68. Asare Christian, MD, MPH: Creating a Holistic Patient Experience to Relieve Pain

Hello everyone, I'm Dr. Darsha, and I'm Dr. Altamash Raja, and welcome to Medicine Redefined. A podcast where we will explore the often overlooked but necessary components of health, what we consider to be the fundamentals. We will investigate topics and practices that can give you and your patients the best chance to optimize a healthy lifestyle. It's time to move the needle forward and put the health back in healthcare. Before we get to today's episode, I want to take this time to talk you all about learning medical Spanish. Now, if you're a healthcare worker, you already know what an asset it can be to have Spanish in your toolbox. There's no need to call the glitchy translator line or pull out Google Translate on your phone or find that one colleague who is fluent. It makes for more comfortable and authentic encounters with your Spanish-speaking patients. Now while I may be able to get by with just 4 years of Spanish in high school, I want to be able to truly connect with my Spanish-speaking patients to let them know that I am able to communicate in their natural tongue. Now this is where my friends at Common Ground International come in. They have been teaching medical Spanish to healthcare students and healthcare professionals since 2003. Their mission is to impact communities through language. Now twice a year Common Ground International offers a free 10-day masterclass that helps you take a medical history and perform a physical exam in Spanish. Not only that, but you're going to walk away with a customized learning plan to improve your medical Spanish over the next six months. And that's not all. After you complete the medical Spanish masterclass with Common Ground, you'll earn 4 free CME Category 1 credits. They only offer this masterclass twice a year, and the next one is coming up very soon on Friday, August 26th, so make sure to mark your calendars. If improving your medical Spanish is one of your goals, and it doesn't matter if you're a beginner, intermediate like me, or advanced, you need to join Common Ground Medical Spanish Masterclass. You can get all the info of dates and scheduling on their website at www.comangroundinternational.com for slash masterclass. Hope to learn Spanish with you. Our guest today is Dr. Asare Christian, a board certified physical medicine and rehabilitation doc. He received his medical degree from the Medical College of Wisconsin in 2009, where he was awarded student of the year in physical medicine and rehabilitation. He then went on and did his internship at Aurora, St. Luke's Medical Center in Milwaukee, and then furthered his training in physical medicine and rehab at Johns Hopkins University School of Medicine in 2013. He is also a graduate of the Mungan Commonwealth Fund Fellowship at Harvard Medical School. He's also obtained a master's at Harvard in public health with a concentration in health policy and management. Dr. Christian's interest in the use of technology to create value for patients led to a recent completion of coursework in artificial intelligence and health care at MIT Sloan School of Management. Currently Dr. Christian is the medical director and owner of Ethan Medicine in Wayne, Pennsylvania, where he has advanced training in chronic pain management, spasticity, ultrasound guided injections, and medical cannabis. Previously, he was the outpatient medical director for Good Shepherd. He has academic appointment with University of Pennsylvania in PM and R, and as you can tell by this very impressive bio, Dr. Christian is not a one trick pony. He's definitely been around healthcare, a good amount, and has vast diverse experiences. So in this episode, we're really going to break down Dr. Christian's approach to healthcare and to his patients. You know, often when we talk about holistic medicine, the first thing that comes to mind is this traditional approach of mind, body, soul, and how do we kind of put all of those together in terms of treatment plan. But Dr. Christian not only focuses on that, he also focuses on a holistic experience so that when the patient's first enters his office to the last time they leave, there's going to be a solid experience. So Dr. Christian's approach is definitely unique and I think, you know, not I think I know you guys, whether you're a healthcare professional or a patient, will take something away from this episode. Without further delay, here is our conversation with Dr. Asari Christian. All right, welcome back to another powerful episode of Medicine Redefined. We've got Dr. Asari Christian here with us across the screen, and all just so you know, the way the way me and Asari connected. So you know, I was doing my PGY two year in her, she just roaming the halls and Dr. Christian here is a locom, right? And this is like the first time we're getting locom's here, we're like kind of like an attending shortage. And you know, we start to talk and he asks you what I'm interested in and I start talking about like precision medicine, functional medicines, stuff like that. And he's like, oh, no way, me too. And so he tells me he went to Hopkins and I'm like, oh, I have a podcast. So to my co-host. And then this is like the best part. He gives me this business card. And when I tell you about a bougie business card, dude, your, sorry, your business card is the best thing I've ever felt. It's actually still on my desk. And sometimes when this is, here's the joke. Sometimes when we're like stressed, we're like, hey, hey, just, just feel the business card. And so my comrades will just feel it and we'll just, it's a really nice business card. So but without further ado, sorry, how, how are you? Thank you so much for joining us here on Medicine Redefined. Yeah, thank you guys so much for having me. I'm doing well and I started to be here to contribute to what you're doing. I think what you're doing is amazing. So hey, I'm happy to be here to line a contribute. Yes. Yeah, absolutely. And again, so when, when we talked, you know, we kind of had a similar mindset. And when you started telling me that you were interested in pain management and, you know, really looking towards goal oriented, coming out of the field of physiatry as all too much and I, you know, are also in, let's start back from the roots though, right? I want to understand and give context to the audience why you chose the field PMINAR. I kind of, how did you decide about that and then going down the route that you did? Yeah, so that's, I know that's a very interesting story for everyone. So for mine, it kind of, I had no idea what PMINAR is. I have to, I think, my second year, 30 of medical school. And I had a grandmother who, I'm from Ghana. So my grandmother had a fall in Ghana and she was having all of these symptoms. That was suggestive of hydrocephalus of TBI. So she was having some balance issues, some incontinence, some cognition issues. And then when I was hearing about that and I, you know, she's in the village and I said, man, this sounds like she has hydrocephalus. And then I said, well, they should take her into the hospital and get a CT. And then it tends out to be the case. So she got diagnosed with the brain injury, got surgery, had a shunt put in place. And then following that, there was no rehab. So now my aunties and my mom have to kind of take off work and really kind of take care of her. So it became kind of like, oh, wow, Ghana, Ghana has all of this trauma and all of this rehabilitation needs and we don't have rehab in Ghana. So the plan was, all right, let me do something that I can eventually be able to contribute that back home. So that's the journey of going into rehab. And it's just been a wonderful experience. Actually, I've done some working Ghana where I was still in medical school. There's some research there and it's set up a fellowship in PMNR because the whole of South Africa, I think only South Africa has a developed PMNR program. And there's so much trauma there, there's so much stroke. You know, some of this risk factors that we have here are becoming big over there. So that's the journey. And it's been a great one and I'm so glad that I went to Physiatry. Yes. So that's interesting, right? Your inspiration kind of was looking at it from the brain injury aspect and a personal story and many of us kind of shared that. But what you do a lot of now is, you know, I think your scope of practice from what we talked about offline, it's really why, right? But I think when people look at it at the surface, they think pain medicine, right? That's the bulk of what you do. And a lot of, you know, interns or really medical students when they're asking me about PMNR, they want to know, okay, well, what are the different fellowships? So what are the different areas of PMNR that I could go into? And there's that somewhat of a hard dealing in the nation, right? So there's both medicine, pain medicine, brain injury, stroke, pediatrics, those are spinal corduroy, those are like the big ones. But where did, where did you make that turn where you're shifting more towards pain medicine? I know you do a lot of post-stroke care as fast as you do, which goes hand in hand with this neurological rehab, but where did that turn come about? Yeah. So this kind of goes back to, you know, finishing residency at Hopkins. I don't know how many were in your class, but I had five and four of my colleagues. Everybody was going into pain. At that time, I was like, you know, well, I don't want to deal with pain. I'm interested in just general physiatry. I like the neuro rehab stuff. So spinal cord injury, TBI, the very things you're talking about. So then I decided to do a fellowship and get an MPH and through that process and it was all to kind of learn about how do I, you know, understand systems, how do I learn how to solve population problems? And then I got there and I recognized that pain is one of the biggest health care or biggest public health problem, right? So pain caused more than all the other disease states that we are talking about affects more than all the other disease states that we talk about, including cardiovascular disease. So when I started my, you know, I finished residency, came to do an attending gig and I was doing neuro rehab. So I started with spinal cord injury, TBI stroke. And then, you know, while doing rehab to optimize function in this patient population, the common theme was they all have pain, right? Everybody have pain. And even in this patient population, it was more, you know, central pain disease, which is more complicated to address. And then there's a people who on top of it have disabilities. So the limitation of what we can do for them in terms of, you know, medicines, we only have a few neuropathic agents or a few things that we can do for these people. So my interest in that kind of just peaked and eventually I started doing, I kind of became the pain person because somebody was doing it. So I became interested in how do I optimize pain or how do I treat pain to help patients be functional. Let's treat it so they don't get so sleepy so they can still participate in rehab and PT. So from there, it became necessary to look beyond care and paradigm of what I have. And since then, I've educated myself and it's evolved to now focusing on pain. But the very thing that we're talking about is in this contest, let's get people healthy. I mean, it became like, okay, the goal is whatever we're doing, let's start from a place of getting people healthy because once people are healthy, everything else works better. So that's kind of the trajectory in the journey. So you graduate and then at what point did you establish, is it ether medicine, brain? Yeah. So, yeah. So when I finished the fellowship, I moved to the Lehigh Valley and work at GUSHIP at the rehabilitation hospital. So this is an independent rehab hospital and I was there for seven years. So through that period of time, I did many things. I'm also interested in program development, so I did some aerodynamic clinic, I did ultrasound clinic, specificity clinic, I built all this program. So and then eventually, I got to a place where, you know, pain became the main thing that I did. Who are back pain, surgery, chronic pain and it just, it became limited what I could do for them. And I started recognizing, incorporating some more education because part of the whole process was I came to recognize that people did not understand what pain is and it was just this simple old idea of looking at pain. I have pain and it has to be a tissue damage and therefore somebody have to give me, you know, something to block that signal, either medicine or injection or surgery. Of course, there's places for those things. So we know when people have chronic pain, even though we have all these resources and we don't know all of the things, all this before I'm still in pain. So there has to be a better way and we already understood that. I mean, we all learned at a medical school that, you know, certain things perpetuate certain chemistry. So really, it became necessary for me to educate patients about, okay, let's talk about you've had this issue, but there's something that is perpetuating this state, this chronic pain. You've had a radiation. It shouldn't last for, you know, 15 years, a radiation should heal in about 36 months. So what is going on that's keeping this pain in place and this is where we kind of dive into a little bit of education and understanding that, hey, what you eat plays a role in your pain. How you move plays a role in your pain. What you're thinking about plays a role in your pain and all of these things are things that we understand from the neuroscience of pain. So just educating patient and empowering people, which is what we are trying to do here became necessary. So that's kind of how that took off and of course, there's multiple ways to support patients with, you know, how to kind of get out of chronic pain, yeah. You know, I really appreciate that you talked about how pain is arguably the most universal thing, right? I would say almost every single person at some point in their life is touched by that, right? There is an exceptional genetic variant who may not experience, but 99.99% of people are going to have some type of pain at some point, whether acute or chronic. And as you kind of suggested, it is a multi-sensory process. And so we do have to take a step back and really take a big picture approach, which is what you're talking about. So two follow questions for you is one, how did you come about the name of eat their medicine? I find that to be very interesting and I'm curious if there's a story behind it. And then two, you kind of highlighted what you think is valuable, but really tell the audience a little bit about what your practice is like today and like what you offer. Yeah, so the name ETHA has multiple meanings. So basic English definition of ETHA means quintessential. So I wanted this to be a quintessential model of healthcare because we don't have case evolving. We wanted to play a part, you know, coming from the rehab center side of things, ETHA also represent the fifth element. So this is medieval philosophy. We have the wind, the fire. And then ETHA was this space that everything flows and all the heavily bodies flows and so they couldn't really quantify what ETHA is. And then in quantum visits, when we look at the observable universe, so I think it's 2019 or 2018, they discover that the universe is a spending. This is the paper from Hopkins and Australia. And when we look at the observable universe, though we, the higher element, nitrogen, oxygen, carbon, we make about 0.3 percent, right? And then the stars, the helium, this huge massive thing is about all of that is about 3 percent. And then there is this thing called the dark matter, which is all this energy that holds the galaxies together. That's about 23 percent. And then there is this other force, which is like overwhelmed all of the galaxies and that's the ETHA. It's about 73 percent of the observable. So that's the energy. So if there is the energy, the universe is a spending and what it's making the spend is the ETHA. So it's kind of esoteric, but it was just kind of like, wow, okay, we want to aspire to something very big and that's where ETHA comes from. And it's something that kind of came to me just by reading some books and some other things like, whoa, I think this is what we want to be. In terms of my current practice and what it looks like, it's, you know, we focus on pain management rehabilitation, but how we are different is we focus on what the pain or impairments prevent individuals from doing is, you know, necessary suffering, unnecessary medications, unnecessary surgeries, unnecessary spending, you know, trying to be a guide for the patient while making the patient the heaviest person possible. So that's the simple approach to what we do. So the end goal for everything we do is let's make you healthy. And that's where it starts because people come and they go, I've done everything. Where's so me? I've gone to physical therapy, I've gone to, I've taken medication, the gubapentin doesn't work anymore, I've done surgery and I'm still in pain, right? They do all of that without changing any of their habits, you know, as we talk, they are still eating junk, they don't think that that plays a role in their pain. They're still stressed and doesn't know how to manage stress. And we know what that means for pain in the state of, you know, being in chronic inflammation asleep, they're not sleeping well, they're not moving. So this kind of becomes an area of, let's figure out how we optimize all of those things, making you healthy. When you're healthy, the pain will go down and educating patients about strategies and how to do that. Because we know it's not easy. I mean, if you're in chronic pain and you have to deal with pain, when you wake up in the morning, when you everywhere you go, you're in pain, how are you going to move around? So it takes a lot more than just, you know, say take a pill. How do we give you that infrastructure in place? So that's kind of the approach and really getting people tools to make sure they can get to where they need to be. Absolutely. So, sorry, two things there first is, I'm a huge etymology geek with an origin story. I absolutely love. So I just find that it's really cool to hear how you kind of branded that with the name and really trying to, you know, dig into a bigger purpose, right? And I think that's just really cool. And then the second thing, talking about pain, right? So, you know, as you connect this to ether and connected to, okay, there's this whole other world out there, right, that we need to recognize with pain, right? It's not just a physical sensation, it can also be mental, like you said, emotional, can pop up at different times of the day, right? There's this whole enigma behind it. So out of all of those, you know, different angles of where pain can originate from, when you have a patient that comes to you, you know, for that first visit, how do you approach that? Is it, you know, do you kind of hit it from all different angles at once or is there kind of a step by step approach that you take a patient through? Yeah. So I think, you know, just talking about kind of conventional medicine standpoint, there's like kind of four frame works of four lenses that I kind of look through when I approach patient. And, you know, you have the rehab side of things, which is, you know, looking at function. So we look at function, what's going on with function? We look at structural things. So this is connective tissue. So this is where the orthopedics, the bitics falls into that place where, okay, is it the disc? Is it a, is it a, is it a, is it a, is it whatever, what structure is going on? And then you have the, you know, rheumatology inflammatory stuff or maybe functional medicine where we're looking at inflammatory markers, influenza pain. And then the fourth lens is the neuroscience, which is, you know, the neuroscience of pain, what's going on in the pain, how pain is being processed and all of those things. So those are kind of like the four lenses that I kind of approach patient with. And then it becomes a function of trying to understand where the patient is, you know, what is the understand of what's going on and where is the first place to start. So because I think part of this is also understanding that, you know, patients have to do the work to get well. And if you're not buying into the story you tell them, how are you going to get them there? So it's very different. As you know, every patient is very different. So it's really kind of listening to people and trying to figure out what is the most important thing to them. So people come in and they, for example, you know, they have a hane asian, they have surgery and, you know, everything is fixed and they're still having pain. So what would do is, okay, let's talk about, okay, the surgery, first of all, giving people education to understand that the surgery is fixed, you are saved because part of this is getting people to understand what happens in the neuroscience side of things, right? So structurally from an orthopedic standpoint, well, yes, the surgery is fixed, the hane asian is fixed, everything is good from that standpoint. So why are you still in pain? It's a function of never system being either hyperactive, trying to be protective of you because you were in pain for so long, or even relating to some trauma, some predisposing trauma that people have had their whole life that has gotten the never system to kind of just fall off because people will say, oh, you know, I've been finding the whole time. And then one time I just tried to go pick up a piece of paper and my back locked out and that was it. They don't really connect that to the predisposing factors. All this trauma that we understand now can actually influence your never system activation and all of that stuff. So trying to kind of provide that education and then looking at the inflammatory level, what is going on? Are they eating something that may be playing a role? And it becomes just simple. I mean, all of this is a whole lot, but really kind of starting from a place of, how do we just, for me, let's get your body to be in a state of home, your stasis and state that it can heal ourselves. So I talk about sleep. Are you sleeping? Well, I'm not sleeping very well. Okay. And I'll say, if we don't get you to sleep, you're not going to heal. And the whole idea is getting people to a place of understanding, we want to heal your pain. This is not about trying to solve a signal. And I can do that for them. So sometimes maybe people need trigger point or maybe people need some augmentation in medication. And what I do is I tell them, this is just addressing the pain signal. Okay. And I will say maybe pain has, as we know, it has an emotional and, you know, a sensory component. I'm blocking the sensory component. But what will keep that going is if you keep eating junk and you create all this inflammatory markers in your system. If you're not managing stress and stress predispose you to chronic inflammation, that's going to make things keep going. So either sometimes, depending on where they are, we can say maybe see a psychologist or maybe people say, you know, I've done physical therapy and then things did not work. So I haven't done physical therapy in six months or sometimes I even see people who have surgery and they were not sent to physical therapy. So they're not moving. They're compensating. There's all the secondary things that go home. So it becomes really teasing out what is going on initially and then provide an education and then being a rehab person, I really kind of dial in on the function. Let's talk about what is it you want to do and then set some goals and then make sure that patients are hitting those goals with the things that we have for them. And even, you know, when we talk about even, you know, sometimes patients don't want to take medicine because of some of the stigma and everything else and I go, let's take the medicine so you can do the therapy or you can go for the walk, the functional things that you want to do. Let's treat and let's translate whatever interventions we're doing into function and then that becomes more relevant. And then depend on where people are. Some people are connected in different levels where they may even be interested in energy medicine. They may be interested in some other alternative approach which I will bring up. I say, have you ever tried acupuncture? Have you ever tried chiropractic? Have you ever tried other things? And then try to put all of it together and tell them that there is no one thing that's going to solve this. It has to be a combination of fundamentally. If you can't do anything, let's look at what you put into your body. Let's talk about how you talk about your pain, the thoughts, the things that influence and what type of traumas have happened in your life. Let's make sure you're sleeping and then let's make sure you're moving. So, I know there's a lot in there but that basically just trying to tease out where they are and then kind of take it from there. And there's more we do as we go along and go from there. You know, it is. As we've talked about time and time again on this podcast, how complex pain is and I think what you've just highlighted is an extremely thoughtful approach because that's what's necessary if you're truly trying to make a difference, right, because I'm a challenge it can be. I really like what you talked when you talked about looking at it from a functional standpoint but also the orthopedic or the medical standpoint. I think when I was an intern here, I remember doing just an elective for a pain in our the person that I worked with the advanced practitioner told me that they like to make a functional diagnosis and from that point, I really thought about every single patient that I see throughout my rehab career, there's a medical diagnosis to that and a functional diagnosis. So, for instance, for those not familiar, the medical diagnosis could be an MCA stroke, right, so there's the middle cerebral artery and the deficits from that from a functional perspective could be right-sided weakness which could difficult, you know, ambulation and that kind of stuff. That's really, really important and that's, again, it's cliché, but, you know, our specialty is really geared towards addressing somebody's function, so I think that is super, super important, especially when somebody comes to you and the goals of care, they're like, I want to be able to walk or I want to be able to throw this ball a hundred miles an hour and I can't because of whatever, right, they're really focused on the function and the pain which go hand in hand and I think a lot of what you talked about I think would to elucidate that process a little bit, maybe if we can use a somewhat of a challenging things and to me, the more common yet challenging thing that I find that we treat is my facial pain, right, another one that can be very challenging are things like migraines, right, and so I'll let you pick which way you want to go and the reasons these I think are challenging is, as you mentioned, the structural issues are easy, right, that biomechanical model that we had for a long time. You see the broken leg, that's easy, right, because you can wrap your mind around that, but things like my facial pain where there's like, I don't know what the fix or migraines, I don't see MRI looks fine, right, your x-ray looks fine, I don't know, I can't help you, so which one of those, whichever one, dealer's choice, and if we could walk through like a challenging patient, I think it might be helpful. Yeah, so I think, I think those two, yeah, we can dive into that, but I would say, let's start with my facial pain, right, so, and then my facial pain, you know, so, musculoskeletal issue that likely we don't have any tissue damage to explain it, right, maybe there's nothing like you say, there's nothing that's going to show up on MRI on the tissue level, maybe there's something you can see with ultrasound, but really with that patient population, what becomes is really trying to tease out what is causing this, okay, so the cause of it, but get into the root causes of it, and I think sometimes, even though our instruments are not able to measure certain things, we know they are root causes, since things are going on, this physiology is so complex, right, at the cellular level, so somebody who have my fascia pain, and let's take somebody who have, you know, a classic example would be like a fibromyalgia patient, right, so this is a patient where, well, we understand maybe some of the pathophysiology, there's some psychological stress, that's chronic in nature, activating sympathetic system, and then with that, you have peripheral visit constriction, right, so that the musculoskeletal issue is getting enough blood flow, and then there is all of this pain that happens, and then centrally also, right, and it goes a lot of times, this my fascia disease state becomes, there's something happening at the periphery at the muscle level, and then there's something else that also happening centrally, so centrally, they've had regulation of the pain signals, and they've developed hyperagesia, small touch causing a lot of pain, you know, and sometimes they've been allodinia, right, something that shouldn't cause pain is causing a lot of pain, you push a little bit and they're inflamed and all of those things, and with those patient population, what tends to like perpetuate the central and the peripheral staff is really, you know, looking at the pathophysiology, so if you have a state of sympathetic dominance where you're causing visit constriction, what helps with that is, you know, can we get you do an exercise that causes visit dilation, and that's kind of what we know, we'll say somebody have fiber in my eyes, you do exercise to help you open the vessels up so you diffuse and you can do well, and then also kind of providing the central state mechanism, so is there some specific medicines that can help with the central state process, and more importantly, sleep, right, if this people are not sleeping, they're always going to be making more cortisol, and that's going to keep pain going, that's going to keep everything hyper, and that's not good overall for, you know, health and cardiovascular and everything else, so it becomes a lot of education on, okay, let's do something that helps with the periphery, let's figure out what's going on centrally, and then let's give you the tools to get you there, so this is where also nutrition becomes an important thing, because the nauseous stimuli, what is making everything going, is this nauseous stimuli, anything your body is perceiving as stressful, so it's not just a stress, any nauseous stimuli will activate, you know, pain signals, right, so it's not just the stress of the cortisol, it's also the inflammatory markers that are being generated from whatever toxins we're getting exposed to, whatever things else we put into our system, so it becomes kind of broad education about what goes on in the periphery, what's going on centrally, and then giving people the tools to get there, and even sometimes people may require, you know, seeing a psychologist, because sometimes you may have all of those things kind of figure out biochemically, you know, functionally you can look at the markers, they don't have any markers in full inflammation, but you know, they've had some trauma in their life, and their nervous system has become very hyperactive, and they've also developed specific habits or behavior because of pain in pain, right, and the thoughts that kind of influence all of that, I mean, pain all the time, this pain is not going away, and we understand even how a patient talks about their pain, influence that pain state, right, because your nervous system is always just kind of looking to make sense of things, so a lot of education, and then providing the tools that are safely, but a lot of that becomes lifestyle modification, let's get the body to have the, you know, the state needs to be, to be able to bring down all this activation, so this is why even, you know, I also think like having some practices that activate parasympathetic dominance, and this is kind of a relaxation response, meditation, yoga, any of those things in combination with something that causes a visit, a visit, a visit, a deletation of the periphery helps with some of this myofascial things that people got to move, so that's kind of my approach, but again, it's very individualized, and you know, who's coming in with that problem, and what else could be playing a role there? It is, but it's also interesting how it often comes down to the basics, almost right, sleep, nutrition, stress management, no matter what the pathology that you have in front of you, you mentioned there may potentially be some changes on ultrasound, what do you see? So I don't do, you know, I don't use ultrasound diagnostically to diagnose myofascial disease, but I know there's some literature that shows that sometimes, you know, that myofascial component, you know, and this is specifically for like trigger points, where people can see this band on imaging, so that's kind of, that's the reference to that, but I don't use that as a diagnostic tool in my practice, yeah. And then with respect to the inflammatory markers, are you looking at like ESR, CRP, anything else that you might consider? Yeah, so previously I did, so with this care and practice, since it's just a function of my care and structure, which is something I'm going to try to kind of set up a little bit more to kind of start looking at inflammatory markers. So hi, you know, CRP sensitive ones, you want to get the sensitive ones just the basics to make sure nothing is going on, but a lot of times when people come in, with what I'm doing now is we're able to tease some of this out with starting with, okay, let's change the diet and see what happens, okay. So sometimes like you said, it's very simple and basic, and you can kind of figure some of these things out by just eliminating some stuff, okay, let's just stop eating sugar for a lot of it, let's back away from the dairy, let's back away from the gluten, see how you do, because I think sometimes patients get, it also depends, it depends access, it depends where you are, yes, getting this biomarkers are great when you've done everything, the simple things else, and nothing has helped, because sometimes I think we tend to kind of jump to all of those things, and we know that, okay, is it going to change the outcome, the outcome is, okay, stop eating junk, okay, if you eat junk, if you stop eating junk, we can maybe make progress here, and they've done all of those things, and nothing is still helping, and I think this is where it helps to kind of get a little bit more into the biomarkers, because sometimes like you said, we can get a whole lot of stuff, especially toxins that you can, you know, you won't pick up with regular type, you know, CBCs or whatever we do, that the functional medicine approach kind of gives you a lot more, and that cost money, and trying to kind of be cognizant of all of those things, so that is my approach with that, and I think once I have the infrastructure, then hopefully I'll be doing a lot more of those things, if people have not responded to the basics, yeah. Right, you know, sorry, I think the key here is too, right, I think a lot of the audience might resonate with what you're talking about in terms of, oh, I might, I've got some, like, trap pain, or I've got some knee pain, but a lot of people listening, and I know this from family too, is they're all trying to figure out what's that one thing that's causing it, right? A lot of people think there's that one caused an effect, and it's a direct correlation, but what you're talking about here is that it's not always that case, right? I mean, sure, as Ultimus talked about, like if you have a fracture or something, right, and you can see that bone being broken, sure, that's it right there, it's a biomechanical process, but what you're saying here is that it can be inflammation, so let's focus on the diet, it could be a lack of sleep, so let's, you know, work on a sleep routine, it could be biomechanical as well, so let's start foam rolling, mobility, getting a good exercise, so what I love here is that, and I think this is the key takeaway, is that it's a multimodal approach, and I don't think a lot of people want to hear that, because oh man, I'm not going to take more work, and not have to figure this out and that out, but in the end, right, I think the game here is not only looking at that pain, but your overall life and function, right? I think the key is that it comes back to the function, and I think it's not, it's more, I don't know how to word this, I guess like a synergistic thing, right? It's not that you're just fixing this my facial pain, it's now that you're going to have more better increased energy, you're going to prevent disease a little bit more, and it just, it keeps adding up into a better lifestyle. Absolutely. That's kind of the key takeaway that I took from that, yeah, and anything, you know, going beyond like the fault lenses that I looked through, I kind of think the other thing is, it's also important for us as clinicians, we have way we understand things, and how do we communicate to the patient, right? Because some of this stuff will make sense to us, and then the audience goes, ah, this doesn't drive. So what I kind of simplify this thing, I say, there is a predisposing factor that we have to think about, something predispose you to to pain, or you know, I have to mention talk about that, there's about 20% of the patients who have genetics predisposing to development of chronic pain, right? It's genetic, it hasn't many has to be turned on, something has to turn it on, so you have predisposing factors, perpetuating factors, and ah, there's another one predisposing precipitating, right? So there is a precipitating factor, which a lot of times patients are able to recognize that, oh yes, I twisted my ankle, this is what precipitated this pain, but the thing that is really important and I hone in with patients is the perpetuating factors, what are the things that are perpetuating your pain, okay? Because we understand the physiology, yes, something predispose you to it, and let's even look at some of those things, because people are sometimes they don't connect it, why, why all of a sudden, you know, this thing just happened out of nowhere, but then when you get a good history of what's been going on in their life, their work has been super stressful, they recently went into a divorce, they recently lost somebody in their lives, and it's just quite fascinating that once I became aware of those concepts, that there is always something, you know, even though it's like, I don't know how this happens, oh yeah, you just lost your daughter, not too long ago, and you know, in the go, my pain has increased, it's so bad, and they don't connect all of those things, right? And we understand the physiology, yes, there is stress going on, of course, that's gonna put you in every system up, you're gonna be making some, you know, activating biochemicals and pushing things up, so really breaking things down to say, there's this three things that goes on, and you can focus on the things that's perpetuating the pain, and this is where some of this element of food, sleep, other things comes in, yeah. I like the perpetuating thing, I think I'm gonna, that's much more refined, I always use this crass example with my patients where I tell them, you know, when they're coming in and they in the history, they'll highlight this perpetuating thing that's, and they want me to inject XYZ, right, to fix the issue, and I think about a quote from a Swarthick Edition coach Eric Cressy, who talked about like, if you're taking Tylenol to, you know, alleviate your headache, but at the same time you're banging your head against the wall, you can take all the Tylenol in the world, like that's not, you know, the solution is to just stop banging your head against the wall, and they seem to get it, but I like what you said, I think it's a bit more sensitive and professional. I'd like to shift a little bit more into the business of practice, you know, we often talk about how the business of medicine drives the practice of medicine, you know, fortunately, depending on your lens that you look at, what, what's your business model now, are you solo, you know, do you have answering support, like, what's that look like? Yeah, so I mean, I think that's a really important concept to talk about, you know, talking about the business of medicine, because we know how healthcare is finance, determine how healthcare is practiced. Yeah, and that's, yeah, you know, we spend a lot of money on healthcare, you know, whatever 20%, whatever the GDP, I don't know what that is, I forgot, but it's a huge amount, and yet it doesn't translate to value, so for me, getting into even this practice, ethomedicine, it was this idea of this value agenda, we've been talking about for a while, you know, I remember being a resident, it was like, okay, value and healthcare, and how do we do it? How do we, can I create this thing? So, it became necessary that we have to focus on value, and I mean, you know, despite noble hospital missions, statement, and all of this things, the true value for patients never get done, and, you know, patients will say, I want to spend more time with that actor, we'll ask them for their prescanine, they say that to us, Mr. Coming for five minutes, 10 minutes we out, right? You know, they want to say, I don't want to wait on the phone for too long, and we still, you know, they will have to wait forever to get, of course, you know, I'm simplifying things, but really listening to patients and getting into a place of what is important to patient, because there's so many things we do in healthcare that are actually about the people in healthcare, not the person receiving healthcare, so how do we design it to be about the person needing healthcare? So, like I said, I was in a traditional practice, kind of following the same paradigm, and insurance tell us what we can get, sometimes it's frustrating, even the very things that you need your patient needs, but, you know, it won't pay for the patient to go see a psychologist, because I see this people and I go, you know, I can't handle your stuff, so you need to go see a psychologist, it's like, I have somebody, right? And insurance will not pay for that, you know, you need a nutritionist, everybody need a nutritional dietitian, at least, if you're in chronic pain, and you have obesity, you have other risk factors, definitely you got to see that, you know, some people need physical therapy, enough physical therapy for, you know, four weeks beyond all of those things, so really it becomes a bit restricted in terms of how the financing takes place in just insurance model, so with this practice, my goal is to how do I figure out how to create value, that's the whole overarching goal is I want to create value for patient, and I want to tell you some of these assumptions, okay? So, really making it all about patients and giving patients options, because the other stuff that also happens with, you know, being in a model where insurance dictates what you do, is, you know, insurance has to come to a place where that it's just based on very old science, right? So, even when we have specific evidence in medicine, as we know, that, okay, beta-blocker helps with, you know, preventing cardiovascular disease, whatever it is, even when the evidence is available, it would take 10, 15 years before that becomes a clinical practice, right? And even it would take another, whatever, 10 more years before everybody else that doing it. So, we know that so, we are moving so fast in advancement, our understanding of, you know, what's going on in our body, we have so many instruments and tools to really push out a lot of data and a lot of information, that can really save people's life, yet, those are things that, you know, it's not, insurance is not paying for that, because it's going to take another 20 years. So, really, I think, you know, having my practice kind of exposed me, and even as a clinician, it helps you to go learn different things, because there's no incentive to, when I was in the other practice, I mean, I wasn't always interested in this functional medicine approach, I mean, I just learn about, okay, how the cell works, we all learn about that in medical school, and then you leave, and you become an attendant, and then it just becomes, okay, this is what we pay for, that's what we do, let's get you to this person, because it's hard. So, I think, like, with this new practice, what I've done is I do the traditional stuff, and I also give patient's option, it's like, hey, I think you're going to need more, you need to pay, it's worth it, for you to go see a nutritionist, educate yourself about a few things you can do, and guide in patient, you can also explore specific supplements that may be helpful for you, you can also explore some regenerative things that are not covered by insurance, and this is all individualists, and being a guide, and that's kind of where it is, you know, being a clinician, and understanding how this principle works, this is going to work for this person, but what I tell my patient with all these new interventions and things that it can help us as to is, first, let's get you healthy, okay, because people will go pay, you know, 30,000 to get themselves, and they're still like, it didn't work out for me, well, your physiology was not healthy, right? We have to make sure that you don't have still inflammatory markers running around, and things that are going to disrupt that whole healing process, so it becomes a lot more educating people to say, this is the baseline, get your body healthy, there's all this intelligence beyond what we can think about, you know, we're sitting here talking, and it's just a bunch of cells, doing all of these things that we don't even have to think about, right? So really getting people to believe like, yo, if you can get this physiology better, everything knows what's better, so that's kind of the approach with what I have, and educating patients, guiding people, and then, you know, being able to give them options, because, you know, if they can pay for peptides, if they can pay for regenerative type treatment, and other anti-aging modalities, and that all of those things are to just really give your body what it needs to become healthy, and that should be the goal for any of these interventions we do, so my practice allowed me to be able to get that, and I also hope that, you know, that's something I kind of wish, you know, I don't think, you know, private practice, some of the stuff is for everybody, but I just kind of wish that even if we are not in that, you know, even if we are certainly ensuring space, hopefully we can start bringing some of these things that we're learning medical school, the basic biochemistry that we just forget, and that's what people, and it's just so basic, right, that we should be able to kind of, you know, bring those things back and educate our patients, and empower them to do the work. Man, there is so much awesome stuff set in there, and you know, a couple things that stand out to me, you talked about just being a guide for the patient, right, I think, when I was naive, I mean, I'm still, I'm an infant, you know, when it comes to my career, right, and so I'm just starting out in the real world, if you will, and you know, often, you would learn all this stuff, and you go through extensive amounts of schooling and training and residency and schooling hours, and you sit in front of this patient and you tell them, hey, look, this is what the science says, this is what I think you should do, and I've turned the page on that, and really it's about, hey, here are the options, and my job to present them to you, and it's your job to pick them off the menu, if you ask for my suggestions, I'm happy to guide you, and I found that approach to be much more helpful, right, because it empowers the patient, and it's shared decision-making, which I think is a key phrase that we often talk about, and then what you talked about in terms of the patient's physiology is not right for it, so a class example comes to mind, right, I mean, we often talk about, you know, osteoarthritis, right, knee osteoarthritis is one of the leading causes of disability worldwide at this point, and so we know that it can be a load-daring problem, right, so if it's like, for instance, rarely any surgeon will do a total knee replacement, no matter how debilitating an end stage arthritis it is, you know, unless the BMI is less than 40, those are typically the hard cutouts for people, and so if a patient has a BMI of 55 to 60, you could do the best PRP in the world, right, if it's not going to be a good environment, right, you need to address the other issues that you talked about, and so I really love that you highlight that, because I think it's so important, I think it's worth asking is how do you generate like referrals, like, you know, how do people even walk into your door? Yeah, so that's a great question, I think, you know, if you have, if you have something that's very special, which I think we do have an ethomedicine, and people doesn't know about what you do, and you know, so this whole idea of marketing and getting people to know what you have to offer is so important, so this is a new territory for me to understand marketing, because none of us, you know, so you don't have an MBA, yes, you didn't learn that in medical school, right, and then I think the other thing that's also coming from that side of things is like in medical school, and maybe now it's changing, because I think we have so much information now, I mean, a little older than you guys, but you know, I think medicine tends to kind of fantasize us, and you just have to go through this lens, I mean, this is how you see the word, is this just, you know, quadrant of, yeah, it has to fit in here, it has to be the evidence, it has to be there, so, you know, and that's very different from trying to be an entrepreneur, trying to be somebody who's going to do things for yourself, you know, those people have to kind of use the instinct, and they have to kind of set from different industries to solve problems, so part of this is really understanding marketing, and you know, I think I'm doing, I'm doing okay, I'm struggling with that, not getting inside of things, even trying to do like Instagram, initially was just like, oh, guys, do I have to sit up front and talk, you know, so, but all of those things, things that you have to do to kind of get out there, so you have to get your message out, and I think it has to be like very clear, it's all about messaging, it's about, you know, understanding your audience, and really just repetition, repetition, repetition, repetition, so for me right now, what I've been doing is, I've kind of look at, you know, providers that I can connect with, so I'm talking to some physicians who can potentially send patients to me, physical therapists, care of practice, psychologists, and these are all people that are also, so I'm building this ecosystem of clinicians, because as we talk about, we know pain is so complex, so I don't want to take on this responsibility of trying to be, you know, I can solve it off for you, it helps to say, you know what, I think, you know, and then we also know, you know, when patient comes to us, you know, being a clinician, sometimes, you know, like, yeah, you know, I can help you, my stuff is going to be limited, you really need to go talk to somebody about this thing that's happened to you, and it's still there, and you haven't resolved it, so having that relationship kind of both ways helps patient come to you, and then, you know, you can also keep patient to them, but I think what I've recognized and then learning is really going in with this approach of I want to create value, so that whole value thing, not just for your patient, to your referral source, you don't want to go take, it's kind of like give-gift take, so really getting out, learning some principles in business, learning some principles, in marketing, learning leadership, all of these things, and actually that's part of why I even went into this thought, it was kind of like, okay, I want to create value, so that was a few things, I wanted to really, you know, do something about the value agenda, I wanted to change the persona of what the patient and the physician is, because there is a persona of a physician and a persona of a patient, especially when it comes to pain, the doctor do to me, no, okay, he has to change, it is this paternalistic approach that doesn't work when it comes to your own health, or when it comes to pain, especially, right, so you are the subject of experiencing pain, and you have to take an active role, and then the other side of it is really also trying to kind of grow, a personal growth process, because, you know, I was comfortable getting my paycheck and getting bonuses, and being a medical director, it's easy, now I have to go, I have to go figure out what EMR to use, and who to talk to, and how to pay my staff, and all of this thing, so there's a lot of growth in there, but I think I've taken a long way to answer your question, but the idea is that, you know, the solutions are there, and we, I think we are in a better time than before, where there's so much access to different technologies, there's all this exponential things going on, so I think once you put yourself out there, and you stay consistent, and connect, it will come, I'm not what I need, I want to be in terms of the patients that I'm seeing, per day, but gradually making progress, so that's what it takes. Yeah, yeah, absolutely, go ahead, Ultraman. Yeah, I really love what you talked about, it's like, you know, doing the hard work, things that we are having been trained for, right? The easy thing would be, hey, listen, I was just reflecting after graduating fellowship, it's like, wow, this has been a nine year journey, right? I've been trained to do something, and I can go out in the world, and it's just plug-and-play, right? I can just lean back on my knowledge, but now, you know, a recent guest came on Brian Souter, talked about how when he started his, his YouTube channel, you know, now he's got close to 600,000 followers, so he's built this amazing thing, but when he first started, and he had to, it took him like six hours to, to do a five minute YouTube video, and you know, now it's just click-click-click-click-click, and the easy thing at that time probably would have been like, man, this is, why would I start this all over again? People go to film school for this, why would I do this? And a lot of what you're seeing, I think speaks to that as well, is you got to step out, you got to step the message, you got to make the message clear, you know, and it's funny because, you know, Darsh does a pretty decent job at social media, much better than I do, and I remember, yeah, it's great. You know, full disclosure, I'm not very comfortable, like putting my stuff up, or taking a clip of me and putting on Instagram, or tweeting, or whatnot, and remember calling came in, and I was like, how do you do this? How do I do this? How do I get better? You know, he had some profound insight that if he wants to share that he can't, but I really appreciate that. Thank you. Yeah. No, yeah, absolutely. So I was going to say like, sorry, everything, your explanation was great, right? Because I think it hones in on this new concept of medicine that we're starting to call precision and performance medicine, right? So you talk about how it's, we're no longer between the masses, you want to change the relationship between provider and patient, right? So it's more precise. We get to actually look at the certain lab values that we need to, and then we can actually modify a certain diet, right? I mean, you look at a diabetic diet, and in the hospital, it's just pancakes and syrup, you know, talk about car control, and you're like, all right, what are we doing, right? And then you also talk about the performance aspects, right? Of that too, which is when I talk about performance, a lot of people think about just physical, but performance is kind of, you know, we talk about on a daily basis, it's also cognitive, how you're thinking, how you're performing at work, emotionally, self-awareness, all these things, right? And I think all of that encompasses the greater portion of when we talk about health itself. One thing you forgot to mention is having awesome business cards. Oh, yes. Absolutely. Yeah, yeah, thank you. And it's also, you know, you have to be your authentic self, and for me, I believe, I believe in like, let's make things look nice. I mean, I go to a hospital, and I mean, you know, I just, I was just in a hospital today to go get traditional, to be part of like a medical stuff, and I got in there and the smell, I was like, come on, and you know, I haven't been in that environment, and I was like, oh, man, you know, and so part of the whole mind design and approach is I want to use the environment to change people's behavior, because what I've come to recognize as part of doing this work is your health is a lagging indicator of your habits, okay? So your health is a lagging indicator of your habits, your thoughts, the actions you take, the actions you don't take, of course, we know genetic plays a role, but even that epigenetics, what turns it on is a function of either your thoughts, your trauma, whatever thing that's going on. So really, what I recognize is like, I mean, business, and I think, hopefully, this is something that maybe, you know, providers will start looking at, we end up having a behavior change. That's why it's hard, right? Because even us here, you know, we know about health, how many of us consistently do the things that we know are supposed to give us, you know, right? Because there's all this programming and how complex we are as a being. So I think really get into a place of, so where do I go find information to really help people change habit? And that's what I talk about strategy. And I think that's what's different about what I do at Ethan Edison, then, you know, maybe other conventional pain medicines where it's like, okay, people come in, we all want to change, you know, people are paradoxical. I want to be healthy. Yeah, no, I'm not going to do the exercise. And we all mean that, right? So having the compassion to understand that this human experience is hard to do. And how do you give people some signs of there is ways to change habit? How do you stack something on top of something? Some of the very things that you talk about on YouTube and giving people skills in terms of, you know, personal development. Because when you're better, it's easy to kind of get to all of those things, right? So it's taking care of all of those things that allows you to have in the peppers, all of these things that are connected. So it's not just one thing about, you know, let's solve this pain signal. So what I did going back to the card question or how I designed it out, it was I wanted to use that environment to change people's behavior. And the idea is that the environment is an invisible hand of behavior change, right? Because people know what they're supposed to do. They don't do it. So when you come into my office, it's been designed with that intention and the whole idea is to create value. So when you come, I have four rooms. And the first room is like meditation is just numbered. Number one, meditation. Number two, exercise. Number three, nutrition room four is sleep. And they're just big signs on the doors, okay? And then we have a lot of plants. It's biophilic. It smells good. Everybody's quiet. We have some nice sounds to kind of, you know, and that's the whole idea. I was like, this is a place of healing. We have to be able to create that for people. So even when people walk into my office, it changes how they feel, right? And I have this room, the sleep room, and it's already set up in with specific smell, specific atmosphere that it brings out the sympathetic tones. So somebody comes and they have a migraine, they go sit there, the light is dim, and a few minutes, they start feeling better even before we do the botox injection. So really using the environment to change behavior, being intentional, why shouldn't the card feels good? And that's what I tell people. I want you to touch this card and you've got to start, we're going to start the healing process. Yes, you know, and whatever it takes, you know, just really trying to make it a better experience. And that's just been the operating system of what we have this experience. Because what's happening is we've had this evolution of, you know, industrial revolution, industrial stuff, information, right? That's what we are now, internet of all things. Now we get into experience revolution. People want to fill stuff 3D. So how do we start kind of bringing some of those things into health to really get people to change behavior, right? Because when you create the experience, like it creates emotion, emotion, crystallized memory, emotion helps us to learn. So how do we kind of plug all of that into to get people there? So that's what we're trying to do. That's the card. That feels so good. That's so amazing. Sorry, you know, I pondered this question quite a bit actually. And I often ask, you know, the previous guest and anybody who comes on is like, how do we really implement behavior change? Because I do agree. I mean, I think a lot of what we do really comes down to that. And I remember asking one of our previous guests shout out to E. C. St. Kowski's, you know, having the difficult conversations with people and getting them to change. How do you get people to change? And a lot of, you know, people who are wiser than me have been doing this. I said, you really can't. If people have to be willing to do them themselves, then you can guide them as you talked about earlier. But nobody has ever talked about this aspect of the environment that you suggested, right? Really approaching to all other senses except the auditory where we're talking and telling them, right? So talking about, you know, the touch, smell, you know, the visual signals that they're coming in and walking into the office. I will ask, though, because I'll be remiss not to is once they've done that, because I think that eliminates the barrier to entry, right? So once they've walked into your office, now they're sitting across from you and you're sitting, you know, they're in the exam table or wherever they might be sitting. And I think you need to kind of seal the deal, right? You need to seal over the punch line, put the message in. What tactical things could you share with me and darsht with us to kind of really hone in that message, like, this is really important that we could do this stuff. You could get them a massage, you could do meditation, but this is going to be six months of work. That's a long time, right? Are there anything that you found to be valuable in the last decade or so they've been practicing? So that's a great question and it definitely hits the point you're trying to make of setting expectations. And I think that's what we do, you know, as clinicians and sometimes we spend some time on it, sometimes we don't really set an expectation for people to say this is going to take work. This is going to take some time. But part of that is also the very thing that we start is getting people to trust, okay? So first of all, you know, patients are being to different places, they've had all this experience, especially if it's chronic pain or chronic disease state, where, you know, they've been to different places and they've had different experiences that has internalized and, you know, they have pre-assumptions and all of this things. So even, you know, people come to my office and they go, you know, I've seen everybody, what are you going to do for me? You know, that's the first thing to tell me, like, you know, they look, I mean, oh, you're young and, you know, I've been to Mayo Clinic, I just came back from Penn and, you know, I have this practice and they go, you know, what are you going to do for me? Mayo told me they can't do anything for me. Nothing to, you know, I'm not saying that against any institution, but the idea is really, you know, just connecting with her, looking at where she is and then trying to figure out how are we going to get you to the next level because that's what people want to know. How is this going to change? How is my pain going to get better? And then we go, okay, um, let's start with, you know, and the patient already knows, they'll tell you, it's like, you know, I'm overweight, I don't feel good about myself, this is stressing me out, I feel like I'm going to end up in the nursing home, all of this things. So they kind of put in all this complaint out there and what I do is I latch on to those complaints, okay? Let's do something about that. I'm not even going to talk about, you know, your, your scoliosis or your post-fusion syndrome. Okay, this is the things that's important to you, kind of latching on to what's important to them and then kind of flipping it around to say, this is what's important to you, you're going to work about that, right? You want to change that, you're complaining that, you know, you're overweight, what are we going to do about that? So there is this Seth awakening process that I try to get patient to go through themselves and then kind of linkage when expectation, they're going to wake up and say, oh my gosh, yeah, I can do something about this, you know, weight and it requires me taking some action and then going beyond that to hold them accountable because that's what we also have to do because it's not easy and I think all of us wants to have a guide. If somebody, you know, I'm doing a business and I wish I had somebody who's telling me, sorry, hey man, go do this marketing thing, who'll talk to this person, I want that and that comes about when you contrast the person telling you that, okay? So first, it's really trying to build some type of trust as a clinician for your patient, setting expectations and saying that this is going to take some time, some things may work, some things may not work and kind of kind of put it all out there, we don't have to kind of like sugar code anything. Yes, okay, you eat all of this stuff, okay, let's start with one. So I just recently talked to a patient, you know, she's the very thing you're talking about, hi, be out my, she can't get surgery, she can't move, she has knee pain and she loves her chocolate and her soda and pain that she did she does, okay, let's start with one, let's give up the, let's give up the soda and gradually go from there and I say, you know, it's going to take some time because this pain signal is not going to go away until we address all of those things. So, expectation, getting people to wake up to a place of I have a role in this and this is ultimately my responsibility, making that clear. I mean, I'm just going to guide you and you have to do the work. So I don't know if I answered the question, but I kind of went all over the place, but really expectation and getting people to know that it's going to take some work, it's going to take time and then being there to support and help them that journey. No, you did, but I do want to ask so in terms of, for that specific patient, right, so a lot of the, seems like the first step that you wanted to approach it from a nutritional aspect, so is that something that you're referring out or are you addressing that yourself? Yeah, so I will, yes, I send this patient to see a nutritionist, I also connected her with a psychologist and all of this has been great, this lady has lost 25 pounds. This is somebody in her 70s, she was so deflated because she was hoping that she's going to go to Mayo and get surgery, you know, and I think that's some, even sometimes, it's just this expectation that patients have, right? She's not a surgical candidate, it's not like Mayo didn't do the work, but that's not the solution for her problem, right? You've had these scoliosis, you've had spinal surgery, you're still having pain, you obese, you're stressed out, you're, your house, you think you're going to end up in a nursing home and you kind of like that's been going on perpetuating all of this things, and then personality type, right? And eating junk because I'm stressed and all of those things, so it started with getting her to see a nutritionist, getting her to see a psychologist, and then getting her to see a physical therapist, and then helping with that, and I kind of help with some other of the sensory staff, we've studied some topical creams, some other pain medications, to kind of put all of that together. And then sometimes for individuals, certain individuals who don't have that specific need, it becomes, okay, let's just do a simple experiment. How do you feel when you eat certain food? You know, people don't listen, you know, there's embodiment, people don't even listen to your body anymore, and your body will tell you, you will know exactly, a lot of times we eat and we just feel, we don't feel good, we just kind of take it as part of how we're supposed to feel. But if you have a disease state, you have pain, I will tell you, I'll say, how do you feel when you eat that ice cream? How do you feel when you have this specific, especially individuals that have like even migraine, right? They go, I don't know what's triggering this. And I say, go back and look in the last 48 hours, what have you eaten that will cost this? So, depending on where people are, I can just say, do an elimination diet, you know, do an anti-inflammatory, you know, something simple. And then if there's somebody who needs a lot more, then this is where we go, let's have you go see a nutritionist, so it tends to be an individual thing and kind of see where people are in terms of capacity resources. And I think this is where, you know, the art of medicine comes in, it's seen where people are and what they're having access to, right? Because we can make all of this recommendations, we think everybody needs to eat right, everybody needs to do exercise. Well, if they don't have access to that, you know, how do you get that to happen? So, yeah. Yeah, you know, speaking of the art of medicine, so I kind of want to bring this full circle to a couple points back and we're talking about marketing and kind of accountability and building that relationship, right? So one of the things you hit on there was accountability. And I think even us as physicians, right, we would all love to have coaches, right? Not ones that make us feel like it, but at least coaches that could hold us accountable, right? And I think we subconsciously have that desire, all of us do. And so when ultimately I ask like, hey, how do I feel comfortable going on to Instagram and things and making these videos? Like that was actually my initial reason for making these videos. So it was, hey, I want a person to develop. So this is a good way for me, I got to practice what I preach, right? Like I actually have to go out there. And then it also relates to being your authentic self, right? And I think when you're putting out all these senses and you're trying to reel these patients in, you're doing it authentically, right? You're doing it by creating value. You're not doing it with the purpose of all I want money or this is where I'm going to get a referral out of this or this, it's let me actually focus it on you, right? And ultimately I talk about this like that motivational interviewing, right? And making sure that the patient can hear because when they go to Mayo and they go to Penn or any other institution, a lot of times they're just going to feel like they're one of many, right? Getting treated and they're going to hear the common kind of diagnoses and symptoms of medical talk. But at least when they come to you, they know that, hey, although I've seen these reputable institutions, I'm coming to somebody here who is not playing a zero sum game. He's also okay with referring me to a psychologist, with referring me to a nutritionist. So he knows his lane, absolutely. But it's also okay with shouting other people out and building a community, right? And so when I look at all this, I'm like, man, this is exactly how I think about social media, this is exactly how I think about marketing and kind of building a brand, a community, but also trying to create value altogether. So it was just funny as you're saying this because I'm like, man, this is exactly kind of how it's related. So let me ask you this, right? Because I think a lot of people in our generation are not only trying to build a brand and get big on social media, et cetera, but also trying to get more into precision, performance medicine, functional medicine, and not necessarily in the rat race. What advice do you have for them? You know, whether it's courses, books, or just next steps, you know, through a medical school residency? Yeah, so I think that's an important question. And also, it's also important because we understand like the traditional medicine has a role in what it does. And it has, you know, every system is designed to get what is the result it gets, right? It's designed to work a certain way. And people need more than that. So, you know, people that are in pain need more than just surgery. Yes, we can do surgery, but there is a lot more that goes into it. So I think if you're coming back from the traditional medicine approach, it's really fundamental to understand the science. Okay? So it makes a huge difference to understand what goes on in the body at the basic level because that's kind of the basis of it. And we all know that. And at some point, we kind of lost it. And then connecting the system, just knowing that, you know, and I like this podcast you guys ate and talking about, it's not just one system, not just the cardiovascular system. Okay, all of that place rules. So the cardiovascular system, the endocrine, the muscles color, and looking at people from that perspective that are even if you're career, even if you're like an orthopedic surgeon, I will, I will hope that since we all end this in medical school, you should be talking to your patient about nutrition and talking about sleep and talking about stress management. This is a very simple thing that we can all do. Okay? So I think the fundamentals, and I think this is why like functional medicine, you know, like Lena was like, yeah, that makes a lot of sense. The root cause, what's causing this problem? And how do we, you know, get people to change that? So getting the fundamentals is very important. Integrating medicine, right? Integrative medicine. Before you get there, you have to understand the conventional stuff. Okay? So I think really knowing the background and getting this objective way of looking at things is very important. It's not the only way to look at things, right? So yes, we have a scientific method that kind of guides us to this is how you can do things. And it's all a function of making sure people are safe. So that is very important because there's alternative approaches. And then sometimes those things can now be as healthy and even going beyond that, we have to get to a place of third person objective truth. So making sure that whatever intervention, whatever things that we bring into patients, it's going to make sense to them, right? You can do your own individual and perspective. Everybody's different. So I think really understanding what goes on in how the body works is a good place to start. So then you can kind of challenge the assumptions. You can look at a supplement and go, okay, this one may work and you can go say, you know what? I don't know if this is the right thing for this right patient because even though it's been promoted, right? We have all of these options that are out there and all of that is to help. But how do you figure out what is the right thing for your patient? The right time, right? Because something that may even work for you today may not be the appropriate thing for you tomorrow. And that's what patients will go, oh yeah, it was working. And it doesn't work anymore. Yes, your physiology has changed. You're living in a different environment. Your house has roads now. Something else is going on. So really getting to a place of having this wisdom, listening to what's going on. And now we've been saying, I think I'm all over the place, but listening to people because your patient is going to teach you. I mean, I got into this space by a patient who took like tyrosine. There's somebody else treating for pain. I just give them opiates, opiates. And then he go, I took tyrosine one and he didn't show up for a while. I was like, he came back and he has found like a functional medicine doctor or somebody who just put on some supplements. And the guy is like, I don't need my opiates anymore. And I was like, whoa, that's interesting. So really listening to your patients helps continue to educate yourself. Start to think about it. Does this make sense? Okay. I understand the biology and the chemistry. Does this thing make sense? Instead of just like, let's just tour this at this person. And that's what we do. I think we kind of lost some of those critical thinking as we come along because it becomes a problem. These are the solutions that are there for you. But there is more to that. Once you step outside of, you know, what I'm getting, you know, what insurance is peaceful. So listen to your people. Having a critical mindset helps with getting to a place where you can really save your patients truly. And it's about also getting to that place of that higher peppers. What are we here? What are we doing? And always reminding that we're in a place to save. And that has to be always fundamental. That, sorry, that is exceptionally sad. I don't have much more to add to that. But you know, I do have a couple of follow-up questions. Before I do that, though, I just want to, for full disclosure, I want to be very clear. I know we mentioned a couple of institutions on here. And I know somebody's going to hear it. And I've got friends with both of those institutions here. They're spectacular. That's not the purpose. What we're getting at is, you know, when you're working a part of the big system, there are some limitations. And often you have to practice within those confines. And so, you know, insert whatever institution you're at. And of course, I also want to say that this has nothing to like, you know, it gives, it's a systems. And I don't put any judgment on things like that. You'll just kind of like explaining the concept of, yes, these patients have been going with this expectation that my problem should be fixed by mail. Well, your problem is not, you know, there's other solutions. So, it has nothing to do and I have a lot of respect for all of those institutions. And yeah, so it has nothing to against that. It would just tell them their patient story. I think the audience of this show understand that. But I think in today's the amazing, it's worth being able to talk about the message as you suggest. So, you know, as we come to a close here, you know, I do want to ask you with respect to pain management, we talked a lot about that, you know, but really it could be anything in medicine. You know, what are you excited about in the future? And then what's next for you? Yeah. So, I'm excited about all these regenerative things that are coming up, up, uh, precision medicine, understanding the genome. We can map it out now and, you know, we can get very specific at the cellular level and modulate some things and get people healthy. So, I think that's very exciting. Beyond that, there's other exponential things going on technology so we can monitor things and we can, you know, get people to change behavior. Some of these like glucose monitoring systems, all these like digital therapeutics that are helping people change behavior, which is kind of what we're doing. So, I think that's very, very exciting to be able to have those options that somebody can get a medicine that works exactly for them. It doesn't have the side effect because we understand what's going on. So, precision medicine is great. But beyond that, I also think that even when we get to this place of being able to modulate biology and get people to be all of those things, I think we still have to remember that, yeah, we have this, we are still complex. You know, there's this, this mind, body, spirit, whatever thing that's out there that, you know, changing, yes, changing the biology alone, we have to still get people to the grounded, right? Because, you know, we are just so complex that I kind of feel like, you know, medicine, we going into medicine, having all these tools shouldn't be like, oh yeah, now we can just give you that and your life is going to get better. People still will kind of have other things that goes on and being able to look at a place of how do we heal people with their tools? It's a sighting. Yes, we can do that. What's next? Looking to learn more about how I can help my patient, finding different ways, collaborating with other people, you know, I've become very interested in peptide medicine recently, and it's been great to be able to have that option for patients and continue to provide education. I think the most important thing is educating people about the options, be there and help people to get to where they need to be. Awesome, very cool. Well, sorry, I know you are currently sandwiched in between Hershey, where I am and South Jersey and you're in Wayne, Pennsylvania. So, where can people, you know, set up an appointment with you if they want to come see you and that I know you also have educational videos on your website. Yeah, so my practice is in Wayne, Pennsylvania, and the name of my practice is Ethan Medicine, and if people want to find out about how to connect with us, they can go to our website at ethamedicent.com. Ether is spelled A-E-T-H-E-R medicine. They can also give us a call 4-8-4-806-1101. I almost forgot my own number. So, 4-8-4-0-6-1101. And what I do is I'm happy to talk to individuals, can I give them a free consultation to see if I will be a good fit. And then something that I do is, you know, part of this relationship building is like knowing where to send patients, because the whole idea is it's very defleating for patients when they go to a place and they go, there's nothing else I can do for you, right? So, yeah, so that's the kind of like the narrative is like, oh well, you know, there's nothing else we can, well yeah, maybe you're not a candidate for surgery, but yeah, maybe you should go see a nutritionist. So, what I like to do is being able to have a place or being able to say, your next step is, yes, maybe you need to go see a surgeon, because sometimes patients will also have disease states where like, you need their surgery, you know, you shouldn't kind of hang on to this and wait. So, really guiding people. And I think that's what it comes to and say, yes, maybe you need to go to Penn and you need to go to that. Or maybe you got to go mail, right, for this first year. So, guiding people to the right place is all part of, you know, what we do to help patients I did in medicine. Awesome. Well, sorry, before I ask you the last question, I just want to say, thank you so much for coming on to our podcast. I mean, it's been a pleasure meeting you, and I believe, you know, every interaction I have is for a reason. And so, it's been awesome having you on here, keeping it authentic, keeping it real fun, fashionable, guys, if you want to see a stylish, if you want to see a stylish doctor, I would Google image, sorry, and see those dapper suits, so I do want to say thank you for coming on. And then the last question we ask everyone, and we kind of touched on this the entire episode, but if you just want to have like a short little segment here is, how do we put the health back in care? I love that. You guys have that as the kind of the theme of what you do here. And I think, you know, maybe other people are spoken to this, but it starts with the people that are in health care, okay? So, we can put health back into health care if the people leading health care are healthy, okay? So, it has to start with us, you know, first do no harm, first heal yourself, okay? So, we got to heal ourselves before we can do no harm. So, I think that's something that we have to really stress in, and I will also love for all the clinicians and medical students to kind of like, let's make health that will go. Let's really do that. And if we can do that, it's easy for our patients to follow, and you can talk the talk, you can walk the walk, and we have to do that. And we do so much, and we give so much in doing it. It's hard to do it because there's all this different players in the game, you know, you have the hospitals, the payers, everybody's trying to game it, but we go into this to help people and to put health in there. So, let's take care of ourselves. And I think it will translate to bringing health back into the system. Absolutely. And thank you guys so much for having me. This has been great. And I look forward to, you know, talking again, some other time, if it's necessary, and we can get into some other things as well. Yeah. Oh, definitely. Yep. Thank you. Appreciate it. All right. Thank you so much for listening to another episode of Medicine Redefined. If you took one or two things away from this episode, then please go ahead and leave a five-star rating and review and let us know what you learn. And if there's things that you're hoping to learn or you want to learn, please tell us. Tell us on social media through Instagram or TikTok or Twitter. You can always email us at medredefined.gmail.com, but we are hoping to make this an awesome experience for all you listeners out there. So thank you again for tuning in. As always, the medical disclaimer, everything in this podcast is for educational purposes only. It is not constitute the practice of medicine, and we are not providing medical advice. No physician, patient relationship is formed. Anything discussed in this podcast is not representative views of our employers. We recommend that you see the guidance of your personal physician regarding any specific health related issues. Appreciate you all.