Lessons Learned: Patrick Finan, PhD

Hello everyone, I'm Dr. Darsha Shah, 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. Before we begin into this week's show, here's a quick word from our sponsor. Contract diagnostics is a firm 100% dedicated to physician contract reviews. They provide a service that all physician families will need at least one time in their careers, most likely a few additional times as well. I love this company as they've helped over 10,000 physicians understand not only what they're signing, but what risks they are taking for their family. All contracts are reviewed by an in-house attorney and presented in a simplified way back to you, using custom documentation, compensation data, and times outside normal business hours, they make it easy for you. All packages are flat priced, so you know what you will pay upfront. Residents and Fellows can even make interest repayments over time. So look them up at doctorapodcastnetwork.com slash contract diagnostics or 888-574-5526. And last week's episode with Dr. Patrick Feining was definitely a doozy. We nerded out a little bit and talked about some of the signs behind pain and sleep. Now if some of the stuff went over your head, don't worry. Both sleep and pain and especially them together can be quite complex. Some of the stuff we're still scratching the surface on and we don't understand. Yet they are extremely important because they're universal and something that every single person has experience and in fact is necessary. So in this episode, Darshan and I talk about the key takeaways that we had that we learned from Dr. Patrick Feining and we even expand on some of the things that we discussed with him. Provide some clarifications and things that we thought might need further diving into and elaborating on. So without further ado, hope you enjoyed this Lessons Learned. All right guys, welcome back to another Lessons Learned with Dr. Oh, no, Lessons Learned from Dr. Patrick Feining. Today we have Dr. Darshan with us. There you go. Is that what your mom calls you? No, she calls you Darshan. Well, maybe that's how we'll lead off next time. Yeah. So Dars, man, recently we had Dr. Patrick Feining, you know, one of the associate professors here at Hopkins and you know, this was an interesting conversation. You know, Patrick's one of those folks who is definitely deep into the research and he's looking at some really interesting things, stuff that is complicated to say the least and has a tremendous amount of significance in terms of how valuable it would be for us to really get a good grasp of it. So just preliminary thoughts like, you know, what did you learn? What was new? What did you already know that maybe you got a greater depth of understanding with? Yeah, no, I thought it was a super cool topic to begin with, sleep, pain, but then the interplay between the two, which is something that not many people think about, right? At least I've never really thought about the connection between the two. Now, I knew a good amount of about pain, I guess, in terms of the different types, such as different receptors, you know, dopamine kind of playing a role. So you know, Patrick is going in depth with the science and what he's currently researching I thought was pretty, pretty cool for people to check out because it's pretty hard for me to replicate what he said just because there's a lot of science into it, but how about you? Yeah, so my first takeaway was just interesting how he described pain, right? So for us, we look at it in the buckets of no-susceptive pain, neuropathic pain, like visceral pain, right, different types. So for my non-medical folks here, like if you came to our clinic, you know, for us Musculos scatle people, sports medicine people, pain that's like numbness, tingling, burning type of pain that's usually related to nerve related pathology, like somebody says, quote, unquote sciatica, that's what we call neuropathic pain, right? No-susceptive pain is like if you just got punched in the arm or if you hit your toe onto like the side of the bed, whatever, that's like from trauma, it's like this dull, achy pain, sometimes throbbing kind of thing. And then visceral pain is kind of like debelly pain, which somebody's ever had a gallbladder taken out or appendicitis had an appendectomy, that's kind of like the visceral pain. I'm sure there's other stuff that I'm, I can't think of right now, but that's kind of like the buckets that will drop it in. His definition, very, you know, psychology oriented stuff, he described it as three main things, he said, there's a sensory discriminative component, which is just kind of you processing, hey, is this painful or is this just a hot stove, right? Then there's the cognitive evaluative component, which is what shall my body do about this, right? That's kind of like your brains interplay, interplay with your hand and kind of that reaction. And then the last one, which is kind of what we spend a lot of time talking about, the active, affective emotional component, which is the emotional state, one is in. This is the state that drives your decisions and stamps the memories with pain. And this is the, this is where I think that the last part is where cognitive behavioral therapy, addressing pain and like mindfulness and meditation and dressing pain, that's, that's kind of the affective, like, you know, the affective component of the pain. Sure. That was fascinating. I've never heard that before. Yeah, absolutely, right? Because I guess it comes down to how we can rewire our brains, rewire our neurons, rewire our near transmitters in a way, just to decrease that chronic pain, which is essentially what we kind of talked about. You know, one of the, one of the really cool things that I thought about when he was talking was how pain is so subjective right now, right? We go to the hospital and we ask somebody, hey, what's your pain on the zero to 10 and one person might say five. Like if, you know, there was any objective way to know that if those two people had the same exact type of pain, one person still might say eight, right? So we know that there's pain tolerance into different people. I got a tattoo on my chest. I didn't feel any pain at all. Somebody else, they must have, they could have been screaming in pain. But what it got me thinking is when we started talking about genetics and snips and how we might be able to in the future, possibly objectify pain by seeing that, hey, Ultramanche, you have this allele in this snip, you don't feel any pain at all or you're at least have a higher pain tolerance versus myself with this allele. And that might change the direction of how we view patients and treat patients because we know that one of the vital signs back in the day used to be pain, right? And that's kind of how we used to give medication based off people's pains, which is no longer really a vital sign that we truly look at. But I just thought that was super, super interesting at least for a futuristic thought. I agree. Well, what's your tattoo say, by the way? So it's backwards. So only I can read in the mirror, but it says you're only a man. So it's a Marcus Arralius quote, you actually have a tattoo on your chest? Yeah, yeah, yeah, yeah. Oh, okay, okay, in my mind, I was just thinking like these big broad letters, no, no, no, I just got a little. I love that. Yeah, I want to, after I finish this book as a side note, I want to maybe kind of get some of the Seneca stuff or Marcus or release. What's that book that Ryan Holliday recommends from Marcus or release? I can't think of right now, he loves, it might be, I think that's one. Yeah, that's all that's all I got this room. I love that. All right, so yeah, you know, coming back to this, yeah, yeah, so it's really important because of kind of the alterations that different people experience with paint, right? It's some, some people have a more positive emotion. Nobody I think has a truly positive emotion with paint, but some people have a less negative emotion with pain. I guess in some sectors, the way some people could have gotten emotional with paint. Actually, yeah, now that I think of it, yes, I agree with you. But yeah, it's so, you know, the pathway, specifically neurotransmitter pathway that he had kind of alluded to was a dopamine pathway, right? And again, we've talked about the dopamine pathway before, you know, being very implicated in reward like behavior, but kind of a newer thought that this is kind of involved in pain related behavior as well. And you know, can this also have be responsible for positive emotions that can affect analgesia and possibly how people might experience drugs of abuse? Like why are some people more susceptible to become, you know, addicted to narcotics, whereas others aren't? And so he mentioned that in the last few years, a number of studies are showing that people with chronic pain are, you know, they do have like evidence of reward processing deficits to natural rewards like even money or other things. So instead of, no, instead of getting money in natural rewards and those kinds of things they're using drugs of abuse and more susceptible to drugs of abuse. So the cool thing that we're going to talk about in a second is how is the, how are these reward related mechanisms modulated by its sleep? But kind of the gene thing that you alluded to. So that's the, specifically, the comped gene. And then there's a, a snip on it, the Val 158 met snip, which I think that we did look up. It's not necessarily available to every single person who has their own data. The one thing that I think point emphasizing worth emphasizing is what you just said, this may tell us something because it can, it cannot tell us if, you know, it can't tell us what the actual changes are, what the actual dopant orgic changes are on a day-to-day basis. It maybe tells you stuff that can happen at the molecular level, but nothing about the actual phenotypic expression, right? This is what the people are encoded with. This is, this is the gene that they're born with. But as we mentioned, the first thing we talked about in the potato podcast is, hey, the affective component, your environmental epigenetics, how you engage with the world, how have you, you know, from the age of, since you were born and all the influences you've had interactions, you've had people, how has your brain been rewired into processed pain? It's such a complex phenomenon that, you know, it can't just be simplified down into this one step and this is why somebody would get it. I think it's a, it's a great academic discussion for me and you to have and us three to have with, or us two to have with Patrick, but I just want to emphasize that for, for every day folks out there, that this isn't something that's kind of the, the be all and all. Yeah, absolutely, right? Just looking at nature versus nurture. You can always have that nurture component, but how much of it is actually nature, you know? We know a lot of people go through trauma in their early years of life and how that changes their pain state, you know, as they get older and a lot of them have to find relief through things like CBT or now we're looking at things like ayahuasca, low dose MDMA and psilocybin just because we know it's working at almost like a subconscious level where people can go back and it seems like rewire or go back into time and look at those memories they might have had and we're now seeing anecdotes of these of people coming out and being more pain free from these trials and things. So just super interesting stuff that I'm really looking forward to here and maybe in the next two, five, ten years of just seeing what really comes out. Yeah, the future is bright. The future is definitely bright and exciting for that. And I think that that brings us to our next point about how we as providers and healthcare practitioners have to be very careful in this notion about, hey, the quote, the pain is just in your head and being dismissive of that. As you mentioned, yes, it is a very subjective process. It's complex as subjective. You getting attached to in your chest? No big. Can you get a tattoo? I might cry like a baby. We don't know why. I mean, maybe we know why. Maybe we can speculate in lots of different things, but we're still trying to figure this out and we're kind of trying to explain, hey, how can we help address this issue? So I love how he walked through any time somebody comes into his clinic in front of them. We acknowledge that yes, the pain is in your head, but we're not just going to say it's not a real thing. Yes, I believe your pain is a very real thing. The other point that I remember entertaining once mentioning is I think it's the lozure model or pain skill, I got to quickly Google it and maybe we can put in the show notes. The reason I remember a medical student asking me, hey, like, you know, that pain skill is subjective thing that you just mentioned. I remember some attending saying that that doesn't necessarily tell them anything, doesn't give them any objective information, right? Useful information. To me, I remember telling the medical student, it does actually because it tells me pain is one thing, but suffering is another, right? And I think that ultimately, if somebody comes in and says, I'm in an eight out of ten pain, I mean, if it's just pain, but they're like, but you know what, I'm okay. I don't want to do anything about it. I'm okay with eight out of ten. I'm like, oh, great, but if somebody's like, I'm in a nine out of ten pain and I'm dying, I think what we're really trying to figure out from that is, are you suffering? Is this affecting your quality of life significantly? So I wonder what we're really asking there. So I think that's, I don't know. What do you think about that? No, I like that, man. That's, that's good advice from me, too. I mean, you know, it's this, when I go in, I ask these patients, I often, so many times disregard it, right? Because you're like, oh, ten out of ten pain. I'm like, okay, come on, like this is not ten out of ten pain, right? And the way I ask the question is, can you tell me on a scale of zero to ten, zero being no pain at all, ten being the worst pain in your life? And then I try to give them an example of something like drastic, like getting hit by a car or something like that, just to give them a frame of reference. And then I'll say like a three might be like a bee sting, right? But again, I'm giving my subjective experience, but I try to give that frame of reference. But even then, a lot of people will then, you know, drop it down a little bit and say, like, okay, maybe a five or six. So at least it allows me to kind of gauge it a little bit better, but at the same time, does it allow me to gauge a suffering as the question? Probably not when I do it that way. And that's the one thing I think providers need the most work on is helping people from their suffering. Yeah. And ultimately that, I mean, that's why we want to, that's why we do it, right? I mean, if you're truly in it to help people, then you want to try to alleviate that because I mean, because it's like, it's like going back to somebody's MRI, right? You look at the MRI and you're like, oh, well, you're, you're imaging looks great. There's nothing wrong with your back on your imaging. And the person is like, but I'm in pain. I'm hurting. I can't do this. And I can't do why. We're like, put your imaging looks great. That doesn't help. Yeah. Right. Let's dive into kind of the meat of it, right? This is the fun part. This is, this is my favorite thing in the whole wide world to do, it's eight hours every single night. Oh, yes. So let's just quickly talk about sleep, right? We're going to talk about how sleep interacts with pain and he had mentioned that we have known over the last couple of decades that it's a, it's a two way street. Sleep and pain are related. But what we've learned over the last couple of years is that the traffic is flowing a little bit heavier one way from sleep to pain, sleep tends to affect pain more. So then pain affects sleep. And again, we know that, as I mentioned, it's a two way street. But just, could you give an overview of like, what are the two main components of sleep that we look at and what do they mean in terms of like quantity and quality? Yeah. So right, we look at REM sleep, which I think most people know is, is the dreaming part, which increases in duration as you go through your sleep. And that's oftentimes when you, you know, they say, when you wake up, you might remember your dreams. That's probably just because you got rid of REM sleep. And then we look at the non REM sleep, right, which is kind of broken down into different stages with N1 and 2 and then we got slow wave. Now each of those types of sleep will be associated with different brain frequency. And during those times, there's also just different neurotransmitters being released and things like that. But when we look at it altogether, the best quality sleep you can get is a good progression through all those stages, right? And I think a lot of people miss that concept because they think the minute their eyes are closed and they're sleeping, they think they think that's all that matters. But it's not necessarily just sleep. Because we know if you have alcohol, your REM sleep is pretty much shot, no pun intended. But, but you need that REM sleep, right, for that, for that restorative process. Likewise, there's other medications, even melatonin, we know, right, doesn't necessarily take you through all those stages of sleep in a proper way. So I think it's very important for people to understand that there are different stages and that, you know, we're about to go into talk about wearables, me with a whoop, you have an aura ring. But you know, that's kind of the most basic overview I can get, anything you want to add to that. Yeah, I know. So I would take it even a step further back and kind of say, all right. So I think the one he he talked about is, you know, they look at when people, okay, when you kind of hit the hay, and you know, you're going to bed, how long does it take you to fall asleep? Truly fall asleep, right? Yeah. Sure. Yeah. Sleep onset, latency. If somebody spends 10 hours in bed, but they only slept four hours or the 10 hours, that tells us a lot, right? Even though if they were trying to sleep, right, that's called sleep, like maintenance insomnia, right? Because some people are laying bed, they're like, you know, I lay in bed and toss and turn, I can't fall asleep. So we know that in medical school, the different types of drugs we address with the elderly, like, you know, Zolpa Dam versus Benzo's, which we know now are basically toxic, both of them. Firstly, they kind of today, you didn't actually kind of put you to sleep. So that's one thing. And then, you know, how long you actually slept? So if you were in bed for eight hours, but you slept seven hours and 30 minutes, that's awesome. I mean, that's over 90% efficiency. That's kind of what we're looking for. That's good. That's what we call dense, good quality sleep. Like you didn't wake up a lot, you didn't toss and turn a lot, you didn't wake up six times to go to the bathroom. I mean, so that's kind of what you're looking for both. How long you were actually sleeps, total sleep time, which is why it's important to give yourself the opportunity of to sleep, you know, eight hours and because eight hours in bed doesn't necessarily mean you'll sleep eight hours. And then, you know, how much tossing and turning you get. And typically, like in trackers, we'll talk about in a second, like Dar said, but, you know, different trackers measure different things. But in terms of the staging, I think he might have misspoke in actually because there's stage one, which you talk about stage one, two, three, or a stage one is kind of the transition. That's the super life phase when you close your eyes, you know, when you like have that, you're about to fall asleep and you kind of do jerk, like a hypnopopic or hypnagogic jerks to call them. That's your stage one. I think everybody's familiar with those stage two is when your eyes stop moving and your brain slow down. Stage three is when you're going deeper into that slow wave sleep that you talked about. That's when your waves are getting bigger. And this is kind of the stuff that's super important for you to recover your musculoskeletal system wise, which is why at some point when I was young and naive, I was like, oh, man, I really need that deep sleep because that's how I'm going to recover more from my injuries. But then there's also stage four, which is also deep, it's very similar to stage three. But now like majority, it's kind of I think more for a science like the way, you know, the waves are a little bit different. And then stage five is kind of the REM sleep. The interesting thing that Matt Walker talks a lot about is REM sleep. We're learning more and more. We didn't talk about this with Patrick, but REM sleep is kind of the true antidote when it comes to your emotional purging. So I remember him and Peter Tia talking about our previous conversation is just during the whole COVID crisis, which is still ongoing technically, but initially because the anxiety levels were so high, you know, Peter was saying how his dreams were much more vivid during the thing. And is it a way for REM sleep to process, you know, all the anxiety and the troubles that you go through out the day? Do you ever find that to be the case? I'm just curious that like if you've had a particularly stressful day or maybe some, you know, difficult time or if you're struggling with something during the day, if your dreams are affected in any way, whatsoever. Yeah, I would, so I've been, I've been stressed lately just being on medicine rotations. I remember even like last night, I tend to remember my dream more. I wouldn't say they're more vivid. I just remember them more, but I lose a dream a lot as well. Oh, I'm going to learn how to do that. Yeah, I've just ever since I've younger, I've been losing a dream a good amount. I do take like, rachy mushrooms as well. And I feel like that's going to be as well, just getting in that state. But yeah, I, you know, I don't, I wouldn't necessarily it's vivid. I would say that I remember it more though when I'm stressed, but I don't get as good quality sleep. I mean, I can just tell by my whoop, my recovery is, is not great when I'm stressed. That's interesting. Yeah. Yeah. And to your point about specific stages of sleep being distributed, I think we know all of them. And the other point that's worth mentioning, this is for your body to go through stage one all the way through a full REM cycle, like that's one, two, three, four REM cycle. That's takes about 90 minutes. And I think that's where the whole polyphasic people were like, oh, maybe I can sleep in 90 minute cycles and get all my sleep. I think that's been largely disproven that you can't do that. That's an efficient way to be productive throughout life. But you mentioned alcohol is one that disrupts REM sleep, right? That's super important, which is it's again, really counter-tube because people will take a night cap and be like, oh, you know, it really helps me calm down and knocks me out. But it actually is only, again, sedating you, right? It's not actually helping you sleep. It's not helping with that sleep quality. I'm going to use, I'm going to steal this from Peter Tia. He mentioned that at some point, some other physician, one of his colleagues told him, you know, if I take a baseball bat and whack you in the side of the head, really hard, do you think you'd be unconscious? Yeah. How can you equate that process? I mean, you're technically out. You look like you're sleeping, but that is not the same as the restorative process of sleeping. Basically, that's what alcohol does. And I think that for different people, different levels matter, I think for some people, maybe a glass of wine is probably okay. You know, you kind of really have to figure out. This is where the tracking stuff is really valuable is, hey, what's that cutoff point where after this point, my sleep quality is truly disrupted. People don't necessarily need trackers to do this. I'm sure you could do it with pencil people and just being very in tune with your own performance the next day and just going on tracking more time. But any thoughts into that to you, I don't personally drink it, but I know you every now and then you like to enjoy it. Yeah. Absolutely. So with whoop, there's a journal that you can input certain things and alcohol is one of them. The thing that completely destroys my sleep the most is alcohol in my journal. My negative 7%, so it will decrease my heart rate variability, it'll increase my resting heart rate while sleeping. And then the next day, I'm making up for the REM sleep. So then about 40 to 50% of my total sleep is actually in deep wave or REM. So I don't go through that natural progression. I quickly hit REM, REM the next night. Yeah. Have you noted, is there like a certain, and we don't want to talk about this if you want to? Do you know if there's a cutoff point like, okay, okay, one glass of wine is okay for me or maybe just like, you know, whatever, like a couple of beers, like do you know what your limits are at one point, it affects you or even the slightest bit will affect you. So I think for me, it's not even about quantity, it's more about the timing of when I'm doing it. So if I'm like, say, day drinking or I'm drinking through the day, I'll be, I'll be okay. Because I think my body can just recover from that, at least from a hydration standpoint and things. But if I'm even having like, it depends, like, why am I okay with? If I'm having like a whiskey or hard liquor or some beer at night, and I have like more than two, and I'm like, let's say three hours or less away from sleeping, it'll definitely affect me a little bit. Yeah. Yeah. Yeah. So I mean, I think that that's a good, you know, self-experiment for people to try. If you have found that you're struggling and you kind of always are using it as, you know, a self-medication strategy, maybe, you know, think twice about it. Not necessarily. So again, you know, we're not anti whatever, obviously, you know, there's a balance to life. But something to think about. The other thing in terms of like disrupting specific stages of sleep, we're talking about sleep and it's association with pain. The fact that opioids disrupt slow wave sleep, you know, deep sleep, just absolutely mind-blowing. Right. Think about that, right? And we're in the middle of an opioid crisis. We're getting better, but we're not, you know, we're still in the neck of the woods. And the, you know, it's, we know that poor sleep causes more pain or increases your perception of pain. We take more opioids to combat that pain, opioids disrupt your sleep cycle. It's just what the heck are we doing, you know, it's, it's, it's unbelievable. I have a patient right now who's a chronic pain patient and we're getting opioids because she in the pain. But then it's that pain is disrupting her sleep and we're waking her up in the middle of the night to give this, right? To give the opioid. Yeah. It's just like in my mind, well, chicken or the egg, what do you do, you know, at one point you're trying to beat the symptoms, the other point, you know, you're trying to look at it from a chronic standpoint and just trying to get her better overall. So, yeah. Yeah. And to give it a shout out to our friends at BS3, BS3 MD, they actually just had an episode on this where they talk about how like the worst thing in medicine that could ever happen is in the new England Journal of Medicine, they actually had an article saying opioids are not addictive. Yeah. Yeah. It's my blog. And, you know, I think a lot of people used to say that in the medical profession, when was that article published, by the way? I want to say they said the 80s, I believe. Yeah. Yeah. Yeah. So, I mean, we're all back pedaling so fast now, right? In medicine, everybody is. Yeah. I was, I was like, you can't possibly be anytime in the last decade or two. Yeah. I mean, that's the worst thing that happened and we're still fighting this uphill battle forever. But yeah, I thought that was, that was quite interesting. And then he also mentioned Clonardine, which is a popular anti-hypertensive, which will link that paper. It turned out that it was Clonardine. He did send us that paper, so we'll link it. But sleep checkers, man, let's just talk about sleep checkers quickly, because super popular, you have one. I have one. I love mine. What do you like about yours? What do you not like about it? And what value do you think it can bring to somebody? Yeah. So, I really love the whoop and honestly, I got introduced to the whoop because, you know, at Penn State Hershey, we're actually doing research with it. So one of my co-residents is actually the principal investigator, and we're looking at resident burnout, along with certain rotations that we go through. So whether it's like a medicine ward or ICU, tracking our burnout rate. So the great thing about whoop is that it looks at kind of a triangle system, I'll call it, looks at recovery, it looks at your heart strain, so how hard you're working out, your heart rate throughout the day, and then it also looks at your sleep. And those three are very interrelated. And so essentially, sleep's going to affect your recovery, your recovery's going to affect how optimal kind of day strain you want, right? So if I'm at like a 10% recovery, I don't want to overtrain because now I'm risking more injury, right? And so the recovery standpoint looks at your heart rate variability, which is essentially kind of just to explain to people the beats within your heart beat, right? So it's a balance between your parasympathetics and sympathetic system. So that's what I love about it. It's a little more fitness driven, more than wellness driven. So for me, you know, just being a fitness junkie, I'm really always trying to push myself and see how can I get more fit? Yeah. Yeah, that's cool. Yeah, no, I thought about that. I contemplated this for quite some time, but I just didn't personally, the fact that I'd have to wear like a wristwatch to sleep is not something that I was about. But now, I mean, I wear an Apple Watcher in the day though. So I got that. And that's essentially just so I can listen to my audio books and you know, that's really cool. Yeah. And in my podcast, so I'm not burning through my phone battery all the time. And it's good to get somehow to check my heart rate when I'm, at least doing so in true training. It looks something like that. I like, I mean, I love the order ring just because of its low profile. It's sticky. I like the fact that I don't have to charge it for like, I have to charge it once a week. It's really cool about that. Two Patrick's point though, I have noted that the first thing I do in the morning as I get up is I run to my phone to check my my sleep data. And I am, I've been more mindful that that's not the first thing I do, you know, I get up. I'm trying not to check my phone and just get flooded with all this anxiety and again, the neurotransmitter hit my face all the emails and all that stuff. So I'm trying to be more mindful of getting up and not spending the first 30 minutes not checking my phone and not even looking at my sleep data because I was, I was very much getting tied down on to not necessarily my sleep score, but another point worth mentioning is that people who are much smarter than us in this in the sleep space agree pretty unanimously that these trackers are probably better for giving you like total sleep quantity. So for instance, or sleep efficiency. So again, going back to the point that if you spent eight hours in bed, how much time did you truly sleep versus how much time were you lying in bed awake or awakeing up in the middle of the night, even though we don't remember. So that's kind of your sleep efficiency. What they're not so good at, different sleep staging. So I was getting up and sometimes I would never hit that average 25% REM sleep and that was like stressing me out, I'm not getting REM sleep, I'm not getting REM sleep. But again, now that I know better, it's like, okay, that's, this is an accurate enough to be able to tell me that there's only a PSC can do that. Does the order ring break it down into what times you're also getting that REM sleep or is it just out of control? Yeah, it shows you a graph and it shows you how you go up and down into the state. It's very cool. It gives you HRV and all that stuff too. I have started, like you were doing, you can add tags, I have started adding little notes, hey, what did I do well last night, you know, what did I, so one of the things my bedtime routine is now including is a hot shower and that dip into like walking out, especially because I keep my apartment at 65 degrees, so walking out, so we know that rapid decrease in core body temperature can help you sleep a little bit better. I guess I know we're all over the place here. We're talking now strategies as well, but yeah, so you know, again, at the end of the day, like it's good to kind of have this data, but if you don't do anything with it, then there's no point, right? And so for you, if somebody, if like you were to come to me, I mean, we're like, oh, this is kind of how app calls affecting me and I would say, okay, why don't we dial it back two and a half hours, three hours, then we'd figure out what that cutoff point for you. For me, it's like, okay, if I'm not sleeping well, it's like, okay, let's try a hot shower and see if that temperature dip helps or something like that or stretching our nighttime routine. I think a lot of times people ask, what do you think about this, what do you think about this tracker? To me, my question is always like, it's great. If you're going to do something, if it's going to drive that behavior change, right? Exactly. Did you ever use any other ones other than Moop or I had a Fitbit way back, but I mean, it was, it was doing sleep a little bit, but those were like the older additions that I'm just not a Fitbit fan. I think you're just looking at reviews is I don't think it's really that accurate compared to like whoop. I've listened to the CEO of whoop on Clubhouse Willa Med. The way they're doing it is very scientific, and which is why athletes are like hopping onto it, using respirations and looking at it between the heart interval. They look at your last five minutes of your slow wave sleep to get your recovery because they know that's when it's the most accurate. There's just really into the science with the algorithms and stuff that they have, so that really drew me into it. Again, it's very focused on changing your behavior. That's their biggest thing that they want to do. The data that you get, I have six months of data now, and it kind of shows me month to month what's been changing. For me, the things that have been working are blue-blocking glasses, ice baths and sauna. Those are like the three main things that have really helped me, and magnesium, which I realized, so I was taking it in the morning a lot of times. It actually shows that I sleep better when I take it closer to sleep later in the evening. Do you, are you doing dry sauna or infrared? I dry. Yeah. Like 20 minutes or? Yeah, I try to go. The gym I go to is really freaking hot. It's like harder than most sauna. I try to go for 20, but I could do 15, usually, I'm about to pass that out. I've been actually scoping at, because even though I built this home gym, but I think next year, I'm going to be able to use this one at the Wi-Fi or something. Yeah. I've been going through the data myself and looking at the literature, and I'm getting increasingly more convinced. Just as a method, even to kind of just spare my joints of due less, and you know, kind of use it as an exercise of the medic, to get the hardware up. All right. So before we close it out, man, I kind of want to, I think just, I know we didn't talk too much about the interplay with mental health and sleep and pain and how like, there's this little triangle connection between all of them. Hopefully, again, in the future, we'll have some other guests and be able to, because there's so much to kind of, you can kind of go down different rabbit holes with this. I think that, especially when it comes to sleep and pain and mental health, you know, this whole excitement came out a few years ago. I think that in the New York Times, they published an article about a woman, I think she was like in her 70s or 80s, who didn't feel pain so much, though, that like she was burning herself and, you know, cutting herself left and right, and then they later figured out that it was, basically, she lived this pain-free existence due to kind of a genetic mutation. Mm-hmm. I think it was like a microdulation of some gene to forget exactly what it was. What was interesting, I remember reading about it is, she also didn't feel depression or anxiety or fear. Mm-hmm. So, you know, that just kind of, that's, I think, I don't think that's the first time that this thought was brought up and this reader started, but that's kind of, it was like, okay, well, there has to be a connection, right? Is there a connection between anxiety, depression, fear, and chronic pain? You know, what does this tell us? We know, so that's one thing to kind of, I want to leave people with, but the other thing is, like, these epigenetic changes, we keep talking about this stuff, another, I might forget exactly where I read this, I want to say probably on, like, Peter's, Peter Chase website is, they were talking about these, looking at, like, college age men in some study and looking at the paternal environment, how that can influence the offspring, and so they saw that in college students, they demonstrated that shortly after, like, these college students reported, like, periods of stress, they showed that their sperm was actually making small, non-quiting RNA changes, suggesting that the environment that they were feeling, right, and their responses to it regulates sperm epigenetics. Yeah. I had the same token, Robert Sipolsky, a guy who wrote this book called, Why Zebra Still Get Alters, talks about how, on one of the previous podcasts, you've learned, he talked about how they've actually noted that children, or, like, you know, again, unborn babies in the womb, if the mom during pregnancy goes through an extremely stressful time, the size of the amygdala can be modified, essentially, the actual physical size of the amygdala, and for most of us, amygdala is this tiny part of the brain that's responsible for, like, your fear and fight and flight, and that's what freaks you out about everything, you know, the lion stresses you out, it's kind of really the culprit and anxiety and all the depression and stuff like that. But literally, depending on how much stress the mom goes through, the babies, amygdala can be larger or smaller, depending on that. I mean, so that's just, like, some mind-blowing stuff right there about how much, like, our environment and stuff can influence it, even before we're born. Yeah. The fact that you bring this up, honestly, I was, I think about it a time to time thinking, hey, in the next three, four years, I might have kids, right, being 28 years old. And that is essentially why I try to optimize my mindset and lifestyle, because I know that based off my lifestyle, it's going to influence the kids just through epigenetics. So that's, like, also a huge motivating factor for me to just, like, you know, get it together and live as healthy as life as possible, and in having a clear mindset. Yeah. And to our medical colleagues and medical students, especially, I mean, this is why we, wise family history is so important in the history, right? Because we know that, I mean, we talk, we joke about this when it comes to performance, you got to pick your parents wisely, right? I mean, you've done that with your, with your great grandma and grandma. But yeah, I mean, that stuff is really, really important and it extends beyond diabetes and coronary artery disease and high blood pressure. It goes to chronic pain and depression and these types of things as well, because these are, these are, and, you know, kind of on the rise as well. Yep. Absolutely. Cool. Awesome, man. Well, that was fun. It was informative. I know that this was a bit more on the sciences side. So hopefully you'll, people can, you know, stick with it, but it's important stuff. And it's definitely worth talking about and hopefully we can continue having these conversations because that's what we learn for sure. Amen. All right. Till next time, buddy. See you. Well, that's a wrap on the show. But before you take off, just remember that this podcast brought to you by contract diagnostics. This is a company that specializes in contract reviews, specializing in something we can all appreciate here. So again, when you or your family have contract needs, give them a call. They'll help you understand your contract and make sure it lines up with your interests and protect the assets that you covered most, your time and family. Find them at Drpodcastnetwork.com slash contract diagnostics or by phone at 888-574-552-SIG. Now for that important disclaimer. Please remember that everything in this podcast is for educational purposes only. It does not cost you the practice of medicine nor should it be construed as medical advice. No physician patient relationship is formed and anything discussed in this podcast does not represent the views of employers. If you or your loved ones have any medical conditions, please be sure to seek out the advice of your personal physician. But if you think you'd like to show, please be sure to subscribe, review, and share with anyone who you think will value from this as well. And until next time, thank you for listening.