of break them, to outgrow them. And it's incredibly safe to do it. Dr. Arnie mentioned all the reasons it's beneficial, actually healthy for the mom, healthy for the unborn child, right, and just to recap some of those, we talked about decreased pain throughout afterwards, right, better tolerance of GI distress, okay, and not many people want to talk about it, but you know what, nausea, constipation, bloating, those are very real things you can imagine. You can imagine that if there is something in that region, like it's going to be hard to pass tools, hey, we got somebody coming in who's going to talk about how important it is to have bowel movements, right, because we don't want to talk about that, but when it comes to your gut health, you know, you have ligamentus laxity because you need to, your body needs, you need to be able to push this thing out. And so they're getting softer. We know that strength training is phenomenal for providing stability. Every, I would say, again, I don't want to say 100%, but it pretty darn close to 100% of women who experience back pain in during pregnancy. Oh, yeah, great. Absolutely. How do you counteract that? First, stability around the SI joints, ligamentus stuff, right, again, it's all about like you and I have learned tons of treatments when it comes to manual therapy about making them more comfortable and treating a math of the fact. But if you can do it through exercise, and that's going to stick longer afterwards, and I haven't even touched on the quote unquote medical component of it, right, the better control of blood pressure and plasma volume and reduced risk of diabetes, not only for yourself, but also for the child, right, glucose, metabolism being regulated is a super important thing, right? And then that is the chicken erecting with obesity that we've talked about a billion, a billion times in the show. So I mean, oh, sleep, better quality sleep. Yes, sleep is a real thing. And some of you during pregnancies are a very real thing, right? I mean, so many women complain about this is, especially as they get closer to the second trimester is when the morning sickness stops stopping and your belly is getting bigger, it's getting harder to sleep at times. And obviously there's so a woman. Yeah, I mean, every single woman has a different experience with it, but I mean, these are all well documented. And so it is safe to do. And you know what, it's so safe that the, the, there's a whole task force for exercise in pregnancy. Actually, there's exercise in medicine.org is a great, I think that's what it is, is it exercise in medicine.com? It is exercise in medicine.org, yeah, yeah, absolutely. Extra in medicine.org and they have resources for pregnancy in there and, and they, I mean, they have it for all kinds of special, the college, quote unquote, special population, sort of like for people with Alzheimer's and brain health and people with diabetes. And, and we'll put it in the, in the show notes here for people to see, but both cardiovascular exercise and strength training is safe to do. In fact, recommended, but this is not medical advice though, so, please, please, please, right? For our medical students, pre men's, right? What are you guys gonna be learning about, Burke I was a triad, right? The clots that you can form, the DVTs and then the mental health issues that we see with pregnancy, right, depression and, I've talked to so many pregnant women, they're like almost every single pregnant woman is depressed, like, they won't talk about it, they won't say anything, they won't even know that's what it is, but at like, post pregnancy, they'll look back and be like, wow, like I was depressed, like, I was sad. that took a toll. And we know, hey, exercise is one of the best antidotes for that, right? In terms of getting the serotonin, the dopamine and all that. So yeah, a lot, a lot there that we're definitely advocating for. Yeah. And just kind of, I know I'm kind of being a dead horse here, but you know how I feel about exercise. But honestly, even the postpartum period, right? Yeah. You have the carry over into postpartum period. And again, you're more likely to do it, get rid of the weight faster. You know, if you, if you exercise in pregnancy, I'm more likely to carry that on because it becomes a habit. And that postpartum period's going to be much easier too. Absolutely. Absolutely. Cool. One of the things I wanted to bring up was, you know, we talked from the barrier sex or size. And I think this is very, very important for the listeners who are definitely trainees. But also patients, right? Because I'm always a big, I'm always telling patients to advocate for themselves. And too often I see patients not speaking up for themselves. But barriers to exercise, right? Like for us, we're always looking to teach our patients how to exercise the frequency of exercise. But being a physician, you're most likely going to be in a privileged position, right? Where it's very easier, or it's very easy to exercise either on a daily basis or to get equipment or whatever, right? We don't have many barriers of resistance as Dr. Arnie states. But the person across from us may, right? You know, especially women, and you're in Baltimore, so you definitely know this, right? Inner city, not being able to maybe get out of the house for a walk, even the parks. You know, I mean, I'm from Philly. I've seen parks filled with needles all around. Yeah, let's, let's, let's go into that for a little bit. Yeah, that one was humbling because, as I mentioned, I first heard about that her talk about it with Dr. Leisure Carter on her own show. And then it happened to me. It actually happened to me where he was doing, doing a procedure in patient patients, like, yeah, it wasn't safe, but now I can find the exercise. And I was just like, man, I can't believe I never talked about that before. And it really just comes about to, you know, meeting the patient where they are, right? This goes back to what we were talking about the other day in terms of context. It's key. And you can't just say, oh, hey, you know, you got to exercise. How, where, when, why, all these things matter, right? And if you really care, if you really want the patient to do well, not just so you can document and say patients non-compliant if they're not exercising or, you know, not taking their medication or whatever it is, you got to meet with the patient where they are. So that is so important. And the social disparities component is something that, that, you know, we don't think about. I recently read of some variation. I'm going to mess, I don't, I'm paraphrasing because I don't remember the quote is, you talk about privilege, you know, one could argue, privilege isn't just having, you know, opportunity or the luxury or something, but also the lack of adversity in life. Adam Grant, work life. Is that where I read it? Yeah, I heard it on there. Yep. Yeah. Yeah, man, that's something about it. And I thought about that for a second and I was like, wow, yeah, because I mean, traditionally, that's what we think privilege is like, oh, you've got nice things in love, but also if you don't have barriers in life, you're also privileged in some sense, right? You've got food on the table, which, which just, so it really, really important to think about. Yeah, I agree. Like if you were a physician, you're going to be privileged in some sort. Yeah, for sure. Cool. Cool. I just want to mention real quick the books that, um, that's already mentioned here because I bred two of them myself and the third one I need to read at some point, but the first one she mentioned was mindset by Carol Duac, right? So for those of you all all in, like the personal development self growth, the images trying to become a better version of yourself and cultivate that mindset where you look at it. I guess it kind of is like, ride holiday and it's with the stilisism, right? It's taken every hardship and looking at it from a positive perspective. Um, so that's kind of the first book. Yeah, the second book is Grit by Angela Duckworth, which I absolutely love actually references my TED Talk because it was that powerful in terms of figuring out your passion, purpose in life, right? And a lot of that takes from going through different experiences. And this third one, which I haven't read, is Untamed, like Glendon Doyle. And she actually has a new podcast out, Glendon Doyle does, but I've heard very great things from a lot of people about that book. I actually listened to, I've got, I think I told you about Blinkist, right? Or it's kind of like bites as versions by 20 minutes, highlights of Untamed. Really good. Actually, how do you recommend it? Okay. So yeah, I did enjoy that too. I might have to pick up the book, but man, let's see it longer and longer. Kind of to put things on a polish here as I start my board prepping, but yeah. All right, man, let's shift gears, right? Because we've been going a little longer than we wanted to. So Dr. Dr. Jerry Belanga visited us recently and we talked about orthopiologics or quote unquote regenerative medicine. So let's start there, man. Let's start there. Let's start let's start with the regenerative medicine, right? One of the things that he alluded to is words matter, right? You have to precise with the words. Yeah. And that actually got me thinking a lot about different things, but I'll give you the first word on that. Yeah. So let's talk about that word regenerative, right? And why it might be a misnomer. So, you know, when we do things like PRP, prolotherapy, and we're doing these kind of interventional procedures and we use the word regenerative, what we're telling the patient, you know, according to Dr. Melanga is your tissues can regenerate, right? And when we think of regeneration, we kind of, you know, patients get into this sci-fi kind of thinking that, oh, everything will go back to normal or, you know, my tissues will grow, my bone will grow, my cells will grow. And that's not necessarily always the case, right? You know, when we we'd like to think that, right? I guess that's kind of how the word came came along is that yes, we might be able to see some healing, but doesn't necessarily mean it's regenerating, right? So we got to use better words and that's why, you know, ortho biologics, it's kind of a better word to use to describe the field rather than regenerative medicine or stem cells. Yeah, I think that they're still refining that term, right? And it's still again, relatively new, although PRP has been around for a long time, but cellular treatments, prolotherapy has been around for a long time, two more than 50 years, and it's been working well. But because ortho biologics, it just kind of suggests that it's only for musculoskeletal issues. And there are other roles of it. I mean, you know, some people are doing it for Botox type procedures. You know, some people are doing it for all kinds of things. And it says that it works for everything. And you kind of can't be there either that he talked about. You kind of have to find a middle ground and look at where the evidence suggests, you know, the whole words matter, mattering. That's not a word. That is an interesting concept, though. I don't think that the term regenerative medicine is as bad as some people might think that I believe. I don't think so. I just think that we have to be very clear when we say that what we're doing. And I think that he did a good job explaining that, you know, if people say, oh, this is going to regenerate tissue and it's going to regenerate cartilage or muscle or, you know, and that in conjunction with stem cells, that gives that perception that that's what it's going to do. So we have to do a better job explaining to people, you know, that this is not what it's doing. And he did a great job talking about all the how our body has an intrinsic ability to regenerative many, right? Or liver does that, organs does that. Most people know about that. But, you know, this concept of words and being precise with them, you know, Dr. Joshua Woolrich, who wrote this, but food isn't medicine recently. I've been actually thinking about that because there can be some harm. He used to have a podcast called cut through nutrition, I think. Yeah. And how food is medicine can be harmful. And I've thought about that quite a bit. And I've gone back and forth on how it can be harmful. But I want to get your thoughts on what you think about that. Like, why here we are talking about that both of you and I agree that we agree that regenerative medicine might not be a great thing because it gives the misperception of like what's going on. But then again, both of us have said, hey, food is medicine. Right. I think we want from that too, right? Right. So I get, it comes back to that point, you just said context, right? Context over content. That's like the theme of our lives now. George Mumford, what a great interview. But yeah, I mean, you know, I did, I wrote a Twitter post on that actually saying like food is medicine. And why that is is that, you know, it has epigenetic power, right? We talk of nutrient genomics. We talk about the microbiome. We talk about how food has this power to regulate your entire body systems, you know, from the autoimmune system to the nervous system to the endocrine system. And from that context, food can act like a drug in a sense, right? Like that's what NSAIDs can do. Or that's what methodorexate can do, right? We know you can heavy hitters or, you know, more of these benign drugs. They're affecting different biochemical processes. And that that's where I was coming from in the sense that food is medicine, right? But then again, you can always take it down this other way, this other pathway where it can do harm. Yeah. Yeah. And so I thought about that. I was like, well, maybe I should write food has medicinal properties. But it doesn't, it's just again, this goes back to, you know, my issue with this. You write these three words on Twitter or you posted on your story. And and then somebody just reads and like, oh, you know, he thinks that again, probably not many people respect me. But if they do, they might be like, oh, no, ultimately says that food is medicine. And therefore I should stop taking my, stop taking my anti-quagulation. And I'll just, you know, vitamin K from and I'll just have more spinach. And that's going to help me from preventing that DVT. You know, no, that's not, no, that's not what we're saying. So it is really difficult. And I can see the harm that it does. But man, yeah, I don't know. I mean, yeah, it's, it's the context over content, man. And what we're talking about for those who don't know is George Mumford, he came on Tim Ferris' podcast, I think is episode 509, maybe amazing, amazing. And this is a, this is an individual who's worked with the elite of the elite athletes to cream the crop. We're talking Michael Jordan, Kobe Bryant, Shaq, those types of individuals and about their mindset and getting them to be more mindful in their experience and talked about that. So I highly recommend that as well to give you some perspective on these things. Yeah. Let's see, let's see what's next. So I mean, this whole Malanga episode is awesome for me because I like as you are, as me, I can't even talk now. You're interested in doing PRP or orthobiology that I should say as a whole as well as I am. So for me to kind of just get my feet wet and learn about this was super interesting, right? And the best thing about Dr. Malanga is his perspective and philosophy, I think, right? Because he loves to break it down to the nitty gritty so that it's very clear and understanding. And so he's very holistic when he comes when his patients walk through the door and you've actually been able to shadow him. So tell us how he isn't practice. It's very much what we heard. Man, it's good. He is an individual who is interested in learning all the time, right? I mean, even when I was a student, a third year medical student, I had the fortune of working with him multiple times as a third year student, fourth year student as a resident. And even as a third year student, he was respectful in the sense that he wanted to learn about, you know, my background. What I had to offer, you know, he found out that I had a strength conditioning background, performance coaching background. And he was always trying to learn more about that. I know we talked about a rehab and learning how to do a proper squat. And he knew I was an osteopath. So osteopathic medicine, how that might have a role in different type of positions. Physician, excuse me, patience. I can't talk either. And that's what I love, man. I mean, we talk about the practice of medicine, right? For our PM and our colleagues that we know that Dr. Dr. Malanga is a legend in the field, right? Because he's a musculoskeletal expert. He is phenomenal when it comes to sports medicine. But he is always, he has always had the learner, learner mindset, right? Learners mind. And that's what it is. That's what's called the practice of medicine. Because it never, you never stopped. You're always learning. You're always trying to get better. And that's what I enjoy. He lets the evidence drive a lot of his decisions, which is what I think it should be, right? When we talk about evidence-based medicine, and what it truly means in the sense of, you know, how you've got the vent diagram, right? And that's always evolving too. And you know, something that he mentioned about, you know, you and I've talked offline a lot about ego. And how, you know, sometimes us as physicians, myself included, 100% myself included, have a problem with ego. And what we don't want to say, you know what? I don't know. I don't know the answer to your question. Like I am, again, that's another thing that I'm trying to make, because historically, what I would say, I'm not sure. Or, and you know, sometimes kind of speculate and answer, or I try to be very clear. I don't know for sure, but I am speculating here. This is what I think might be having, or this is my understanding. And that's why I'm extrapolating this thing to be very clear that I don't know for sure what's going on. And then, you know, my thing with orthobiologics is, again, because I've had the, the fortunate working with him, I was exposed to this field that very early on in my medical career. And so I've been involved at looking at the literature as it's come out. And I mean, it comes out so fast now that it's hard to keep up with it. But so then working with other attendings who perhaps aren't as up-to-date on literature, we'll say, oh, no, there's no evidence for that. Oh, we got to be very careful not to work with clinical snake oil salesman, right? Just like, no, that's not true. You know, you got to do your due diligence because I always go back to again, you know, we, the burden of proof is on us as physicians when our patients are suffering. And we need to provide the best possible cure if we are trying to alleviate that suffering. And if there's something out there that might help, then you got to do your due diligence to see if you can help the patient or not. And if you know that something out there exists and you haven't done your due diligence, then you say, you know what? I know somebody out there who does a lot of this, maybe go talk to that person. If you don't have the time because that's a very real thing, man, like I'm not naive enough here to say that, oh, you know what, when I'm going to leave and I'm going to practice full time, I'm going to do all the things. No, you know, maybe I don't have time to keep up with the literature or, you know, if women come, if a woman comes in and they're dealing with something with pregnancy, I'm not the best person to train you. I don't know about that. However, I know X, Y and C. And this is why we talk about the whole developing your network is arguably the most important thing, right? Absolutely. Yeah, I mean, his attention to detail, his goal standard is evident, you know, through his podcast, Malanga Talks. And he's even written a book on like the physical exam, right? And I think we're so trained in medicine now through our intern year to kind of just let go of that art of the physical medicine, right? And I think that oftentimes carries over, right? Because you need to learn that during your foundation, right? As a medical student, as an intern, but as you get older and older, you, you know, it's repetition where you're like, oh, I'm sure the heart sounds are the same. I'm sure her strength is still five out of five. Oh, her lungs, yeah, whatever, you know, but those things matter, especially if you're looking at a holistic approach and you want to do your due diligence and give the patient the, you know, the most excellent care that you can. So that was just, you know, evident from him during that talk. Yeah. And I mean, again, this goes back to, you know, traditions are hard to break is the other thing that you asked him about is cryotherapy, icing, right? I mentioned when I was in high school, it's like, ice is nice, high does not just do ice on everything. And as we learn in science, we have to, again, in science, this is why people like get pissed off about how, I don't know, 20 years ago, coconut oil was bad. Yeah. Yeah. 10 years ago, coconut oil was the best thing ever. And now coconut oil is bad again. I don't know. I don't know where we are. We're coconut oil to be honest with you. But you know what? For that, it's good. I can probably do it. No, that's just anecdy. But actually, when I was using a lot, I was working out, but now I just don't. We digress though. No, but you know what, man, hey, that's what science is about, man. You know, we're always learning, we're always evolving. And I want to be the first one to say, what I used to believe yesterday was not the best. Today, my thoughts are, I want, I want that to happen. We've talked about this is again, one of the coaches, Mike Boyle, strengthen conditioning, Mike Boyle, up in the Boston area, he would always say, I reserve the right to change my mind. I steal that from all the time because, heck, man, you've got to be able to say the problem is though, we're lucky to say, I was wrong. What do you think that is, man, especially especially in our field? Why do you think that's such a problem? Oh, the ego, man. Thank you. I just think, you know, we're in competition with medical students, right? Like, so I had a professor at VECOM and she went to Georgetown, which was notorious for like, cut throat, other medical students will find your binder, rip it up, throw it away, put it on fire. And if you were in the bottom 10 of the class, you would actually get kicked out. So like, we have been taught in this tradition that you need to compare yourself to the person to the left and right of you. And it's just ingrained in your head. And even me currently, you know, during my current rotation, I'm comparing myself to my co-intern and the senior and I'm like, man, I'm super dumb, right? And I have to look at the big picture and say, you know what? But I have so many other strengths. And maybe I have a weakness in this where I can get better at it. But like, why am I comparing myself? Right? And again, I talk about my tattoo that I got and that's the reason I got it, right? You're only a man. There's always room to learn. You're not, you know, you are a master at something, but you're not the master at everything. And that's okay. And I just think it's ingrained in medicine. And it's tough. I mean, that's what I try to do on social media. I try to keep it real. I try to tell people like, hey, you just got to focus on yourself. And that's it, you know, and help patients and do the best you can and look at the picture of life because medicine can consume you like that. As we both know. Yeah. For sure. So, man, before we close out, let me ask you this, is what advice would you give either your colleagues or maybe actually even for you? Because, like you said, you want, you could just get your feet wet in the world of ortho-biologics. Or if patients ask you about ortho-biologics, what advice would you give them in terms of they say, hey, Doc, you know, I've heard of this concept of return of medicine or, you know, I've got this knee issue and I've been thinking about PRP. What are your thoughts? Yeah. So context over content, right? So what is it for? So we got to go through it all, right? What is a patient looking for? What are their goals, right? Dr. Malinga talks about, well, if they want that real quick fix and there's nothing you can do about it, maybe they got to go through surgery, right? But otherwise, you go through risk and benefits. Hey, this is what surgery will do for you. These are the complications. This is PRP. This is what it will do for you based off, you know, who are you seeking to go to? If I don't know something, that means I got to go and look it up. And like you said, if I'm not willing to do that, send it out to the next best person. But from there, it really comes out of the papers, right? We talk about the PLRA, classification, how different people do in PRP are doing different things. And that has a big effect on kind of the complications or the effectiveness of PRP. So I think, you know, for me, personally, and for those, there's a huge boo with people going to PMR as we know, start reading about it, start learning about it, ask your program to get an ultrasound course, you know, ask your program to bring speakers on for didactics, you know, that's what, so what I'm trying to do, I think, you know, programs are willing to listen. PMR is one of those fields that every program is so different, right? Some people are really going to brain injury, some are good at spinal course, some have great ultrasound training. There's going to be deficiencies and there's going to be strengths. But, you know, as if you can bring up those ideas in such a new field and connect with others, I think it makes it easier as you kind of go down the road, you know, P-J-3, P-J-4, and then fellowship in onwards. Right on, man. I love that. Yeah, I would just add on to that is four patients who are interested for their own musculoskeletal ailments. What I would say is be careful, which you read, be careful, which you hear, because, you know, nowadays, it's just about who's got the loudest message that gets across. And sometimes that can, that can, and you know, he talked about the beautiful baby in the dirty bath water, right? And that's, I think, part of the reason, you know, those individuals that I had mentioned who say, oh, we have to be careful not to be snake-holes, a salesman, and they mean well, we all have good intentions. There's just a few bad apples, right? They're ruined if everybody, you know, and so for the patients, because again, the signal's out there. There's a lot of misinformation out there. And the internet can be a powerful thing, and you can get it. It's just knowing where to look, knowing who to ask the right person. And, you know, that's the challenge. Hopefully, a lot of great resources. He mentioned interventional orthopedics foundations, a great resource. American Medical Society Sports Medicine is amazing for this. American College of Sports Medicine probably has some as well. I would look for reputable resources in the field of medicine, and PubMed, right? PubMed is a great resource. If it's an article, you can kind of try to read more into it, not everybody's trained to do that, but those are some of the things that I would mention for my colleagues who are in musculoskeletal medicines, even not, is if this is an area of interest, it can be done. It's, you know, again, the papers are out there. The evidence, I would say, is, you know, very strong for some specific ones, like lateral apocondylosis. He talked about tennis, elbows, a very common thing. Knees, knee arthritis, some good stuff is coming for greater trochanteric pain syndrome, which is historically known as trochanteric presides. It's not really a thing. Now, as we know, you guys can do it. Like, we can all do it too. And if we don't have time, then again, that's what we refer out. That's where we say, hey, this is a better person. And to your point about what specifically did they have done, if a patient comes, and they say, I had this done, we really got to ask them. We have to be very precise about the diagnosis that was made, but also the treatment. So kind of what you alluded to is his analogy, actually, I'll steal it from him, is he used the fertilizer analogy, right? With PRP. Yeah. If you don't put enough fertilizer, the lawn is not going to be green and beautiful. Not using enough PRP, right? Not using enough platelets. If you use way too much fertilizer, now you just got a bunch of crap on the lawn, literally it's all brown. What he wants that either, right? Yeah. If you remember, that is efficacious dosing. That's the same thing with nutrition supplementation. That's what it is, right? You don't use the right amount of dosing. It doesn't get better. Use too much the dose makes the poison. You can become harmful as well. So that's the last thing I'll say on that, man. I think that we've probably talked about yours off at this point. Any last word, man? No, man. Just here it is. We've recat episodes 12, 13, 14, and you know, I must listen not only to the patients and the lay people, but also the practitioners out there, because I think we can all learn something from these two amazing people, Dr. Arnie and Dr. Malanga. Sounds good, Ben. See you next time. All right. See you. And as always, guys, remember that important disclaimer that everything in the podcast is for educational purposes. Only it does not constitute the practice of medicine. No shit to be construed as medical advice. No physician patient relationship is formed at anything discussed in this podcast does not represent the views of our employers. However, if you enjoy the show, please be sure to subscribe, review, and share with anyone who you think will gain value from this. Until next time, guys, thank you so much for listening.